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Management of tuberculosis: training for district TB coordinators

31 décembre 2005 Organisation mondiale de la santé

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WHO/HTM/TB/2005.347h

Management of Tuberculosis Training for District TB Coordinators

ADVOCACY AND COLLABORATION FOR TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

This set of training modules has been prepared by the Stop TB Department, World Health Organization, Geneva. The project was coordinated by Karin Bergström. Malgosia Grzemska and Fabio Luelmo were the main technical advisers. The modules were designed and developed by Florence C. Johnson and Patricia Whitesell Shirey of ACT International, Atlanta, Georgia, USA. The American Thoracic Society (ATS), the Centers for Disease Control and Prevention (CDC), Atlanta and the Royal Netherlands Tuberculosis Association (KNCV) have all contributed to the development of the modules through the Task Force Training (TFT) of the Tuberculosis Coalition for Technical Assistance (TBCTA). The modules were field-tested in South Africa through the support of the National Tuberculosis Control Programme of South Africa.

This publication was partially funded by the Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development, through the Tuberculosis Coalition for Technical Assistance, a cooperative agreement to accelerate the implementation and expansion of the DOTS strategy in developing countries.

Advocacy and Collaboration for TB Control Contents Page

Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................2 1. 2. 3. 4. 5. Obtain support for the district TB control programme from political and administrative authorities..................................................................................... 3 Promote the DOTS strategy to non-public health facilities and collaborate with them in TB control efforts................................................................3 Promote the DOTS strategy to private physicians, physicians’ associations, and medical and nursing associations .........................................................................5 Promote the DOTS strategy and TB control services to community organizations and their leaders....................................................................................7 Collaborate with the HIV/AIDS programme..............................................................9 5.1 5.2 5.3 5.4 5.5 Exchange information on services available for HIV testing and for TB case detection and treatment ......................................................................10 Involve HIV testing and care sites in intensified TB case detection ...............10 Encourage use of TB infection control measures in crowded settings ............10 Stay informed of national-level decisions on interventions related to TB/HIV ............................................................................................11 Coordinate information on HIV and TB provided as part of training for staff at health facilities and HIV testing and care sites....................................11

Summary of important points ............................................................................................13 Self-assessment questions..................................................................................................14 Answers to self-assessment questions ...............................................................................16 Exercises ............................................................................................................................19 Exercise A.................................................................................................................20 Exercise B .................................................................................................................22 Exercise C .................................................................................................................24 Annexes A: Key messages about TB for the community ........................................................25 B: Informing TB patients, family, and contacts about HIV and TB ........................27

Advocacy and Collaboration for TB Control Introduction The term advocacy has been used in many ways in public health and in other fields. As defined by WHO, advocacy is “winning the support of key constituencies in order to influence policies and spending and bring about social change.” Advocacy involves identifying the people who can help your programme, and planning the best ways to communicate with them. Successful advocacy can create a basis of support that can influence decision-makers.1 As used in this course, the term advocacy means promoting and gaining support for the DOTS strategy and TB control services. Module C: Conduct Supervisory Visits for TB Control describes how to promote the DOTS strategy during supervisory visits to public health facilities. Module G: Monitor and Evaluate TB Control describes district meetings that can be used to promote the DOTS strategy to staff of public health facilities. This module describes other examples of advocacy, such as: • • Meeting with the mayor, the district financial officer, or other political or administrative authorities to gain support and funding for TB control activities, Informing non-public health facilities and private physicians about the success of the DOTS strategy and TB control services, in order to involve them in collaborative activities, Informing community leaders about TB control services provided free of charge, so that these leaders will in turn encourage the community to use the services, Meeting with community organizations to obtain support for and participation in TB control activities.

• •

The District TB Coordinator can have an important role in advocating the DOTS strategy and TB control services to all types of health-care providers, health authorities, community leaders, political leaders, and various community organizations in the district. These individuals and groups can then become partners in advocacy. Advocacy can lead to increased support for and use of TB control services. Advocacy can also lead to collaboration, that is, working together towards a common purpose. In this module you will learn about collaboration with non-public health facilities. In contrast with public health facilities, which are managed by the government and open to all of the public, non-public health facilities include all health-care facilities that are: • • not managed by the government, e.g. managed privately or by nongovernmental organizations (NGOs), or managed by the government but not open to all of the public, e.g. managed by the police, military, social security, or prison system.

TB advocacy – a practical guide. Geneva, World Health Organization, 1999 (WHO/TB/98.239).

To increase the scope of TB control efforts, it is important to convince these non-public health facilities to adopt the national guidelines for TB case detection and treatment, and to collaborate with them as they implement the guidelines. This module will also describe possible ways to collaborate with individual private physicians, with community and other organizations, and with disease control programmes, particularly the HIV/AIDS programme. The district TB control programme will ultimately reach more of the population with a good mix of public and private health-care providers. This module includes many suggestions for achieving such a mix.1

Objectives of this module Participants will learn how to: • • • • • Obtain support for the district TB control programme from political and administrative authorities Promote the DOTS strategy to non-public health facilities and collaborate with them in TB control efforts Promote the DOTS strategy to private physicians, physicians’ associations, and medical and nursing associations Promote the DOTS strategy and TB control services to community organizations and their leaders Collaborate with the HIV/AIDS programme 4 5 3 Refer to section: 1 2

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

For more information, refer to the document titled Public-private mix for DOTS, practical tools to help implementation. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.325).

Obtain support for the district TB control programme from political and administrative authorities

In many districts, particularly those with decentralized financial management, it is the responsibility of the district political or administrative authorities to provide funding for the district TB control programme. For example, the district authorities may provide funding for fuel for travel related to supervision, for staff, and for improvements to health facilities (such as adding TB microscopy units). As the District TB Coordinator, you must make it clear what resources are needed by the district TB control programme and why. As background information, political leaders will be interested in a description of the DOTS strategy and its benefits, such as improving the sputum conversion rate and treatment success rate in the district. When they understand the benefits of the DOTS strategy, political leaders may be able to assist you in gaining financial support for the district TB control programme. The District TB Plan will be a useful tool in requesting and obtaining resources for the programme. You will learn to develop a plan in module I: Develop the District Plan of Action for TB Control. When you develop the plan for the coming year, meet with political leaders (such as the mayor or council members) to present the programme’s targets and planned activities. Prepare carefully for meetings with political leaders and other authorities, and tailor messages to their interests. Guidelines for developing messages for specific groups are given in section 4 of this module.

Promote the DOTS strategy to non-public health facilities and collaborate with them in TB control efforts

As defined for the purposes of this course, public health facilities are those managed by the government and open to all of the public. Non-public health facilities include those that are: • • not run by the government, e.g. private clinics or health facilities managed by NGOs, or run by the government but not open to all of the public (e.g. health facilities managed by the police, military, social security, or prison system).

Non-public health facilities may be non-profit or for profit. Some may be managed by large private or government-owned corporations. Typically, a district TB control programme should begin by ensuring good TB control services at public health facilities, where they have more influence. However, once TB control activities at public health facilities are organized and functioning, it is important to promote the DOTS strategy and TB control services to non-public health facilities and work towards collaboration with them. (There will be more information about when it is appropriate to expand to non-public health facilities in module I: Develop the District Plan of Action for TB Control.)

Identify the non-public health facilities in your district. Find out whether they are currently diagnosing TB or treating TB patients and, if so, what their current practices are. Determine whether their practices are consistent with the national guidelines for TB control and, if not, how they differ. Meet with the responsible medical officer of each facility, and, as needed: • • • • • • Describe the DOTS strategy and its effectiveness, giving examples of results such as changes in the sputum conversion rate and treatment success in the rest of the district. Provide the national guidelines for TB case detection and treatment. Describe the benefits of improved procedures (directly observed treatment, use of FDCs). Describe the quality-controlled public TB control services now available free of charge at public health facilities in the district. Describe reporting procedures. Discuss ways for the facility to participate in TB case detection and treatment according to the national guidelines.

To begin a collaborative effort with a facility, you will need to reach agreement with the responsible officers about what the facility will do, and what the district TB control programme will do in return. The arrangements may be different at each facility. There are several ways in which a non-public health facility can participate in TB control efforts. It may: • • • Refer TB suspects to public health facilities for diagnosis. Refer TB cases to public health facilities for treatment. Be contracted or designated by the public TB control programme to diagnose and provide treatment for diagnosed TB cases. If participating in this way, the facility should report on TB case detection, sputum conversion, and treatment outcomes.

A facility that has laboratory capabilities (such as a private hospital) may also be designated or contracted to do sputum smear microscopy. In return for the facility’s participation, offer support and incentives from the TB control programme, such as: • • • • • Drugs free of charge for the facility’s patients Recognition as part of the national TB control programme Training of the facility’s staff through provincial or district courses Training materials, such as Management of Tuberculosis: Training for Health Facility Staff, and support to help implement the training course Quality control of the facility’s TB microscopy unit, or new equipment such as a microscope, or services provided free of charge at a public TB microscopy unit.

Once a basic collaborative arrangement is decided upon, it should be planned in more detail, as described in module I: Develop the District Plan of Action for TB Control.

Promote the DOTS strategy to private physicians, physicians’ associations, and medical and nursing associations

Many people seek care from private practitioners, even where public services are widely available. In one country, 88% of rural and 85% of urban patients with TB first went to private practitioners; 50% were treated, partly or completely, in the private sector. In such situations, it is critical to involve private practitioners in diagnosis and treatment of TB according to the DOTS strategy. If private practitioners are not fully informed and involved in the DOTS strategy, the following problems may be common: • • • long delays in diagnosis of TB partial or irregular treatment of TB high default rates among TB patients.

You may approach private physicians individually or through their professional associations. Working through professional associations to reach private physicians may be more costeffective than trying to reach individual physicians who may manage only a few TB cases per year. Likewise, it may be most efficient to reach other health-care professionals in the private sector, such as nurses and pharmacists, through their professional associations. Identify the leaders of professional associations that include private physicians, nurses, pharmacists, or other health-care practitioners. Before meeting with the leaders of these associations, find out about current practices related to TB control in the private sector, so that you will know what to emphasize in the meetings. For example, find out: • • • how private physicians usually diagnose TB, how their patients obtain anti-TB drugs, and whether treatment is directly observed.

When you have an understanding of current practices, meet with each leader to describe the DOTS strategy, its benefits, and successes in your district. Have available and refer to pamphlets, brochures, and posters about the DOTS strategy provided by the national TB control programme. Get agreement from the leader of the professional association to provide information to the membership. Offer assistance such as printed materials or speakers for professional conferences. Printed materials can be distributed during joint MOH/Medical Association seminars on TB case management and at the annual celebration of World TB Day (24 March). The information that should be provided to private practitioners and/or their professional associations includes: • • • the national guidelines for TB case detection and treatment, and a brief summary of the essential content regarding diagnosis and treatment for easy reference, description quality-controlled public services for TB case detection and treatment provided free of charge, names and locations of health facilities where these services can be obtained.

After informing private physicians and medical associations about TB control services available at public health facilities, you may be able to develop collaborative relationships with private clinics or practitioners. Some examples of collaborative relationships are described below:

The private clinic or practitioner may: Refer TB suspects to the public health services for sputum examination. Detect TB cases using sputum smear examination plus other procedures and refer those cases to public health services. Report TB cases diagnosed.

While the district public health services may: Provide sputum examinations free of charge; diagnose smear-positive TB and provide TB treatment free of charge; refer the patient back (with results) for other care as needed. Provide TB treatment of referred cases free of charge; refer the patient back for other care as needed. Provide sputum smear microscopy for TB diagnosis free of charge to patients of private practitioners, on condition that cases are reported. Provide access to sputum smear microscopy, anti-TB drugs, and TB Treatment Cards free of charge. Contribute a microscope; offer supervision and quality assurance of private laboratories performing sputum examinations.

Provide directly observed treatment.

Perform sputum smear microscopy in private laboratories.

Be sure to follow up initial meetings with more detailed planning and take action to implement the plans.

STOP Now do Exercise A – Written Exercise When you have reached this point in the module, turn to page 20 and follow the instructions for Exercise A.

Promote the DOTS strategy and TB control services to community organizations and their leaders

Community organizations and their leaders can become partners in advocacy with the district TB control programme. Community organizations and their leaders can inform the community of TB control services and encourage use of the services. This type of advocacy can begin when TB control services in the community achieve approximately 80% sputum conversion rate, suggesting approximately 80% treatment success. (You would not want to actively encourage the community to come for TB control services until they reach this level of effectiveness.) Once this level is reached, meet with the following groups and leaders to promote the DOTS strategy and TB control services and obtain help in advocacy: • • • • • • Community organizations and their leaders Influential community members at all levels in the community Women’s groups and village health committees Faith-based organizations Parent/teacher associations (PTAs) Non-medical professional associations (such as teachers, taxi drivers).

Tailor your messages to the groups or individuals with whom you meet. For example, community groups need messages about symptoms of TB, how TB can be cured, and when and where services are available free of charge. These types of messages are summarized in Annex A. The national TB control programme should also provide promotional materials that you can use with the community. When developing messages for a specific person or group, keep in mind the following guidelines: Message content: • • • • • Ensure that the message is technically sound. Describe the extent of the TB problem and that the DOTS strategy is the best solution. Provide examples of successes in the district. Explain that, without directly observed treatment, drugs may be misused, leading to drugresistant TB. Stress the cost-effectiveness of the DOTS strategy.

Written messages:1 • • • • Use clear, simple language that is not condescending but is free of medical terms and jargon, while still technically accurate. Use simple graphs to illustrate points powerfully. Choose a single most important message and repeat it. Use pictures, bold headings, and photographs if possible. These will be remembered; lengthy text and details will be forgotten.

Written informational materials may be available from the national TB control programme, but be careful to judge whether they are appropriate for your purposes at the district level.

Spoken messages: • • • • • • • • Speak in clear, simple language. Be concise; minimize the number of words used. Do not try to quote too many facts and figures. Control and vary your voice’s volume, pitch, inflection, and speed. Use interesting and clear slides and overheads if possible. Use compelling photographs of patients if possible. Focus on conveying one message, and repeat it again and again. Talk about the subject in an interesting way.

When community organizations have been fully informed about TB disease and TB control services, their members may become valuable collaborators with the TB control programme, as well as partners in advocacy. For example, community organizations may: • • • • • be a source of community TB treatment supporters, inform others in the community about TB disease and TB control services, raise funds for TB control activities or for patients in need, support TB patients during treatment to encourage adherence, help TB patients with transportation or with child care while they go for treatment.

STOP

Now do Exercise B – Written Exercise and Group Discussion

When you have reached this point in the module, turn to page 22 and follow the instructions for Exercise B.

Collaborate with the HIV/AIDS programme

It is important for TB control programmes and HIV/AIDS programmes at all levels to establish ways to collaborate. The purposes of TB/HIV collaborative activities are: • • to decrease the burden of TB in people living with HIV/AIDS (PLWHA), and to decrease the burden of HIV in TB patients.

Recommended collaborative TB/HIV activities are described in detail in the WHO Interim policy on collaborative TB/HIV activities.1 Activities suited to the district level are described in this module. The district TB control programme should collaborate with both public and non-public providers of HIV testing and care services. Collaborative TB/HIV activities are essential for the following reasons: • • • • • PLWHA (people living with HIV/AIDS) are much more likely to develop TB. Preventive therapy for TB (isoniazid preventive therapy2) can be offered to PLWHA. TB can be cured in PLWHA, although the chance of relapse and death is higher. Intensified TB case detection and treatment among PLWHA interrupts disease transmission. There are benefits to TB patients of knowing their HIV status: – It facilitates prevention, diagnosis, and treatment of complications. – It enables planning for care of the patient’s family and children. – It may be possible to provide drug therapy to reduce HIV-related infections (co-trimoxazole preventive therapy). – It may be possible to provide antiretroviral therapy (ART) to improve the quality and duration of life. For pregnant patients, ART also reduces the chance of mother-tochild transmission of HIV. • TB patients need to know their options for HIV testing (specifically, where to go locally).

As the District TB Coordinator, it is important for you to meet regularly with the district HIV coordinator and District Medical Officer (DMO) to exchange current information about HIV testing and TB control services, agree on ways to collaborate, and make coordinated plans. The District TB Coordinator, district HIV coordinator, and DMO should be the core members of a district TB/HIV coordinating committee. Other members could include representatives of NGOs or community-based organizations providing HIV-related services, patient support groups, etc.

Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.1, WHO/HTM/HIV/2004.1). 2 Isoniazid can be given to prevent progression of TB infection to active TB disease. It must not be given alone to persons with active TB. It is given daily as self-administered therapy for 6–9 months.

5.1

Exchange information on services available for HIV testing and for TB case detection and treatment

An important way for the HIV/AIDS and TB control programmes to collaborate is to exchange information about the locations of services and provide this information to patients. Health workers who manage TB patients must be informed about HIV testing services available in the area, including specific locations of facilities, so that they can provide information to patients when it is needed. They must also be informed about whether drug therapy is available for PLWHA, whether ART to prevent HIV transmission to the foetus is available for pregnant women, and where to refer pregnant women. Likewise, health workers who care for PLWHA must be informed about the high risk of developing TB in PLWHA, and when and where to refer patients for TB control services. They need to know specific locations of facilities that diagnose and treat TB, and understand that these services are free of charge. Try to arrange for health facility staff responsible for TB control services to visit the nearest HIV testing site, and vice versa, to see and hear directly about services offered. 5.2 Involve HIV testing and care sites in intensified TB case detection Work with the district HIV coordinator to involve HIV testing and care sites in TB case detection. Early diagnosis of TB in PLWHA will increase their chance of survival. HIV testing counsellors and HIV care providers should be trained to ask all adults whether they have had cough and, if so, for how long. They should ask these questions every time that patients come for care. Staff should be instructed to refer patients who have been coughing for 2 weeks or more for sputum examination. In some HIV testing and care sites, it may be possible to collect sputum samples and have them examined on site. Staff can then refer TB cases for treatment. A referral system should be established. 5.3 Encourage use of TB infection control measures in crowded settings TB transmission is increased in crowded settings (such as health facility waiting rooms, prisons, police and military barracks, and shelters for the homeless or refugees). In these settings, people with or at risk of TB and HIV are frequently living close together. Infection control measures such as the following are important to reduce TB transmission: • • • • • Early recognition of pulmonary TB suspects Separation of pulmonary TB suspects from others until a TB diagnosis is excluded or confirmed and treatment started Maximizing natural ventilation in the facility Protection of HIV-positive persons from possible TB exposure (for example, by transferring HIV-positive staff away from medical wards) Offering isoniazid preventive therapy to PLWHA who do not have active TB. Use of antiretroviral drugs does not preclude the use of isoniazid preventive therapy.

Work with the district HIV coordinator to encourage and assist with implementation of these infection control measures in crowded settings. 5.4 Stay informed of national-level decisions on interventions related to TB/HIV Depending on national policy, health facilities may offer specific preventive measures or treatments related to TB/HIV. Some possible examples are: • • • • • providing condoms and encouraging condom use, ensuring that all TB patients are offered HIV testing, giving isoniazid preventive therapy to PLWHA who do not have active TB, giving co-trimoxazole preventive therapy to reduce morbidity and mortality in TB/HIV patients and other PLWHA, giving ART to PLWHA.

Decisions should be made at the national level about how the necessary drugs and supplies for these interventions will be procured, how they will be distributed and stored, and what types of facilities will offer the interventions at the district level. If the interventions will be offered at health facilities providing TB control services, collaborate with the HIV/AIDS programme to ensure that health facility staff receive the necessary resources and training. 5.5 Coordinate information on HIV and TB provided as part of training for staff at health facilities and HIV testing and care sites Training for staff responsible for TB control should include relevant information about HIV, and training for staff at HIV testing and care sites should include information about TB: • Training for staff at HIV testing and care sites staff should describe: – – – – – how to ask adults about cough, where to send adults for sputum examination if coughing for more than 2 weeks, other symptoms of TB besides cough (such as weight loss, fever, chest pain, fatigue), when to refer patients to a clinician for TB diagnosis, and drug interactions between ART and anti-TB drugs.

If HIV testing staff will also collect and send sputum samples, refer TB cases for treatment, or treat TB cases, additional training will be needed in these tasks. • Training for staff responsible for TB control services should include information such as: – how HIV is spread, – ways to prevent transmission (for example, safer sex, use of condoms, and safe blood and injection practices), – where to send patients for HIV testing, – whether HIV testing is free of charge, and – drug interactions between ART and anti-TB drugs. Ask the HIV coordinator about specific information to include in training for staff responsible for TB control services in health facilities.

Module D: Inform Patients about TB of the course Management of Tuberculosis: Training for Health Facility Staff, includes basic messages that health workers should tell TB patients about HIV. These messages are also given in Annex B of this module. If health facility staff will be expected to provide counselling related to sexual issues and HIV, they will need special training. If health facility staff will be expected to offer special preventive measures or treatment for PLWHA (e.g. co-trimoxazole, isoniazid), as described in section 5.4, ensure that their training addresses who should receive this intervention, dosages, etc.

STOP

Now do Exercise C – Written Exercise and Group Discussion

When you have reached this point in the module, turn to page 24 and follow the instructions for Exercise C.

Summary of important points • The term advocacy, as used in this course, means promoting and gaining support for the DOTS strategy and TB control services. Advocacy can lead to collaboration, that is, working together towards a common purpose. The district TB control programme should promote the DOTS strategy to the following authorities, organizations and health-care providers, and plan to collaborate with them, as appropriate, in TB control efforts: – – – – – • political and administrative authorities, to ensure sustained support for the programme; non-public health facilities, such as clinics and hospitals sponsored and managed by private corporations, NGOs, the police, military, and social security or prison system; private physicians, physicians’ associations, and medical and nursing associations; community organizations (such as women’s groups, village health committees, faith-based organizations) and their leaders; the HIV/AIDS programme in the district, to ensure implementation of TB/HIV collaborative activities.

•

Collaborative arrangements will vary. To begin a collaborative effort, reach agreement with the non-public health facility (or with private physicians, etc.) about what they will do, and what the district TB control programme will do in return. Community organizations and their leaders may be partners in advocacy. They may inform the community of TB control services and encourage use of the services. This type of advocacy can begin when TB control services in the area achieve approximately 80% sputum conversion rate, suggesting approximately 80% treatment success. Community organizations may collaborate with the district TB control programme by: – – – – – serving as a source of community TB treatment supporters, informing others in the community about TB disease and TB control services, raising funds for TB control activities or for patients in need, supporting TB patients during treatment to encourage adherence, helping TB patients with transportation or child care while they go for treatment.

•

The District TB Coordinator, district HIV/AIDS coordinator, and DMO should be the core members of a district TB/HIV coordinating committee. Collaboration should begin by exchanging information on services available for HIV testing and for TB case detection and treatment, and providing this information to patients. The District TB Coordinator and HIV/AIDS coordinator should work together to involve HIV testing and care sites in TB case detection (that is, asking adults about cough and referring those coughing for 2 weeks or more for sputum examination). The District TB Coordinator and HIV/AIDS coordinator should work together to implement infection control measures in crowded settings (such as prisons, barracks, and shelters), where people with or at risk of TB and HIV may live close together. The HIV/AIDS and TB control programmes should coordinate information provided as part of training for staff of health facilities and HIV testing and care sites.

•

Self-assessment questions Answer the self-assessment questions below to check what you have learned. Then compare your answers with those on pages 16–17. 1. Which of the following are examples of advocacy, as described in this module? (Tick all that apply.) ____ Informing physicians’ associations about the success of the DOTS strategy in order to plan ways to collaborate in TB case detection and treatment ____ Meeting with a women’s organization to inform them about TB control services provided free of charge and to obtain their help in patient support ____ Meeting with the mayor to gain financial support for TB control activities ____ Describing TB control measures to a prison director in order to improve TB control in the prison 2. Advocacy can lead to _____________________, that is, working together towards a common purpose. List three types of individuals or groups that may become involved in collaborative efforts with the district TB control programme:

If a private clinic agrees to refer TB suspects to the public health services for diagnosis and treatment, what can the district TB control programme offer in return? (Give two examples.)

List three ways that community organizations can collaborate with the district TB control programme:

True or false? a. ______ Isoniazid preventive therapy can be offered to PLWHA who do not have active TB . b. ______ TB patients need to know where they can go for HIV testing. c. ______ TB cannot be cured in PLWHA. d. ______ An HIV-infected person is more likely to develop TB.

List three infection control measures that reduce TB transmission in crowded settings where people with TB and HIV may live closely together:

In order to increase TB case detection at HIV testing and care sites, what skills or knowledge should be included in training for staff at these sites? (List at least two examples.)

Now compare your answers with those on the next page.

Answers to self-assessment questions If you had difficulty answering any question, turn back and study the section indicated. If you do not understand something, discuss it with a facilitator.

1. 2. 3.

All answers should be ticked. All are examples of advocacy. (See page 1) Advocacy can lead to purpose. (See page 1) collaboration , that is, working together towards a common

You may have listed any three of the following: (See page 13) – non-public health facilities, such as clinics and hospitals sponsored and managed by private corporations, NGOs, the police, military, or social security or prison system; – private physicians, physicians’ associations, and medical and nursing associations; – community organizations (such as women’s groups, village health committees) and their leaders; – the HIV/AIDS programme in the district.

You may have listed two of the following services that the district TB control programme can offer: – – – – Provide free sputum examinations Diagnose smear-positive TB Provide directly observed TB treatment free of charge Refer the patient back to the private clinic for other care as needed. (See section 3)

You may have listed any three ways that community organizations can collaborate with the district TB control programme, for example: – – – – – be a source of community TB treatment supporters, inform others in the community about TB disease and TB control services, raise funds for TB control activities or for patients in need, support TB patients during treatment to encourage adherence, help TB patients with transportation or with child care while they go for treatment.

(See section 4) 6. Choices a, b, and d are true. Choice c is false: TB can be cured in PLWHA, although the chance of relapse and death is higher. (See section 5)

You may have listed any three of the following infection control measures that reduce TB transmission in crowded settings: – – – – – Early recognition of pulmonary TB suspects, Separation of pulmonary TB suspects from others until a TB diagnosis is excluded or confirmed and treatment started, Maximizing natural ventilation in the facility, Protection of HIV-positive persons from possible TB exposure (for example, by transferring HIV-positive staff away from medical wards), Offering isoniazid preventive therapy to PLWHA who do not have active TB.

(See section 5.3) 8. Some examples of skills or knowledge that should be included in training for staff at HIV testing and care sites: – – – – how to ask adults about cough, where to send adults for sputum examination if coughing for 2 weeks or more, other symptoms of TB besides cough (such as weight loss, fever, chest pain, fatigue), when to refer patients to a clinician for diagnosis.

If staff at HIV testing and care sites will also collect and send sputum samples, refer TB cases for treatment, or treat TB cases, additional training will be needed in these tasks. (See section 5.5)

The End Congratulations on finishing this module!

Exercises for Module H: Advocacy and Collaboration for TB Control

Exercise A Written Exercise – Collaboration with private physicians

In this exercise you will list ways that the Faba District TB Control Programme could eventually collaborate with private physicians. Read the background information and answer the questions. Background information In Faba District, about half of the population chooses to use private providers rather than public health services. There are an estimated 150 000 visits to private providers such as private physicians and clinics each year. There are two private clinics in Agraville: one with 5 and one with 4 physicians. There are also 6 physicians working alone in private practice (some of whom also work in the public health service). In total, there are about 27 physicians in the district. While most of the private physicians are in Agraville, there is also a physician working in Bella Health Centre who has set up a private practice with afternoon and evening hours of 16:00–20:00. There is no organized medical association or nursing association in Faba District, but many of the physicians belong to the local Rotary Club. The District TB Coordinator, Dr Oke Karimi, wants to meet with individual private physicians to promote the DOTS strategy and discuss ways to collaborate. Questions 1. Before meeting with private physicians, what kinds of information should Dr Karimi obtain about their current practices related to TB? List several questions that Dr Karimi should attempt to answer:

What might be a convenient way to meet with a number of private physicians in Faba District at once?

Dr Karimi finds that many private physicians (even those also working in public health service) rely on X-rays for diagnosis rather than sputum smear microscopy. They also send patients to the pharmacy to buy anti-TB drugs to be taken at home. Based on these findings, what are some points that Dr Karimi should make when he meets with private physicians? (List at least three points.)

Looking towards collaboration in the future, what are two things that private practitioners in Faba District could do, and two things that the public health services could do in return? (Write your answers in the table below.)

The private practitioner could:

While district public health services could:

When you have finished this exercise, check your answers with a facilitator.

GO BACK to page 7, section 4, and read until the next stop sign.

Exercise B Written Exercise and Discussion – Collaborating with organizations in your district

In this exercise the group will share ideas about organizations that could be contacted in their districts and potential ways to collaborate. To prepare for the discussion, write brief answers to the following questions: 1. In your district, are there medical, nursing, pharmaceutical or other health care-related associations that you could contact about collaboration with the TB control programme’s efforts? If so, what types of associations?

How could you contact these associations? How could you provide them with information?

What are possible ways that these associations in your district could collaborate in TB control efforts?

In your district, what community organizations could you contact about collaboration with TB control efforts? (List groups that are not primarily focused on health care but that may have an interest in collaboration.)

How could you contact these community organizations? How could you provide them with information?

What are possible ways that these community organizations could collaborate in TB control efforts?

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 9, section 5, and read until the next stop sign.

Exercise C Written Exercise and Discussion – Collaboration of HIV/AIDS and TB control programmes

In this exercise the group will discuss how HIV/AIDS and TB control programmes currently collaborate, or could potentially collaborate, in their districts. To prepare for the discussion, write brief answers to the following questions: 1. Is there an HIV/AIDS programme in your district? If so, is there currently collaboration between the HIV/AIDS and TB control programmes?

If there is collaboration, what type of collaboration is it?

What problems or constraints have been encountered, if any, and how have they been resolved?

If there is no current collaboration with the HIV/AIDS programme, how could the programmes potentially collaborate in the future?

What actions could you take to begin collaboration?

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 13 and read and work to the end of the module, page 17.

Annex A: Key messages about TB for the community • What is tuberculosis (TB)? Tuberculosis, or TB, is an illness caused by a germ that is breathed into the lungs. TB germs can settle anywhere in the body, but we most often hear about TB of the lungs. When the lungs are damaged by TB, a person coughs up sputum (mucus from the lungs) and cannot breathe easily. Without correct treatment, a person can die from TB. • TB can be cured TB can be cured with the correct drug treatment. The patient must take all of the recommended drugs for the entire period of treatment in order to be cured. Drugs for treatment of TB patients are provided free of charge. Treatment can be done without interrupting normal life and work. • How TB spreads TB spreads when an infected person coughs or sneezes, spraying TB germs into the air. Others may breathe in these germs and become infected. It is easy to pass germs to household members when many people live closely together. Anyone can get TB. However, not everyone who is infected with TB will become sick. An HIV-infected person is much more likely to develop TB. • How to prevent TB from spreading To prevent the spread of TB to others in the family and community: – – – Take regular treatment to become cured. Cover the mouth and nose when coughing or sneezing. Open windows and doors to allow fresh air to flow through the home.

There is no need to eat a special diet or to sterilize dishes or household items. Individuals can be protected by immunization with BCG before infection, or isoniazid preventive therapy after infection, to prevent development of active TB and spread to others. • Who should be examined or tested for TB? All adults (aged 15 and older) who have cough for 2 weeks or longer should have their sputum tested for TB. In addition, anyone who consults a clinician and presents symptoms consistent with TB (such as cough, bloody sputum, loss of weight, fever) or signs (abnormal X-rays) should be tested.

All children aged under 5 years living in a TB patient’s household should be examined for TB symptoms. This is especially important because children aged under 5 years are at risk of severe forms of the disease. Young children may need preventive therapy or referral to a clinician. Other household members should be tested for TB if they have cough. • Necessity of directly observed treatment If a patient is diagnosed with TB, the treatment must be directly observed. This means that an observer (such as a health worker or community TB treatment supporter) must watch the patient swallow all the drugs. This will ensure that the patient takes the correct drugs regularly for the required period of treatment. If injections are needed, they will be given properly. By seeing the patient regularly, the observer will notice whether the patient has side-effects or other problems and will know immediately if the patient interrupts the treatment. A patient who does not take all of the drugs will continue to spread TB to others in the family or community. The TB will not be cured. It is dangerous to stop or interrupt treatment, because then the disease may become incurable. With directly observed treatment, the observer will know if a dose is missed and will quickly investigate the problem. If the patient must travel, or plans to move, it is important to let the observer know so that arrangements can be made to continue treatment without interruption. • Where to obtain TB control services free of charge Locations and names of health facilities offering TB control services free of charge, and hours that the health facilities are open.

Annex B: Informing TB patients, family, and contacts about HIV and TB Health workers should inform TB patients and their families and contacts about the risk of HIV and its relationship to TB, and how to prevent transmission of HIV. Health workers should give basic information at the first meeting with the TB patient, and encourage the patient to ask questions throughout treatment. Health workers should ask all women of childbearing age with TB whether they are pregnant. If a TB patient is pregnant, they should refer her for voluntary counselling and testing (VCT) for HIV. Messages about HIV

• An HIV-infected person is much more likely to develop TB. • TB can be cured in HIV-infected persons, although the chance of relapse or death is higher. • There are benefits to knowing HIV status: – It facilitates prevention, diagnosis, and treatment of complications. – It enables planning for care of the patient’s family and children. – It may be possible to provide drug therapy to reduce HIV-related infections (co-trimoxazole preventive therapy). – It may be possible to provide antiretroviral therapy (ART). • To find out your HIV status, these are the options: ... Explain options available locally for HIV testing. • To prevent HIV transmission, all sexually active people should use condoms, no matter what their HIV status. Messages about pregnancy and HIV testing

• • •

If you are pregnant, an additional benefit to knowing your HIV status is that it may be possible to provide antiretroviral therapy to prevent transmission of HIV to the child. All children born to an HIV-positive mother will test positive for the first months of life because of antibodies that the infant receives from the mother. Without antiretroviral therapy, the chances that children born to HIV-positive mothers will be infected with HIV and continue HIV-positive are 1 in 3. With antiretroviral therapy, the chance of mother-to-child transmission is reduced.

The next page presents a brief Guide for informing patients about TB and HIV. This guide summarizes how to ask questions and provide the relevant messages above. In the course Management of Tuberculosis: Training for Health Facility Staff, in module D: Inform Patients about TB, there is a role play exercise in which this guide can be used.

Guide for informing patients about HIV and TB Use this guide for TB patients in areas where HIV is common. Note the special messages for pregnant women.

During the visit: Demonstrate a caring, respectful attitude. Speak clearly and simply. Encourage the patient to ask questions.

Ask TB patients: Do you know what HIV and AIDS are? What do you know? If patient’s understanding is not adequate

Then give relevant messages:

HIV is an infection that destroys your body’s defences against disease. A person can have HIV infection and not know it. An HIV test can tell you whether or not you have this infection. People infected with HIV may eventually develop severe illness, commonly known as AIDS.

Do you know your HIV status? If known or unknown There are benefits to knowing your HIV status: to help prevent, diagnose, and treat complications; to enable planning for care of your family and children; to possibly receive drug therapy to reduce HIV-related infections; – to possibly receive antiretroviral therapy.

– – –

An HIV-infected person is more likely to develop TB. TB can be cured in HIV-infected persons, but the chance of relapse is higher. To prevent HIV transmission, all sexually active people should use condoms, no matter what their HIV status. If unknown If TB patient is a woman of childbearing age, also ask: Are you pregnant? If pregnant An additional benefit to knowing your HIV status is that it may be possible to provide you with antiretroviral therapy to prevent transmission of HIV to your child. All children born to an HIV-positive mother will test positive for the first months of life because of antibodies received from the mother. Without drug therapy, the chances that children born to HIVpositive mothers will be infected with HIV and continue HIVpositive are 1 in 3. With antiretroviral therapy, the chance of mother-to-child transmission is reduced. If pregnant and HIV status unknown Refer for voluntary HIV testing and counselling. Explain options available locally for HIV testing.

Review: Ask checking questions (to ensure that the patient remembers important messages and

knows what to do next). Reinforce earlier messages, or give more information as needed.

WHO/HTM/TB/2005.347i

Management of Tuberculosis Training for District TB Coordinators

DEVELOP THE DISTRICT PLAN OF ACTION FOR TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Develop the District Plan of Action for TB Control Contents Page

Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................2 1. Assess extent and quality of current TB control services ...........................................3 1.1 Review and update map showing TB control services in the district ................3 1.2 Determine the number, proportion, and locations of health facilities providing TB control services............................................................................3 1.3 Determine whether TB control services are adequately reaching children .......4 1.4 Review current sputum conversion rate.............................................................5 2. Plan to maintain and improve current TB control services.........................................6 2.1 Set a sputum conversion target for the coming year..........................................6 2.2 Identify activities needed to maintain and improve current TB control services and achieve the sputum conversion target ...........................................7 3. Plan to expand TB control services ...........................................................................9 3.1 Determine whether to expand TB control services to more public health facilities ........................................................................................9 3.2 Set a target for expanding TB control services to more public health facilities............................................................................................................10 3.3 Identify activities needed to expand TB control services to more public health facilities ......................................................................................10 3.4 Plan to expand TB control services to non-public health facilities .................12 4. 5. Identify activities needed for planning, monitoring, and evaluation at the district level.....................................................................................................15 Develop the District TB Plan ....................................................................................16

Summary of important points ............................................................................................18 Self-assessment questions..................................................................................................19 Answers to self-assessment questions ...............................................................................21

Exercises ............................................................................................................................23 Exercise A.................................................................................................................24 Exercise B .................................................................................................................25 Exercise C .................................................................................................................26 Exercise D.................................................................................................................28 Annexes A: District Plan of Action for TB Control and Planning Chart ................................42 B: Special studies......................................................................................................51

Develop the District Plan of Action for TB Control Introduction Every year, usually in October or November, when results of monitoring from the 3rd quarter are available, the District TB Coordinator must develop a District Plan of Action for TB Control for the coming year (hereafter called District TB Plan). The best plans are realistic, practical, and based on a thorough knowledge of the current TB situation in the district. By monitoring activities and indicators, and by conducting supervisory visits to health facilities throughout the year, you should already have a good basis for planning. In addition, you will want to evaluate the district TB control programme by assessing the extent and quality of current TB control services; this evaluation must precede planning.

Monitoring and evaluation

Planning

Implementation

Monitoring and evaluation will help you identify successful activities that should continue, as well as some that should be improved. The District TB Plan should always include activities to maintain and improve existing TB control services. If monitoring of the sputum conversion rate indicates that existing services are of good quality, then the District TB Plan may also include activities to expand TB control services to more health facilities in the district. The District TB Plan should always include TB/HIV collaborative activities. While the work of detecting and treating TB cases occurs at the health facility level, most of the activities listed in a District TB Plan will occur at the district level. These are the activities that allow the health facilities to do their work, for example, supplying anti-TB drugs, training health workers, and ensuring laboratory support. When you develop the District TB Plan, you will plan activities that are largely your responsibility as the District TB Coordinator. This plan should form the basis of your month-to-month and day-to-day calendar.

Objectives of this module Participants will learn how to: x Assess extent and quality of current TB control services x Plan to maintain and improve current TB control services x Set a sputum conversion target for the coming year x Determine whether to expand TB control services to more health facilities in the district x Set a target for expanding TB control services in the district x Specify activities in a District TB Plan Refer to section: 1 2 2.1 3.1 3.2 2.2, 3.3, 4, 5

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

Assess extent and quality of current TB control services

In module G: Monitor and Evaluate TB Control you learned about evaluation of district targets, which generally occurs at the end of the year, after the District TB Plan has been developed. In this module you will learn about evaluation, which should be done as a basis for planning, that is, assessment of the extent and quality of current TB control services. 1.1 Review and update map showing TB control services in the district Maintain a map of the district, such as the one in module B: Faba District, showing public and other health facilities, TB microscopy units, population, and roads. The map may also show facilities offering HIV testing and counselling. The key to the map should include: names of health facilities, a description of services provided, the managing organization (e.g. MOH, NGO, military, prison, private), outpatient load, and number of TB cases registered (if TB control services are offered). Update the map and related information before developing your District TB Plan. For example: x Obtain from the District Medical Officer any new population data (number of people per area). x Update information on public and non-public health-care providers. x Obtain the most recent available information from health facilities on outpatient load. x Estimate the number of TB cases registered at each health facility in the current year. (To do this, multiply the number of cases registered in the previous quarter by 4; or add the number of cases from the past 4 quarters.) x Update information on location of TB microscopy units and number of microscopes and microscopists at each. 1.2 Determine the number, proportion, and locations of health facilities providing TB control services Referring to the district map and information from monitoring, determine the number of health facilities currently providing TB control services in the district. To be counted, a health facility must meet the following criteria: x be continuously supplied with anti-TB drugs and supplies; x have at least one health worker trained to detect and treat TB cases according to the national guidelines; x have access to a TB microscopy unit; and x actually detect and treat TB cases. Calculate the proportion of public health facilities providing TB control services as follows: Number of public health facilities providing TB control services______ Number of public health facilities in the district

Note: Some health facilities may not yet have staff trained to detect TB cases, but may provide directly observed treatment for TB patients living nearby. These facilities would not be counted in the numerator of the proportion until all of the preceding criteria are met. If this proportion is low, there will be opportunities to expand TB control services in your district, once good quality services are achieved at facilities already providing them. If your district TB control programme has already expanded to non-public health facilities, also calculate the proportion of those facilities providing TB control services. Also consider the distribution of TB control services throughout the district. Notice on the map the locations of the health facilities currently providing TB control services. Are they spread throughout the district, or close together? Are they near the areas with the largest population? Are the facilities providing TB control services the ones with the largest outpatient loads? 1.3 Determine whether TB control services are adequately reaching children Children who have TB are often smear-negative and diagnosed by physicians in hospitals or paediatric clinics, but they should have TB Treatment Cards and be registered in the District TB Register. If health facilities are doing a good job of diagnosing TB in children, referring children who are contacts of adult patients for diagnosis, and ensuring that children who have TB are registered for treatment, then it is expected that approximately 5–15% of TB cases registered in the district will be aged less than 15 years. To determine the proportion of TB cases that were aged less than 15 years, refer to the Quarterly Report on TB Case Registration for the quarter that just ended. The cohort for this proportion includes cases registered in the quarter that just ended. You will need to add together cases from several cells on the Quarterly Report on TB Case Registration to find the numerator and denominator for this proportion. Proportion Time frame for cohort Formula for calculatinga Sources of data From the Quarterly Report on TB Case Registration, add: Block 1, new pulmonary smearnegative cases (column 2), aged <15 years + Block 1, extrapulmonary cases (column 3), aged <15 years + Block 2, all male and female new pulmonary smear-positive cases in age group 0–14 years From the Quarterly Report on TB Case Registration, add: Block 1, column 4, total new cases + Block 3, total of all four cells

Proportion of TB cases who were aged less than 15 years

Number of TB cases aged less than 15 years Quarter that just ended

Total TB cases (all ages)

The numerator is above the dashed line and the denominator below it.

If the proportion of TB cases aged less than 15 years is lower than 5%, it is possible that: x health facilities are not referring children who are household contacts of TB patients for diagnosis, and/or x hospitals and paediatricians are not sending children diagnosed with TB to the health facilities for treatment. If this proportion is higher than 15%, there is under-diagnosis of adults or over-diagnosis of children (perhaps because physicians diagnose as cases those who are infected with TB but who do not have active TB disease). Once good referral practices are established for children, this proportion should remain steady within the 5–15% range. If there is a large change, investigate whether there have been changes in staff or procedures that affect the number of children being registered. 1.4 Review current sputum conversion rate Before developing the District TB Plan, as part of quarterly monitoring following the 3rd quarter, calculate the sputum conversion rate for the district. (This rate will apply to the cohort of cases registered in the 2nd quarter, for which you have just completed a Quarterly Report on Sputum Conversion.) The sputum conversion rate is a good indicator of the quality of TB control services in the district, as well as a good predictor of treatment success.1 Following is a reminder of how to calculate the sputum conversion rate and where to locate the necessary data: Indicator Proportion of new sputum smearpositive TB cases who converted at 2 or 3 months (sputum conversion rate) Time frame for cohort Quarter that ended 3 months ago Formula for calculatinga Number of new sputum smearpositive TB cases who converted at 2 or 3 months Total new sputum smearpositive TB cases Sources of data Quarterly Report on Sputum Conversion, bottom row, “Total converted at 2 or 3 months” Quarterly Report on Sputum Conversion, first column

The numerator is above the dashed line and the denominator below it.

The district should strive for at least 85% sputum conversion, which should ultimately lead to approximately 85% treatment success (unless there are many defaults or deaths in the continuation phase of treatment). If the district has not yet achieved 85% sputum conversion, identify problems (for example, follow-up sputum examinations not done, defaults, deaths, problems with patient adherence to treatment, problems with treatment services, or drug resistance). Investigate causes of problems and identify solutions, as described in section 5 of module G: Monitor and Evaluate TB Control. Try to incorporate these solutions into the District TB Plan for the coming year. Treatment outcome rates for “cure” and “treatment completed” are measured separately and then added together to determine “treatment success.” However, there is a delay of 12 months (after all patients in the cohort are registered) to measure these outcome indicators, so they may not be useful for annual planning. For planning purposes, it is better to look at the sputum conversion rate for smear-positive patients registered in the quarter that ended 3 months ago. The sputum conversion rate should approximate the eventual “treatment success” rate for this cohort. 1

Plan to maintain and improve current TB control services

2.1 Set a sputum conversion target for the coming year With the aim of increasing treatment success in facilities already providing TB control services, set an annual target for conversion of new sputum smear-positive cases in the district. This target should not be considered an end in itself, but rather a milestone to be achieved on the way to improved TB control in the district. A target is expressed as a number, proportion, or rate. A target should include a date, location (the district), and measurable level to be achieved. The following format is recommended for the district’s annual target for maintaining and improving existing TB control services: By the end of 200__, the quarterly sputum conversion rate in the district will reach at least __%.

You will evaluate this target just after the end of the 4th quarter of the coming year, for the cohort of cases registered in the 3rd quarter of that year. When setting a target for the district, you must predict how much improvement can realistically be made. Think about factors that may help or limit improvement, for example: staff changes availability of training for staff availability of anti-TB drugs availability of laboratory support feasibility of using community TB treatment supporters or additional health facilities to provide directly observed treatment (to increase convenience and decrease defaults) x increasing HIV prevalence in the area. x x x x x If your district has already reached the level of 85% sputum conversion, the basic target should be to maintain at least this level. Maintenance may be more of a challenge than it seems as the district adds TB control services to more health facilities. If these facilities have less experienced staff, or are located in more populous, disease-stricken areas, it will require much effort to maintain the 85% sputum conversion rate. However, expansion to additional facilities will make treatment more convenient and may reduce defaults. If your district has achieved 85% sputum conversion, and TB control services are already provided in almost all health facilities in the district, consider setting a target higher than 85%. There are always ways to improve services and increase sputum conversion. In areas with low incidence of HIV and low drug resistance, it should be possible to reach 90% sputum conversion.

STOP

Now do Exercise A – Written Exercise

When you have reached this point in the module, turn to page 24 and follow the instructions for Exercise A.

2.2 Identify activities needed to maintain and improve current TB control services and achieve the sputum conversion target Having set a target, your next task is to identify district-level activities that will contribute to achievement of the target. Of course, the critical work of detecting and treating cases will occur at health facilities. But you must identify the district-level activities that will allow and encourage the health facilities to do this work. It is helpful to think of activities in categories, such as: x x x x supervision training drugs and supplies laboratory support.

Typical activities in each category are listed below.

Category

Examples of activities

– Provide prison health officer with relevant modules of the course Management of Tuberculosis: Training for Health Facility Staff, that is, Training module B: Detect Cases of TB and C: Treat TB Patients.

– Arrange for a trainer to help conduct initial training of prison health clinic staff using the above modules.

– Provide copies of modules and supplies needed for initial training. Drugs and supplies

– Ensure drugs delivered to prison before 7 August. – Add drugs/supplies for prison to regular quarterly order for district. – Discuss laboratory needs with district laboratory supervisor (for initial screening and ongoing).

Laboratory support

– District laboratory tests sputum samples from initial screening, 5–7 August. – Arrange for a health worker (from public health facility) and for supplies to Other collaboration/ assistance collect sputum samples from all prisoners and staff with cough (projected dates, 4–6 August, all on-the-spot collections, early morning each day).

– Visit prison twice in August to answer questions; offer support as needed. – Continue monthly visits to ensure TB case detection and treatment are done as planned, record cases in the District TB Register, provide support, etc.

STOP Now do Exercise C – Written Exercise and Group Discussion When you have reached this point in the module, turn to page 26 and follow the instructions for Exercise C.

Identify activities needed for planning, monitoring, and evaluation at the district level

You have already identified activities in the areas of supervision, training, drugs and supplies, and laboratory support. These activities are needed to maintain and improve TB control services, solve problems, and possibly expand TB control services. There are some other critical activities that must be done at the district level that will require much of your time as the District TB Coordinator, and must thus be included in the District TB Plan. These are activities related to: x planning x monitoring x evaluation. In addition, there may occasionally be activities related to special studies designed to investigate problems or obtain additional information in order to improve the TB control programme. Category Examples of activities

– As a basis for planning, review results of monitoring and evaluation; identify Planning

problems, possible causes, and solutions. – In October or November, develop District TB Plan for the coming year (including targets, activities, and schedule).

– On an ongoing basis, monitor implementation of the District TB Plan; identify problems, causes, and solutions. Monitoring

– At the beginning of each quarter, complete Quarterly Reports on TB Case Registration, Sputum Conversion, and Treatment Outcomes.

– At the beginning of each quarter, calculate and analyse six district-level indicators. – As a basis for planning in October or November, assess current extent and quality of TB control services. Evaluation

– When 4th quarter monitoring results are available, in January or February, evaluate achievement of annual district targets.

– Summarize evaluation results and recommendations. Special studies Activities will vary greatly depending on the type of study and the district’s level of involvement (e.g. whether the district is planning or simply participating in the study). See Annex B: Special Studies.

Develop the District TB Plan

Besides setting district-level targets and specifying activities to achieve those targets, it is important to schedule and budget for activities. The schedule and budget must be practical and realistic. If your initial schedule or budget is not realistic, you may need to revise your targets or activities. A District TB Plan should include: x relevant background information (such as monitoring and evaluation results that influenced the plan) x district targets for the coming year x activities needed to: – maintain and improve services (including activities to solve problems) – expand services (if appropriate) – plan, monitor, and evaluate district TB control efforts – collaborate with other programmes, especially the HIV/AIDS programme x who is responsible for each activity (or with whom it will be done) x when each activity will occur x resources needed to implement each activity, with an assessment of whether or not resources are available and, if not, plans for obtaining resources. If additional resources are needed and cannot be obtained, you will need to determine which activities are most important to implement using available resources, and perhaps delay or cancel other activities. A suggested format for the District TB Plan is shown in Annex A of this module. The last page is a fold-out Planning Chart on which you can roughly schedule, month by month, the activities that you have planned. Once you have put all of the activities on the schedule, you can determine whether it is realistic. If not, you may need to adjust the timing of certain activities, or obtain help with some of the activities.

Example

An example of a District TB Plan is given in module B: Faba District. This is the plan implemented by Faba District in 2004. In the next exercise, you will help to develop a District TB Plan for 2005, including activities for expansion of TB services in Faba District. The District TB Plan can be used in several ways: x Show the District TB Plan to the District Medical Officer (DMO) and your supervisor. Use the plan to request resources needed. x The DMO will incorporate activities from the District TB Plan into the District Plan of Action for Health and will allocate resources for TB control. Use the District TB Plan as a tool to defend the resources needed for TB control services.

x Use the District TB Plan to request and obtain resources from, or to arrange collaborative activities with, potentially interested organizations in the district, such as businesses, NGOs, TB control associations. x Use the District TB Plan to arrange collaborative TB/HIV activities. x Most importantly, use the Planning Chart of TB control activities to plan your day-byday calendar. Post the Planning Chart on the wall of the district office as a reminder of activities planned. As each month approaches, put activities from the Planning Chart on your personal calendar. Remember: A plan is no good unless it is implemented.

STOP

Now do Exercise D – Written Exercise and Group Discussion

When you have reached this point in the module, turn to page 28 and follow the instructions for Exercise D.

Summary of important points x Every year (usually in October or November, when monitoring results are available from the 3rd quarter), develop a District Plan of Action for TB Control (District TB Plan) for the coming year. x Base the District TB Plan on results of supervisory visits to health facilities, quarterly monitoring of indicators (such as the sputum conversion rate), and assessment of the extent and quality of current TB control services. x As appropriate for your district, include in the plan two types of targets: – A target for maintaining and improving existing TB control services (a sputum conversion target), such as: By the end of 200__, the quarterly sputum conversion rate in the district will reach at least __%.

– When appropriate, a target for expanding TB control services to more public or nonpublic health facilities, such as: By the end of 200__, __ out of __ health facilities (specify type) in the district will provide TB control services.

x Factors influencing the decision to expand to more public health facilities include: – – – – the sputum conversion rate for health facilities currently providing TB control services: is it at least 80%? the number, proportion, and locations of facilities in the district currently providing TB control services the accessibility of the facilities and use by the population resources available for expansion (for example, resources for more drugs, training, supervisory visits, laboratory support).

x It is appropriate to focus on expanding TB control services to non-public health facilities when: – – – most public health facilities in the district are providing TB control services according to the national guidelines; on average, the sputum conversion rate at public health facilities is at least 80%; and the population’s access to TB control services can be increased by expanding to nonpublic health facilities.

x The District TB Plan should include activities in areas such as supervision, training, drugs and supplies, laboratory support, collaboration, planning, monitoring, and evaluation. Specify who will be responsible for the activity, where the activity will take place, and the time by which it will occur. x Ensure that the schedule and budget for activities are realistic. If not, you may need to obtain additional resources, or revise the district targets or activities.

Self-assessment questions Answer the self-assessment questions below to check what you have learned. Then compare your answers with those on pages 21–22. 1. The District Plan of Action for TB Control for the coming year is usually developed in October or November, when results of monitoring from the _______ quarter are available.

A target for maintaining and improving existing TB control services should specify the quarterly _________ _______________ rate to be reached by the end of the coming year. In addition to this type of target, many districts will set a target for _______________ TB control services.

True or False? a. ______ It is never realistic to set a sputum conversion target higher than 85%. b. ______ Before expanding TB control services, the district should achieve a sputum conversion rate of at least 80% at public health facilities currently providing TB services. c. ______ It is necessary to offer TB control services in all public health facilities before expanding to non-public facilities. d. ______ In order to provide TB control services, a health facility must have access to a TB microscopy unit. e. ______ If the necessary resources to implement the District TB Plan cannot be obtained, then the plan should be adjusted.

List four factors that should influence the decision about whether or not to expand TB control services to more public health facilities:

List four categories of activities to be considered when specifying activities to achieve targets:

Tick (¥) to indicate which of the following items should be included in a District TB Plan: a. ___ Monitoring and evaluation results that influenced the plan b. ___ Targets for the coming year c. ___ Activities to achieve targets d. ___ Timeline for activities e. ___ Persons responsible for activities f. ___ Human and financial resources needed g. ___ Routine patient care activities to be done at health facilities

Now compare your answers with those on the next pages.

Answers to self-assessment questions If you had difficulty answering any question, turn back and study the section indicated. If you do not understand something, discuss it with a facilitator.

The District Plan of Action for TB Control for the coming year is usually developed in October or November, when results of monitoring from the 3rd quarter are available. (See page 1) A target for maintaining and improving existing TB control services should specify the quarterly sputum conversion rate to be reached by the end of the coming year. In addition to this type of target, many districts will set a target for expanding TB control services. (See sections 2.1 and 3.2) a. False While 85% is a good basic target, there are always ways to improve services and increase sputum conversion. In areas with low incidence of HIV, it should be possible to reach 90% sputum conversion. (See section 2.1) b. True (See section 3.1) c. False It is appropriate to focus on expanding TB control services to non-public health facilities when: – – – most public health facilities in the district are providing TB control services according to the national guidelines; on average, the sputum conversion rate at public health facilities is at least 80%; and the population’s access to TB control services can be increased by expanding to non-public health facilities

Sometimes it is more cost-effective to expand to a large, accessible nonpublic health facility before including all of the small, remote public health facilities. (See section 3.4) d. True (See section 1.2) e. True (See section 5) 4. Factors that should influence the decision of whether or not to expand TB control services to more public health facilities: (See section 3.1) x the sputum conversion rate for health facilities currently providing TB control services: is it at least 80%? x the number, proportion, and locations of facilities in the district currently providing TB control services x the accessibility of the facilities and use by the population x resources available for expansion (for example, resources for more drugs, training, supervisory visits, laboratory support). 21

Four categories of activities to be considered when specifying activities to achieve targets: (See section 2.2) x x x x supervision training drugs and supplies laboratory support.

Other categories listed might include collaboration (section 3.4), monitoring, planning, evaluation, or special studies (section 4). 6. Items a–f should be ticked. Item g, routine patient care activities at health facilities, should not be ticked. Most of the activities listed in a District TB Plan will occur at the district level. These are the activities that enable and support the routine patient care activities done in the health facilities. (Exception: if a patient care activity is new or requires special monitoring, it may be listed in the plan.) (See page 1 and section 5) Note: If you finish this module before the rest of the group, please take the time to read Annex B about special studies.

The End Congratulations on finishing this module!

Exercises for Module I: Develop the District Plan of Action for TB Control

Exercise A Written Exercise – Setting a sputum conversion target

In this exercise you will set a sputum conversion target for the year 2005 in Faba District. 1. Read the following background information: It is October 2004, and time to plan for the coming year in Faba District. The sputum conversion rate has just been measured at 85% for the cohort registered in the 2nd quarter of 2004. The sputum conversion rate has been steadily increasing over the past 5 quarters. The District TB Coordinator believes that treatment has improved as a result of better supervision and training of health workers. Patient adherence to treatment has also improved, as shown by a decrease in the default rate from 17% (as measured one year ago) to 9%. With greater use of community TB treatment supporters, it is expected that the default rate will decrease even more. In 2005, it is expected that TB case detection will continue to improve now that additional health staff have been trained to ask about cough. More sputum examinations will be done as a result. The district laboratory supervisor and District Medical Officer (DMO) have promised to increase laboratory support through addition of a TB microscopy unit. Previous problems with a lack of sputum containers have been resolved. Transportation of sputum samples from High Road Health Post has been irregular and difficult, but has improved. Training (using the course Management of Tuberculosis: Training for Health Facility Staff) will continue to be provided two times per year by the provincial level. It is expected that training will be available for any new staff. The supply of anti-TB drugs to the district is expected to be adequate and reliable. 2. Making your best estimate of what can be achieved in Faba District, complete the target statement below as if you were the District TB Coordinator. Answers will vary. By the end of 2005, the quarterly sputum conversion rate in Faba District will reach at least ___%.

When you have completed this exercise, review your answer with a facilitator.

GO BACK to page 7, section 2.2, and read until the next stop sign.

Exercise B Written Exercise and Discussion – Planning activities to solve a problem

In this exercise you will list and discuss activities needed to solve a problem in Faba District. In a later exercise you will include these activities in the District TB Plan for 2005. 1. Read the following background information: Transportation of sputum samples from High Road Health Post has improved but is still irregular and difficult. Nurse Yakisa Natore at High Road Health Post has been carrying sputum samples on the bus to Bella Health Centre, and the samples are then transported, along with those from the health centre, to the TB microscopy unit at Agraville Hospital. The round trip to Bella Health Centre on the bus takes several hours, and Nurse Natore can rarely spare the time. Sometimes she sends samples with someone else who is going towards Bella Health Centre or towards the hospital. For example, when there is a supervisory visit to the health post, Nurse Natore sends any sputum samples that have been collected to the hospital with the District TB Coordinator. Nurse Natore at High Road Health Post would like to have transportation so that sputum samples can be taken more easily and regularly to Bella Health Centre. She also needs transportation to visit patients who miss visits for treatment and to take drugs to a new community TB treatment supporter who cannot come to collect them at the health post. The District TB Coordinator agrees that it would be a good idea to provide a means of transportation for High Road Health Post. However, he knows that funds to purchase a vehicle or motorcycle will not be readily available. 2. List at least three activities that could be included in the District TB Plan to help solve the transportation problem at High Road Health Post. Think creatively, and remember to state activities specifically (for example, specify who will be responsible for the activity and when it should be accomplished).

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 9, section 3, and read until the next stop sign.

Exercise C Written Exercise and Discussion – Expansion of TB control services

In this exercise you will decide whether to expand TB control services in Faba District in 2005 and, if so, where to expand. The group will also discuss whether their own districts are ready for expansion of TB control services. Consider information about Faba District: Throughout this course, you have been given much information about Faba District, for example, a map showing where TB control services are currently provided, the District TB Plan for 2004, information on recent sputum conversion rates, and other information from monitoring. By October 2004, it is evident that most of the planned activities for 2004 will be accomplished. The District TB Coordinator has been able to make regular supervisory visits. Health facilities are now using the Register of TB Suspects and asking more outpatients about cough. The demand for miscroscopy has increased, and will continue to grow. The district laboratory supervisor and DMO have promised to increase laboratory support through addition of a TB microscopy unit (one microscope and one microscopist). Health posts have begun to use community TB treatment supporters in the villages to give directly observed treatment more conveniently. The nurse at Cara Health Centre has been providing directly observed treatment for patients who live closer to Cara Health Centre than to Denali Health Post. The nurse at Cara Health Centre has been very cooperative in this effort and has expressed interest in further training related to TB control. To prepare for a discussion, briefly write your opinions about expansion of TB control services in Faba District: 1. Should TB control services be expanded in Faba District? Why or why not?

If TB control services should be expanded, in which additional facility(ies) should the services be offered? Why?

Where should the new TB microscopy unit be placed? Why?

If you think that TB control services should be expanded, fill in the blanks in the target statement below: By the end of 200__, ___ out of ___ public health facilities* in the district will provide TB control services. * Substitute other types of facilities if appropriate.

Now think about your own district, and answer the following questions: 5. Is your own district ready for expansion of TB control services to more public health facilities, or to non-public health facilities? Why or why not?

What are examples of non-public health facilities to eventually approach in your district in order to expand TB control services? How might those facilities participate in TB control efforts?

How could public health services support the non-public facilities?

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 15, section 4, and read until the next stop sign.

Exercise D Written Exercise and Discussion – Completing a District TB Plan

In this exercise you will complete a District TB Plan and Planning Chart for Faba District for 2005. Dr, Karimi has completed most of the plan, but some activities are missing. You will add the missing activities and judge whether the plan is practical. 1. Review the partially completed District TB Plan for 2005 on the following pages. Notice that activities are missing in two sections of the plan: A4. Laboratory Support (page 31) – The missing activities relate to maintaining and improving existing TB control services by ensuring good laboratory support. B2. Training (page 32) – The missing activities relate to training staff to prepare for

expansion of TB control services to additional health facilities in Faba District. 2. Follow the instructions below to complete section A4. Laboratory Support: a. Look at Exercise B on page 25 of this module, and recall the group discussion about activities needed to solve the problem that High Road Health Post has had with transporting sputum samples to the TB microscopy unit at Agraville Hospital. Refer to the group’s suggestions, which were written on the flipchart. b. In section A4 of the plan (page 31), list in logical order several of the activities suggested by the group to solve the problem. c. List the person(s) responsible for each activity and when it will be done. d. Tick whether you think that resources are available or needed for the activity. 3. Follow the instructions below to complete section B2. Training: a. Recall the group discussion in Exercise C (page 26) about expansion of TB control services in Faba District. The group should have reached a decision about which additional health facility(ies) will provide TB control services in 2005. This decision was recorded on the flipchart. (Note: Your group’s decision may differ from Dr Karimi’s decision to expand to Cara Health Centre and Emeral Health Post. Use your group’s decision in this exercise, even though it may lead to some inconsistencies within the plan.) b. In each facility selected for expansion, staff will need training to prepare them to provide TB control services. Think of several activities that will be involved in

training the staff. In logical order, list these training activities in section B2 of the plan (page 32). c. List the person(s) responsible for each activity and when it will be done. d. Tick whether you think that resources are available or needed for the activity. 4. Now you are ready to complete the Planning Chart. Fold out the Planning Chart on pages 37 and 39. Notice that the same activities are listed on the Planning Chart as on the plan. On the Planning Chart, however, the time scheduled for each activity is plotted. This allows one to see what activities are happening simultaneously in all of the various categories. Copy onto the Planning Chart, in section A4, the activities for laboratory support that you just listed in section A4 of the District TB Plan. Then plot a reasonable time for each activity. Copy onto the Planning Chart, in section B2, the training activities that you just listed in section B2 of the District TB Plan. Then plot a reasonable time for each activity. Review the entire Planning Chart to see if the activities are scheduled in a logical, practical way. Should some activities occur in a different order? Are too many activities planned for a certain time? If so, how would you adjust the schedule?

6. 7.

When you have finished this exercise, review your answers with a facilitator. When everyone is finished, there will be a group discussion of question 7.

GO BACK to page 18. Read and work to the end of the module (page 22).

2005 District Plan of Action for TB Control for ________

26 October 2004 Name of District TB Coordinator:__________________ Oke Karimi Faba Name of district: ___________________ Date plan prepared:______________

Background information (e.g. monitoring and evaluation results that influenced this plan): To date, 5 out of 8 public health facilities in the district provide TB control services, and there is one TB microscopy unit, for a population of 150 000.

As measured after the 3rd quarter of 2004, the ratio of TB suspects tested to outpatients was about 4%. This improvement is a result of improved case detection in health centres and health posts. These are now using a Register of TB Suspects and reliably collecting and sending sputum samples for examination. Problems with lack of sputum containers have been resolved. Better transportation for sputum samples is still needed for High Road Health Post.

The overall positivity rate for the district has decreased from about 10% (as measured at this time last year) to about 7%, probably because less seriously ill patients are being asked about cough and tested. (This is good, because fewer positive patients will go unnoticed.)

12% of TB cases were aged less than 15 years, which is in the expected range; 60% of TB cases were sputum smear-positive.

Sputum conversion rate for cases registered in the 2nd quarter of 2004 was 85% (increased from 80% for cases registered in 2nd quarter 2003).

Treatment outcomes for cases registered in the 3rd quarter of 2003 were as follows: Cure: 69% (improved from 54%) Completion: 9% (down from 18%) Treatment success (cure + completion): 78% Died: 6% Default: 9% (down from 17%) Failure: 3% Transfer out: 3%

Using community treatment supporters should continue to decrease the default rate. Having achieved good sputum conversion and good TB control services in 5 health facilities, plans for 2005 include expansion to Cara Health Centre and Emeral Health Post, with a TB microscopy unit to be placed in Cara Health Centre.

Target for maintaining and improving TB control services:

87 5 the quarterly sputum conversion rate in the district will reach at least ____%. By the end of 200____,

Target for expanding TB control services (if appropriate):

7 out of ____ 8 public health facilities in the district will provide TB control services. 5 __ By the end of 200__, 30

A. Who and with whom When a)TB coord a) monthly Resources Available Needed Human Financial Human Financial

Activities to maintain and improve TB control services:

State activities in each category specifically (including what, where, and how many):

9 9 9 9 9 9 9 9 9 9

b)TB coord, Denali nurse b) March visit a) 7 Jan

9* 9 9 9 9

A1. Supervision a) Conduct monthly visits to each of 5 health facilities currently providing TB control services: Agraville Hospital, Bella Health Centre, and Gadara, High Road, and Denali health posts. b) Explain to Denali nurse about new TB microscopy unit planned for Cara Health Centre – describe when it will start and how to use. A2. Training a) Confirm arrangements for new health worker at Bella Health Centre to take February course in Management of Tuberculosis organized by province. b) Health worker attends training course in “a” above. c) Assist health facility staff with initial training of community treatment supporters. (May-Gadara, June-High Road). A3. Drugs and supplies a) Order anti-TB drugs and supplies for the district. Increase orders of sputum containers if needed. b) Distribute drugs to 5 health facilities (7 when Cara and Emeral are added). a) TB coord b) 1 health worker c) TB coord, HP staff b) 7–11 Feb c) May&June visits a)1st week of each quarter b) 1st week of each quarter c) 20 Nov a) monthly b) quarterly a)TB coord b)district storeroom officer c)TB coord a-b)TB coord, District lab. supervisor

c) Order supply of Register of TB Suspects for 2006. A4. Laboratory support a) Visit microscopy unit at Agraville Hospital; review TB Laboratory Register b) Obtain summary laboratory reports (for quarterly monitoring)

9 9

etc.

Plans to obtain additional resources, if needed:

*If additional resources are needed, types and amounts must be specified before the plan is complete.

B. Who and with whom When a-c) mid-Jan a-c) TB coord, nurses at Cara & Emeral Resources Available Needed Human Financial Human Financial

Activities to expand TB control services:

State activities in each category specifically (including what, where, and how many):

d-f) TB coord d) 1, 2 April e) 15, 30 April f)Same day as Denali visits g) TB coord h) TB coord, private physicians g) May h) mid-June

9 9 9 9

B1. Supervision (public health facilities)a a) Meet with the nurses at Cara Health Centre and Emeral Health Post to explain the DOTS strategy, gain cooperation, and discuss plans. (Separate meetings for each facility.) b) With the nurses, determine who will do TB-related tasks. Observe or discuss where patients will be interviewed, where sputum samples will be collected, where drug kits and files will be kept, etc. c) Decide on a starting date for providing TB control services (propose: 1 & 2 April). d) Visit facilities on the starting day to assist as needed. e) Visit facilities twice in the first month to follow-up with newly trained staff, assess performance, provide feedback and support, etc. f) After first month, conduct regular monthly supervisory visits.

Collaboration (with private practitioners) g) Informally investigate current practices in private sector related to TB. (Ask physicians, pharmacists, private laboratories.) h) Meet with physicians in 2 private clinics in Agraville (2 meetings) to discuss DOTS strategy and possible collaboration. B2. Training a)

a) TB coord

9 9 9 9 9 9 9 9

b) 1st week Jan b) TB coord, b) end Feb, distr. storerm 25 March officer c) 1st week c) TB coord d) TB coord, each qtr distr. storerm d) March officer, nurses

a) end Jan.

9 9 9

B3. Drugs and supplies a) Estimate needs for Cara Health Centre and Emeral Health Post based on data from other facilities; add to the district order: initial supply of forms and registers, quarterly supply of anti-TB drugs, quarterly amount of other TBrelated supplies (needles, syringes,sterile water, sputum containers). b) Arrange for anti-TB drugs and related supplies to be delivered to Cara Health Centre and Emeral Health Post by 25 March. Check that they are delivered. c) Closely monitor drugs and supplies used, and adjust the next orders based on use. d) Arrange for a reliable way for Cara Health Centre/EmeralHealth Post to receive or collect deliveries of drugs and supplies each quarter. B4. Laboratory support a) Visit selected site with the district laboratory supervisor to assess how to set up a TB microscopy unit there. b) Take actions to ensure that TB microscopy unit (microscope and trained microscopist) will be available by April. (Obtain microscope; provide training.) a)TB coord, Distr. lab supervisor b)Distr. lab sup. b) Feb/Mar

If expanding to public health facilities, describe supervisory activities. If expanding to non-public health facilities, list collaborative activities not covered elsewhere.

Plans to obtain additional resources, if needed:

C. Who and with whom When a) TB coord TB coord, DMO a) 3–14Oct b) 21 Oct Resources Available Needed Human Financial Human Financial

Activities to plan, monitor, and evaluate TB control services:

State activities in each category specifically (including what, where, and how many):

C1. Planning a) Develop District TB Plan. b) Present District TB Plan to DMO.

9 9 9 9 9 9 9 9 9 9 9 9

C2. Monitoring a) Complete 3 quarterly reports and analyse 6 indicators. a)TB coord a)1st week of each quarter b) monthly c) monthly d) every 6 months (Feb, July) a) Jan 2005 b) 3–14 Oct

b) Monitor number of sputum smears being done. b) Distr. Lab. Supervisor c) TB coord d) TB coord, health facility staff a) TB coord b) TB coord

c) Monitor other activities planned, and update calendar. d) Conduct district meetings of health facility staff responsible for TB control services.

C3. Evaluation a) Evaluate achievement of district targets for 2004. b) Assess quality and extent of TB control services in the district in 2005 (first 3 quarters).

9 9

C4. Special studies (if appropriate)

None planned for 2005.

Plans to obtain additional resources, if needed:

Collaborative TB/HIV activities and other activities:

Other activities could include advocacy, coordination with other districts or organizations, attending meetings or conferences, etc.

State activities specifically (including what, where, and how many):

Who and with whom When a-b) TB coord, HIV coord, HIV testing staff a-b) 4 March

Resources Available Needed Human Financial Human Financial

9 9

D1. Collaborative TB/HIV activities a) Conduct brief training at new HIV testing site on how to ask about cough and where to refer patients who have been coughing for 2 weeks or longer for sputum examination. b) HIV testing site staff visit outpatient department of Agraville Hospital to observe TB control services. c) Nurses Abu and Dalia from Agraville Hospital visit HIV testing site to observe HIV testing services. c) Nurses Abu & Dalia, HIV testing staff 9 c) 11 March

D2. Other activities a) Attend provincial TB control conference. a) TB coord

a) 8–9 Dec

Plans to obtain additional resources, if needed:

Planning Chart: Schedule of district-level TB control activities* Feb March _______ _______ _______ _______ _______ _______ _______ _______ _______

For year: 2005 3rd quarter Aug Sept Oct Dec _______

1st quarter April June July _______

Jan

2nd quarter May

4th quarter Nov

_______

___

A. Activities to maintain/improve TB control services A1. Supervision a) Conduct monthly visits to each of 5 health facilities (Week 2–Agraville Hospital, Week 3–Bella & High Road, Week 4– Denali and Gadara). b) Explain to Denali nurse about new TB microscopy unit to start at Cara HC – when and how to use. A2. Training a) Confirm arrangements for new health worker at Bella to take Feb provincial course in Management of Tuberculosis. b) Health workers attend Feb training course. c) As needed, assist facility staff with initial training of treatment supporters (May–Gadara, June–High Road).

A3. Drugs and supplies a) Order anti-TB drugs and supplies for the district. Increase orders of sputum containers if needed. b) Distribute drugs to 5 health facilities (7 when Cara and Emeral are added). c) Order Registers of TB Suspects for 2006.

A4. Laboratory support a) Visit microscopy unit at Agraville Hosp; review TB Laboratory Register. b) Obtain summary laboratory reports (for quarterly monitoring). c)

e) etc.

________

B. Activities to expand TB control services B1. Supervision (public health facilities) a) Meet with nurses at Cara and Emeral. b) With the nurses, discuss who will do TBrelated tasks, arrangement of facility, etc. c) Decide on starting date for providing TB control services (propose: 1 & 2 April). d) Visit facilities on the starting day to assist as needed. e) Visit facilities twice in the first month to follow-up newly trained staff, assess performance, & provide feedback/support. f) After first month, do regular monthly visits, same day as Denali Health Post. Collaboration (w/ private practitioners) g) Informally investigate current practices in private sector related to TB. h) Meet with physicians in 2 private clinics in Agraville (2 meetings) about DOTS strategy and possible collaboration.

B2. Training a)

B3. Drugs and supplies a) Estimate drug and supply needs for Cara Health Centre and Emeral Health Post; add to district order. b) Arrange for anti-TB drugs and related supplies to be delivered by 25 March. Check that they are delivered. c) Closely monitor drugs and supplies used; adjust the next orders based on use. d) Arrange for a reliable way for Cara/Emeral to receive or collect deliveries of drugs and supplies each quarter.

___(lab sup)_ ____

___(lab sup)_

____

____ ____ ____ ____ ____

____

B4. Laboratory support a) Visit selected site with district lab. sup. to assess how to set up TB microscopy unit. b) Ensure that TB microscopy unit will be available by April. C. Activities to plan, monitor, and evaluate TB control services C1. Planning a) Develop District TB Plan. b) Present District TB Plan to DMO. C2. Monitoring ____ a) Complete 3 quarterly reports and analyse 6 indicators. b) Monitor number of sputum smears being done. c) Monitor other activities planned, and update ____ calendar. d) Conduct district meetings of health facility staff responsible for TB control. C3. Evaluation ____ a) Evaluate achievement of 2004 targets. b) Assess quality and extent of TB control services in the district in 2005 (first 3 quarters). C4. Special studies (if appropriate) None planned for 2005. D. Collaborative TB/HIV activities and other activities D1. Collaborative TB/HIV activities a) Conduct training at new HIV testing site on how to ask about cough and where to refer patients coughing for 2 weeks or longer for sputum examination. b) Staff of HIV testing site visit Agraville Hosp. & observe TB control services. c) Nurses Abu and Dalia (Agraville Hosp) visit new HIV testing site.

___

D2. Other activities a) Attend provincial TB control conference.

Jan

Feb

March

April

May

June

July

Aug

Sept

Oct

Nov

Dec

Annexes

A. District Plan of Action for TB Control and Planning Chart ................... 42 B. Special studies .......................................................................................... 51

Annex A District Plan of Action for TB Control for ________

Name of district: ___________________ Date plan prepared:______________ Name of District TB Coordinator:__________________

Background information (e.g. monitoring and evaluation results that influenced this plan):

Target for maintaining and improving TB control services:

By the end of 200____, the quarterly sputum conversion rate in the district will reach at least ____%.

Target for expanding TB control services (if appropriate):

By the end of 200__, __ out of ____ public* health facilities in the district will provide TB control services.

* Substitute other types of health facilities if appropriate.

A. Who and with whom When Resources Available Needed Human Financial Human Financial

Activities to maintain and improve TB control services:

State activities in each category specifically (including what, where, and how many):

A1. Supervision a) b) c) d) etc.

A2. Training a) b) c) d) etc.

A3. Drugs and supplies a) b) c) d) etc.

A4. Laboratory support a) b) c) d) etc.

Plans to obtain additional resources, if needed:

B. Activities to expand TB control services: Who and with whom When Resources Available Needed Human Financial Human Financial

State activities in each category specifically (including what, where, and how many):

B1. Supervision/Collaborationa a) b) c) d) etc.

B2. Training a) b) c) d) etc.

B3. Drugs and supplies a) b) c) d) etc.

B4. Laboratory support a) b) c) d) etc.

If expanding to public health facilities, describe supervisory activities. If expanding to non-public health facilities, list collaborative activities not covered elsewhere.

Plans to obtain additional resources, if needed:

C. Who and with whom When

Activities to plan, monitor, and evaluate TB control services: Resources Available Needed Human Financial Human Financial

State activities in each category specifically (including what, where, and how many):

C1. Planning a) b) c) d) etc.

C2. Monitoring a) b) c) d) etc.

C3. Evaluation a) b) c) d) etc.

C4. Special studies (if appropriate) a) b) c) d) etc.

Plans to obtain additional resources, if needed:

Collaborative TB/HIV activities and other activities:

Other activities could include advocacy, coordination with other districts or organizations, attending meetings or conferences, etc.

State activities specifically (including what, where, and how many):

Who and with whom When

Resources Available Needed Human Financial Human Financial

D1. Collaborative TB/HIV activities a) b) c) d) etc.

D2. Other activities a) b) c) d) etc.

Plans to obtain additional resources, if needed:

Planning Chart: Schedule of district-level TB control activities* Feb March April June July Sept Oct Dec 2nd quarter May 3rd quarter Aug 4th quarter Nov

1st quarter

A. Activities to maintain/improve TB control services A1. Supervision a) b) c) d) etc.

Jan

A2. Training a) b) c) d) etc.

A3. Drugs and supplies a) b) c) d) etc.

A4. Laboratory support a) b) c) d) etc.

B. Activities to expand TB control services B1. Supervision/Collaboration a) b) c) d) etc.

B2. Training a) b) c) d) etc.

B3. Drugs and supplies a) b) c) d) etc.

B4. Laboratory support a) b) c) d) etc.

C. Activities to plan, monitor, and evaluate TB control services C1. Planning a) b) c) d) etc.

C2. Monitoring a) b) c) d) etc.

C3. Evaluation a) b) c) d) etc.

C4. Special studies (if appropriate) a) b) c) d) etc.

D. Collaborative TB/HIV activities and other activities D1. Collaborative TB/HIV activities a) b) c) d) etc.

D2. Other activities a) b) c) d) etc.

* Numbers and letters of activities correspond with those in the District Plan of Action for TB Control.

Jan

Feb

March

April

May

June

July

Aug

Sept

Oct

Nov

Dec

Annex B: Special Studies The purpose of all special studies should be to improve the quality of the TB control programme. Special studies need not be complicated. A special study may be a quick investigation of a problem discovered by regular monitoring. Small studies may be conducted at the district level (for example, by using data already available in registers to answer a new question, or by interviewing patients). There may also be larger, more complex studies, initiated at a higher level, in which the district may participate. It is important to select an appropriate, useful, and feasible objective for a special study (including specific questions to be answered and information to be obtained). Carefully describe the purpose of the study and methods to be used. After the study, analyse findings to identify implications of study results (such as actions to be taken based on results). Following is a short list of possible issues to study. On the next page is a table that briefly describes reasons why one might study each issue, possible methods for collecting data, and types of problems and causes that may be uncovered. While these studies could be done at the district level, other studies might not be suitable at the district level (for example, because they require too large a sample). Examples of possible issues to study: x x x

x x x x x

Proportion of adults attending health facilities who have cough lasting 2 weeks or more (prevalance of cough lasting 2 weeks or more) Delay in diagnosis of smear-positive pulmonary TB (time between the date that patient has been coughing for 2 weeks and the date of initial positive sputum examination) Other time intervals such as: – Time between start of TB symptoms and seeking care – Time between first seeking care at a health facility and sputum examination – Time between sending sputum to TB microscopy unit and receipt of results at health facility – Time between diagnosis of TB and start of treatment Number of visits to health facilities after developing cough but before sputum examination Time of default or interruption of treatment Reasons for default or interruption of treatment For initial defaults (TB cases who never start treatment), proportion with specific reasons for not starting Proportion of new smear-positive TB cases that did not receive directly observed treatment during initial phase.

If you decide that it is important to conduct a special study in your district, be sure to include the study in your District TB Plan, listing the activities and resources needed to carry out the study. You may request support for your protocol and analysis from your supervisor at the next level. Sample protocols for two special studies are provided in this annex: x x

Study of delay in diagnosis of smear-positive pulmonary TB. Study of prevalence of cough (lasting 2 weeks or more) in adults attending health facilities.

Examples of possible issues for special studies

Reasons for study Time between start of TB symptoms and seeking care, reasons for delays in care-seeking Interview current and recent patients If many patients delayed seeking care, community education may be needed to encourage people to seek earlier care for cough. Promotion may be needed to encourage use of TB control services provided free of charge.

Find out

Methods

Examples of findings and implications

– The proportion of severely ill

patients is high, and – The death rate is high, and – The proportion of smearpositive cases with +++ sputum results before treatment is high. Time between first seeking care at a health facility and diagnosis Number of visits to health facilities (with cough) before sputum collection Review dates recorded in Registers of TB Suspects at health facilities Interview current and recent patients

You want to know whether delay in care-seeking or delay in diagnosis is a cause.

If there is a long time between seeking care and diagnosis, or several visits to facilities for any cause before diagnosis, TB suspects are not being identified (by asking about cough) or tested. Motivate clinicians; train health staff; and organize system to ask about cough and collect sputum samples for testing.

Review records to analyse causes and times of death. Proportion of TB patients who are infected with HIV Offer HIV testing to all TB patients, or do an unlinked HIV prevalence study.

If deaths are related to late diagnosis/treatment, reduce delay in diagnosis and treatment (see above). If high HIV, coordinate with HIV/AIDS programme to provide co-trimoxazole and ART if available.

52 What is the real proportion of TB suspects (people coughing 2 weeks or more) among adults attending health facilities? What is the proportion of TB suspects that actually have smear-positive TB? In a few health facilities, systematically ask all adults about cough and duration. Test sputum samples of those with cough of 2 or more weeks’ duration. Compare results with routine facility data.

The death rate during TB treatment is high and you want to know whether HIV infection is a cause.

The ratio of TB suspects tested to adults attending health facilities is low.

If the real proportion of TB suspects among adult outpatients is low, analyse reasons (e.g. attendance of mostly healthy women and children, few males) and develop strategies to reach other adults. If the real proportion is higher from routine facility data, investigate and improve facility’s procedures for detecting and testing TB suspects.

Reasons for study If defaults are primarily in first 3 months, consider whether difficulties associated with directly observed treatment are a cause; if so, consider using community TB treatment supporters. If defaults are later, determine whether health workers are stressing the need to continue and finish treatment. Investigate reasons for defaults as described below.

Find out

Methods

Examples of findings and implications

Time of default

The default rate is high and you want to know why.

Review TB Treatment Cards of defaults (e.g. all defaults registered in a certain quarter)

Reasons for default

Find and interview defaulters

If there are common causes of defaults (e.g. inconvenience, unkind staff), address the causes. If patients have moved without notifying the health facility, stress the need for proper transfer procedures and home visits to new patients.

The sputum conversion rate is low and you want to know why. Analysis of TB Treatment Cards

Reasons for patients not having a negative result at 2–3 months:

Focus on the most common reasons for lack of conversion. For example, if many “non-converters” were actually not examined at 2–3 months, stress the need for this sputum examination to health workers; ensure they have the necessary sputum containers and laboratory support. If many patients were actually still positive:

53 Already died Already defaulted Sputum not examined at 2–3 months Transferred Still positive Is drug intake really directly observed? Review TB Treatment Cards. Interview patients and community treatment supporters, during and after treatment.

– monitor treatment practices (Are cases self-

administering treatment in the initial phase?)

– consider severity of cases (Do most have +++ smears?)

– monitor selection of treatment regimen (Are re-

treatments identified and given appropriate regimen?)

The treatment failure rate is high.

If many patients are doing self-administered treatment in the initial phase, they may be doing irregular treatment. Address the causes of self-administration. For example, if there are problems with accessibility of the health facility, consider using community TB treatment supporters. If community TB treatment supporters are not observing, find out the cause.

Sample Protocol Study of delay in diagnosis of smear-positive pulmonary TB Objectives People with persistent cough sometimes visit various health facilities (for cough or other reasons) before they are identified as TB suspects and have sputum collected for diagnosis. Delay in diagnosis decreases cure rates and increases the spread of infection in the community. The objective of this study is to determine diagnosis delay, that is, the average duration of delay between: x x

the date that the patient started coughing, and the date of the initial positive sputum smear.

This delay may be influenced by the patient’s delay in seeking care as well as health facilities’ missing opportunities to actively ask about cough, identify TB suspects, and collect and send sputum for examination. The study will also determine the average number of missed opportunities for diagnosis (i.e. the number of times that patients visited health facilities after developing cough, but before having sputum collected for examination). Study methods A. Selection of patients Select all new sputum smear-positive pulmonary TB cases registered in the District TB Register in a single quarter. B. Case interviews 1. Case contact Contact eligible cases identified from the District TB Register within 30 days of starting treatment. 2. Administration of questionnaire All selected cases will be interviewed by a trained interviewer using a questionnaire. (See sample questionnaire on the next page.)

Sample questionnaire on delay in diagnosis of TB Note: For all dates, enter day/month/year. For example, enter 5 October 2004 as 05/10/04. It can be difficult for patients to recall dates. Use prompts as needed; for example, ask about dates in relation to life events. If patients can only remember dates in general terms, use the following rules: If the patient recalls a date as being “at the beginning of the month,” record the 1st day of the month. If “the middle of the month,” record the 15th of the month. If the “end of the month,” record the 30th of the month. Interviewer: Date of interview: District TB number: Name of patient: Age: Sex (M/F): Date of positive smear before treatment: Date treatment started: ...................................................... Hello, my name is __________ and we are doing a survey to find out about your experience with diagnosis of your tuberculosis in order to improve services. Are you willing to talk with me for a few minutes about your health? 1. Have you had cough during this illness? (Y/N) [IF NO COUGH, STOP HERE] [IF YES, go to question 2] 2. When did you develop cough? (Prompt and assist patient recall. Record approximate date.) 3. After developing cough, but before having sputum collected, did you visit any health facilities for cough or for any other reasons? (Y/N prompt: Examples of possible reasons could include another illness or injury, or bringing a child for health care.) [IF NO, conclude the interview] [IF YES, go to question 4] 4. How many times did you visit health facilities for cough or other reasons before having sputum collected? (Do not count the visit at which sputum was collected.)

Thank you for taking time to answer these questions. ......................................................

After the interview: 5. Record the number of days between start of cough (answer to question 2) and date of initial positive smear: _____ days 6. Subtract 14 days (2 weeks) from the number of days in item 5: _____ days between the date that the patient had been coughing for 2 weeks and the date of the initial positive sputum smear.

Sample Protocol Study of prevalence of cough in adults attending health facilities Background The identification of pulmonary TB suspects is based on asking about the presence of cough in all adults attending health facilities for any reason; and examining sputum smears of those with cough lasting 2 weeks or more. To evaluate the performance of health staff in asking about cough, it is necessary to know the real prevalence of cough lasting 2 weeks or more in that population group. Objective To determine the prevalence of cough lasting 2 weeks or more in adults attending (public) (primary health facilities) (health centres) (hospital outpatient departments) for any reason. Methods 1. Selection of (xx) health facilities of a particular type (for example, public, primary health facilities, health centres, hospital outpatient departments), and estimate of the daily attendance of adults. 2. Duration of the study in days sufficient to question 1 000 adults (If at least 4% have cough lasting 2 weeks or more, this will yield at least 40 adults with cough.) 3. Systematic questioning of all adults attending those facilities for any reason, using the questionnaire on the next page. 4. For adults with cough of 2 weeks or more, collection of one spot sample and request for a second overnight and third (spot) samples for smear examination. 5. Examination of smears and follow up as per national TB control programme guidelines. Resources One nurse or trained staff to administer the questionnaire, and a supporting nurse to collect sputum samples. Forms, sputum containers, access to TB microscopy. A hospital or health centre may receive 20–200 adults per day. If 50 adults are seen on the average, the study would need to last 4 weeks in order to include 1 000 adults (50 × 5 days per week × 4 weeks = 1 000). If 100 adults are seen per day in larger facilities, the study can be done in 2 weeks. It is convenient to include several facilities (for example, 4) of the same type, staying at each facility one week. Analysis The study will provide: the number of adults interviewed at the health facility, which should be all adults visiting the facililty (denominator), and the number with cough of 2 weeks or more (numerator). Calculate the proportion of adults with cough of 2 weeks or more among those interviewed. This proportion can be compared with the proportion found during routine work (the number of TB suspects listed in the Register of TB Suspects divided by the number of adult outpatients attending the facility.) This study will also provide the proportion of smear-positive TB cases found in adults with cough lasting 2 weeks in this population, although with a lower degree of confidence. 57

Sample questionnaire on prevalence of cough in adults attending health facilities Health facility: Survey staff: Dates: Ask questions of all persons aged 15 years and older. Record answers in the table provided. Number interviews consecutively. We are studying the reasons why people come to this health facility. May I ask you a few questions? 1. What is your reason for attending the health facility today? 2. Do you have a cough now? Y/N [IF NO, stop. IF YES, continue.] 3. How long have you had the cough? (If necessary, prompt: Less than 2 weeks? 2 weeks or more?) [If less than 2 weeks, stop.] If cough 2 weeks or more: Please go to the nurse (indicate where) while you are waiting for your appointment. The nurse will help you collect sputum and will send it to be tested. The sputum examinations are free of charge and will find out if you have infectious disease of the lungs. The nurse will follow the standard NTP procedures for examination of TB suspects, and will inform the patient of the purpose, that it is free of charge, when to return with an additional sample, and when to find out the results. The patient will be entered in a Register of TB Suspects (or similar form used by the health facility). Interview number 1 2 3 4 5 6 7 8 9 10 Continue on the next page, beginning with interview 11 and using as many pages as needed. There is room for 30 interviews per page. Reason for coming to health facility Cough? (Y/N) If cough, duration (<2 weeks or 2 weeks)

Page ___ of ___ Interview number Reason for coming to health facility Cough? (Y/N) If cough, duration (<2 weeks or 2 weeks)

WHO/HTM/TB/2005.347n

Management of Tuberculosis Training for District TB Coordinators

FACILITATOR GUIDE

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Facilitator Guide Contents Introduction to this Facilitator Guide ......................................................................................... 1 Guidelines for A: Introduction................................................................................................A-1 Guidelines for B: Faba District .............................................................................................. B-1 Guidelines for C: Conduct Supervisory Visits for TB Control ............................................... C-1 Guidelines for D: Provide Training for TB Control ...............................................................D-1 Guidelines for E: Manage Drugs and Supplies for TB Control.............................................. E-1 Guidelines for F: Ensure Laboratory Support for TB Control ............................................... F-1 Guidelines for G: Monitor and Evaluate TB Control .............................................................G-1 Guidelines for H: Advocacy and Collaboration for TB Control.............................................H-1 Guidelines for I: Develop the District Plan of Action for TB Control ..................................... I-1 Guidelines for J: Field Exercise – Supervisory Visit ............................................................... J-1 Guidelines for all modules ....................................................................................................All-1 Facilitator techniques .................................................................................................All-1 When participants are working...................................................................................All-5 When providing individual feedback .........................................................................All-6 When leading a group discussion...............................................................................All-7 Schedule for the course.........................................................................................................All-8 Overhead transparencies .......................................................................................................All-9

Facilitator Guide

Introduction to this Facilitator Guide For whom is this course intended? This course is designed for District TB Coordinators who are responsible for planning, organizing, implementing, and evaluating activities of a district TB control programme. A district usually serves a population of 100 000 or more. TB control may be the District TB Coordinator’s primary responsibility, or TB may be just one of several disease areas of responsibility. Depending on the size of the district and the number of staff available, the District TB Coordinator may be one person or a team of people. If a district is large, one full-time person solely responsible for TB control services, or a team approach, may be justified. For the purposes of this course, the person (or team) responsible for TB control at the district level is called the District TB Coordinator. The District TB Coordinator is usually a physician or a nurse and may be male or female. He or she works at the district health office and may also have clinical duties at the hospital. The job of District TB Coordinator is primarily administrative and managerial. Although the District TB Coordinator must be thoroughly familiar with clinical guidelines of the national TB control programme, he or she is primarily responsible for enabling and monitoring the implementation of these guidelines, rather than actually treating patients.

What methods of instruction are used in this course? This course uses a variety of methods of instruction, including reading, written exercises, discussions, demonstrations, and practice of supervisory skills at a real health facility. Practice, whether in written exercises, discussions, or in the health facility, is considered a critical element of instruction.

How is the course conducted? • Small groups of participants are led and assisted by “facilitators” as they work through the course modules (booklets). The facilitators are not lecturers, as in a traditional classroom. Their role is to answer questions, provide individual feedback on exercises, lead discussions, etc. • The modules provide the basic information to be learned. • The modules are designed to help each participant develop specific skills necessary for managing TB control activities at the district level. Participants develop these skills as they read the modules and practise skills in written exercises and group discussions.

• To a great extent, participants work at their own pace through the modules. In some activities, the small group will work together. Homework is not recommended. • Each participant discusses any problems or questions with a facilitator and receives prompt feedback on completed exercises. (Feedback includes reviewing and discussing the exercise with the participant.)

What is a FACILITATOR? A facilitator is a person who helps the participants learn the skills presented in the course. The facilitator spends much time in discussions with participants, either individually or in small groups. For facilitators to give enough attention to each participant, a ratio of one facilitator to five or six participants is desired. In your assignment to teach this course, YOU are a facilitator. As a facilitator, you need to be very familiar with the material being taught. It is your job to give explanations, answer questions, talk with participants about their answers to exercises, lead group discussions, and generally give participants any help they need to successfully complete the course. You are not expected to teach the content of the course through formal lectures. (Nor is this a good idea, even if this is the teaching method to which you are most accustomed.)

What, then, DOES a FACILITATOR do? As a facilitator, you do three basic things: 1. You INSTRUCT: • Make sure that each participant understands how to work through the materials and what is expected in each module and each exercise. • Answer the participant’s questions as they arise. • Explain any information that the participant finds confusing, and help the participant understand the main purpose of each exercise. • Lead group activities, such as group discussions and the visit to a health facility, to ensure that learning objectives are met. • Promptly review each participant’s work and give correct answers. • Discuss how the participant obtained the answers in order to identify any weaknesses in the participant’s skills or understanding. • Provide additional explanations or practice to improve skills and understanding.

•

Help participants to understand how to use skills taught in the course in their own districts.

2. You MOTIVATE: • • Compliment the participant on correct answers, improvements, or progress. Make sure that there are no major obstacles to learning (such as too much noise or not enough light).

3. You MANAGE: • • Plan ahead and obtain all supplies needed each day, so that they are in the classroom when needed. Monitor the progress of each participant.

How do you do these things? • Show enthusiasm for the topics covered in the course and for the work that the participants are doing. • Be attentive to each participant’s questions and needs. Encourage the participants to come to you at any time with questions or comments. Be available during scheduled times. • Observe participants as they work, and offer individual help if you see a participant looking troubled, staring into space, not writing answers, or not turning pages. These are clues that the participant may need help. • Promote a friendly, cooperative relationship. Respond positively to questions (by saying, for example, “Yes, I see what you mean,” or “That is a good question”). Listen to the questions and try to address the participant’s concerns, rather than rapidly giving the “correct” answer. • Always take enough time with each participant to answer questions completely (that is, so that both you and the participant are satisfied).

What NOT to do ... • During times scheduled for course activities, do not work on other projects or discuss matters not related to the course. • In discussions with participants, avoid using facial expressions or making comments that could cause participants to feel embarrassed. • Do not lecture about the information that participants are about to read. Give only the introductory explanations that are suggested in the Facilitator Guide. If you give too

much information too early, it may confuse participants. Let them read it for themselves in the modules. • Do not review text paragraph by paragraph. (This is boring and suggests that participants cannot read for themselves.) As necessary, review the highlights of the text during individual feedback or group discussions. Do not assign homework. Do not be condescending. In other words, do not treat participants as if they are children. They are adults. Do not talk too much. Encourage the participants to talk. Do not be shy, nervous, or worried about what to say. This Facilitator Guide will help you remember what to say. Just use it!

• • • •

How can this FACILITATOR GUIDE help you? This Facilitator Guide will help you teach the course modules. For each module, this Facilitator Guide includes the following: • a list of the procedures to complete the module, highlighting the type of feedback to be given after each exercise • guidelines describing: – – – how to do demonstrations and lead group discussions points to make in group discussions or individual feedback how to lead a visit to a health facility and structure the field exercise there

• copies of answer sheets for exercises. Answer sheets are also provided in a separate packet for each participant. Individual answer sheets should be detached and given to each participant after exercises, during individual feedback, or after a group discussion. After the guidelines for each module, there is a section of this Facilitator Guide titled “Guidelines for all modules.” This section describes training techniques to use when working with participants during the course. It provides suggestions on how to work with a cofacilitator. It also includes important techniques to use when: • • • participants are working individually, you are providing individual feedback, you are leading a group discussion.

The Facilitator Guide also includes a sample course schedule, which the course director will adapt to the local situation.

The last section of the Facilitator Guide includes pages that can be made into overhead transparencies for use with an overhead projector. If there is an overhead projector available, photocopy these pages onto clear plastic sheets to make overhead transparencies. To prepare yourself for each module, you should: • • • • • • • • • read the module and work the exercises, check your answers by referring to the answer sheets, read in this Facilitator Guide all the information provided about the module, plan with your co-facilitator how work on the module will be done and what major points to make, collect any necessary supplies for exercises in the module, make any overhead transparencies needed, think about sections that participants might find difficult and questions they may ask, plan ways to help with difficult sections and answer possible questions, plan questions that will encourage participants to think about using the skills taught in their own districts.

Checklist of instructional materials needed in each small group

Item needed N: Facilitator Guide Set of eight modules (A–L) and answer sheets (M) Copy of course schedule For reference as needed, a complete set of course materials for Management of Tuberculosis: Training for Health Facility Staff (WHO/CDS/TB/2003.314)

Number needed 1 for each facilitator 1 set for each facilitator and 1 set for each participant 1 for each facilitator and participant

1 set for each small group

Checklist of supplies needed for work on modules Supplies needed for each person include: • • • • • • • name tag and/or name card for table 2 pens 2 pencils with erasers paper highlighter folder or large envelope to collect answer sheets calculator (optional but helpful)

Supplies needed for each group include: • • • • • • • large paper clips (helpful to mark place in the module while doing an exercise) pencil sharpener stapler and staples 1 roll masking tape extra pencils and erasers flipchart pad and markers OR blackboard and chalk overhead projector (if possible), supplies for making overhead transparencies, and erasable markers for writing on overhead transparencies

Facilitator Guidelines for A: Introduction Procedures 1. Introduce yourself and ask participants to introduce themselves. 2. Do any necessary administrative tasks. 3. Distribute and introduce module A: Introduction. Participants read the module (pages 1–8). 4. Answer any questions about module A: Introduction. 5. Explain your role as facilitator. 6. Participants briefly describe their districts and their responsibilities as District TB Coordinators. 7. Continue immediately to module B: Faba District. Feedback ------

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----------------

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Notes for each of these numbered procedures are given on the following pages.

A-1

Introduction of yourself and participants Introduce yourself as a facilitator of this course and write your name on the blackboard or flipchart. As the participants introduce themselves, ask them to write their names on the blackboard or flipchart. (If possible, also have them write their names on large name cards at their places.) Leave the list of names where everyone can see it. This will help you and the participants learn each other’s names.

Administrative tasks There may be some administrative tasks or announcements that you should address. For example, you may need to explain the arrangements that have been made for lunches, transportation of participants, or payment of per diem. Request that participants turn off mobile phones while the group is meeting. Distribute the course schedule and point out when your group will be doing a field exercise on how to conduct a supervisory visit to a health facility.

Introduction of module Distribute module A: Introduction. Explain that the module briefly describes the importance of tuberculosis as a public health problem. The module also describes the course methods and learning objectives. Explain that this module, like all the modules that the participants will be given, is theirs to keep. As they read, participants can highlight important points or write notes on the pages if they wish. Point out the annex that begins on page 9. This annex includes forms that are commonly used at the health facility level. They are presented here for reference but are not taught in this course. How to complete these forms is taught in the course Management of Tuberculosis: Training for Health Facility Staff (WHO/CDS/TB/2003.314). Also point out the glossary that begins on page 15. Participants should look in the glossary when they encounter an unfamiliar term. Point out the list of references at the end of the module. This list includes all documents referred to in the course, as well as some useful web sites. Ask the participants to read pages 1–8 in module A: Introduction now. They do not need to read the annex, glossary, or list of references.

Answering questions When everyone has finished reading, ask if there are any questions about the module or the purpose of the course. Answer any questions. A-2

Reinforce that the course is focused on management of TB at the district level. Although details of procedures may vary in some districts, the skills and information taught in the course should be applicable in most districts. 5. Explanation of your role as facilitator Explain to participants that, as facilitator (and along with your co-facilitator, if you have one), your role throughout this course will be to: • • • • • • guide them through the course activities answer questions as they arise or find the answer if you do not know clarify information they find confusing give individual feedback on exercises where indicated lead group discussions lead a field exercise at a health facility.

Participants’ responsibilities in their districts Explain to participants that you would like to learn more about their districts and their responsibilities as District TB Coordinators. This will help you understand their situations and be a better facilitator for them. For now, you will ask participants to briefly describe their districts and their jobs. During the course you will further discuss what they do in their districts. Begin with the first participant listed on the flipchart and ask the questions below. Note the answers on the flipchart. • • • • What is the name of the district where you work, and where is it? What is the approximate population of the district? How many public health facilities are in the district? What are your main responsibilities as District TB Coordinator?

Note: Have the participant remain seated. You should ask the questions and have the participant answer you, as in a conversation. It is very important at this point that the participants feel relaxed and not intimidated or put on the spot. (Though it may be interesting to ask more questions, do not do that now. This should not be a long discussion.) 7. Continuing to the next module Proceed directly to module B: Faba District.

A-3

Facilitator Guidelines for B: Faba District Procedures 1. Distribute and introduce module B: Faba District and the map of the district. Feedback ------

2. Participants read the module (pages 1–6). 3. Introduce the District Plan of Action for TB Control (District TB Plan). 4. Continue to module C: Conduct Supervisory Visits for TB Control.

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Notes for each of these numbered procedures are given on the following pages.

B-1

Introduction of the module and map of Faba District Note: It will be helpful to have an overhead transparency of the map of Faba District when you introduce this module. You may prepare an overhead from the map at the beginning of the module or from Overhead H, included in the white pages at the end of this Facilitator Guide. Distribute module B: Faba District. Use an overhead projector to show the map of Faba District. Point out that the same map is at the beginning of module B: Faba District. Explain that this district will be used in many of the examples and exercises throughout the training course. Participants will become very familiar with Faba District and will also encounter some of the neighbouring districts. Faba District may be similar to or very different from the participants’ own districts. The basic principles and procedures taught in the course apply to all districts, whether or not they resemble Faba District. Using the overhead, point out the population of the district, the capital (Agraville), and the paved and dirt roads. Point out the public health facilities (hospitals, health centres, and health posts) currently providing TB control services. These are indicated by shaded boxes or circles. Two private clinics in Agraville are indicated by triangles. Point out the table below the map that indicates services provided, outpatient load, and TB cases in 2003. Keep your explanation brief and introductory; participants will refer to the map themselves many times during the course. Explain that, for the purposes of the training course, the present year in Faba District is 2004. The past includes the year 2003 and earlier. By the end of the course, participants will help to plan for the future (2005) in Faba District.

Reading in the module Ask the participants to read pages 1–6 in module B: Faba District now and stop reading at the stop sign. They should just enjoy the “story” and not worry about remembering everything. When Faba District is used in exercises or examples in the course, a review of the relevant information, or additional information, will be given as needed.

Introduction of the District TB Plan Explain that pages 7–10 show a District Plan of Action for TB Control (District TB Plan) for the year 2004 in Faba District. The fold-out pages at the end of the module show a Planning Chart that goes with the plan. Ask participants to look at page 7 and notice that the plan was prepared in October 2003 by the District TB Coordinator, Dr Oke Karimi. It is an important part of the District TB Coordinator’s job to develop such a plan each year (usually in October or November) for the coming year. This type of plan may be called by a different name in participants’ own districts, but their plans should include similar elements.

B-2

Tell participants that they do not need to read the plan carefully now, but that they may wish to study it more closely later as they find time. They will learn how to develop a District TB Plan in module I: Develop the District Plan of Action for TB Control. For now, simply point out the basic elements of the plan (e.g. background information, targets, activities in various categories, who will do each activity, when it should be accomplished, and resources available and needed). Explain the fold-out pages are a Planning Chart on which the activities from the plan are displayed month by month throughout the year. Bold dots on the Planning Chart show activities that can be accomplished in a day; lines show activities requiring a period of days or weeks. The dots and lines show approximately when the activities will occur; more specific deadlines may be shown in the plan itself (pages 7–10, in the “When” column). Give one example to illustrate: • Ask participants to look at activity A3 under “drugs and supplies” on page 8. This activity says that the District TB Coordinator will order anti-TB drugs for the district during the first week of each quarter. The ticks show that resources are available for this activity. Ask participants to look at the Planning Chart, page 11, activity A3. The dots for this activity show that it will occur during the first week of each quarter (i.e. in January, April, July, and October).

•

Again, there is no need to read the plan carefully now, but participants may study it later as they find time. 4. Continuing to the next module Proceed directly to module C: Conduct Supervisory Visits for TB Control.

B-3

Facilitator Guidelines for C: Conduct Supervisory Visits for TB Control Procedures 1. Distribute module C: Conduct Supervisory Visits for TB Control. Introduce the module. Show and explain the pictures and instructions that will guide participants through all the modules. 2. Participants read pages 1–5 of the module. When they reach the stop sign on page 6, they turn to page 38 and write answers to the questions in Exercise A as preparation for the group discussion. 3. Lead the group discussion for Exercise A. 4. Participants go back to page 6 and read until the stop sign on page 15. Participants do Exercise B on page 41 as individual work. 5. Participants go back to page 15 and read until the stop sign on page 25. Participants do Exercise C on page 57 as individual work. 6. Participants go back to page 26 and read until the stop sign on page 30. Participants do Exercise D on page 59. 7. Participants go back to page 30. They read section 8 and the summary of important points (page 32). Explain to the group what is at the end of each module: summary of important points and self-assessment questions. Explain the purpose of the self-assessment questions and how to do them. Participants do the self-assessment questions on pages 33–34 and compare their own answers with those on page 35. 8. Conclude the module. -----

Feedback -----

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Group discussion Individual feedback

Individual feedback

Self-checked -----

C-1

Introducing the module Explain that this module describes how to conduct supervisory visits to health facilities that do TB case detection and treatment. Review the list of objectives on page 2 of the module. Show and explain the pictures and instructions that will guide participants through all the modules. They will read in the module; turn to the back of the module to do an exercise, receive feedback on their work; and then go back and continue reading in the module. • When participants reach a stop sign, they should stop and follow the instructions. The instructions are usually to turn to a specified page and do the exercise. (Show page 6 as an example.) All exercises are in the back of the module.

STOP

•

Every exercise asks participants to work on their own (indicated by the picture of a pencil at the top of the page). This means that each participant should work through the exercise by his or herself and write the answers in his or her own module. However, if a participant has a question about what to do, or about the module text, the participant should ask a facilitator for help without delay. After each exercise, participants receive feedback on their work. Feedback may be given in a group discussion or in individual feedback. Explain: −

•

Where this picture appears at the top of an exercise, a facilitator will lead a group discussion after all participants have finished the written part of the exercise. (Ask participants to see the example on page 38 of the module.) In the discussion, participants can review their answers and benefit from hearing the thoughts of others.

−

Otherwise, feedback is given individually. This is true for most exercises in the course. When each participant has finished the exercise, he or she will review the answers with a facilitator. This private discussion is called individual feedback. In this discussion, the participant and the facilitator will review the participant’s work and compare it with the answer sheet. This is an opportunity to talk with the facilitator one-on-one and ask any questions. If a participant has made errors, the facilitator will help clarify any misunderstanding. The purpose is to help each participant learn.

•

At the end of each exercise, there is a go back arrow with instructions to turn back (to a certain page) to begin reading again in the module where they left off. (Show example on page 40.) Participants should follow the instructions and then continue reading until the next stop sign. C-2

Ask participants to begin reading in the module, beginning at page 1 and reading until they reach the first stop sign (on page 6). They should follow the instructions given in the box at the stop sign. 2. When participants are reading This reading assignment (pages 1–5) or later reading assignments may be difficult for some who are not accustomed to extended reading. Observe whether any participants are struggling. If a participant is visibly struggling, go to that individual and ask (quietly) whether the participant has a question or needs help. You may need to explain a form or the instructions for an exercise. Find out the problem and try to address it. Leaving a participant to struggle is likely to result in frustration and loss of motivation. 3. Exercise A: Written Exercise and Discussion – Assessing a schedule for supervisory visits Individual work on written exercise

Watch as participants begin working on this first individual exercise. Be sure that they know what to do, have a pencil, etc. Some participants need a bit of encouragement to begin writing in the module book. Give participants time to think about and write answers to the questions before the discussion begins. Discussion

Ask for a volunteer to tell the group the answer to question 1. If you do not agree with the answer given by the participant, ask another participant to suggest an answer. Then ask for different volunteers or ask specific participants to provide answers to each of the rest of the questions, so that all participants contribute to the discussion. You should accept a variety of answers to questions 4, 5, and 6, as long as the participants’ answers are reasonable. Emphasize the point that the schedule should allow the District TB Coordinator to visit for a reasonable period of time, not just to make a quick appearance and register the new patients. Give each participant a copy of the answer sheet to keep. When the discussion is finished, ask participants to go back to page 6 and read until the next stop sign (page 15). Explain that, at that point, they should turn to page 41 and do Exercise B as individual work. When they complete Exercise B, they should let a facilitator know they are ready for individual feedback. (Depending on the room arrangement, they might raise their hand for a facilitator to come to them, or may come to the facilitator.)

C-3

C: Conduct Supervisory Visits for TB Control

Possible Answers to Exercise A 1. 2. Five facilities are currently providing TB control services: Agraville Hospital, Bella Health Centre, Denali Health Post, Gadara Health Post, and High Road Health Post. Yes, the District TB Coordinator can easily travel to these facilities. There are paved roads to all of them, and the distances are not too great (the facility that is farthest from the District office in Agraville is High Road Health Post, and it is about 46 km away). Monthly visits are recommended. The schedule seems feasible. The District TB Coordinator may have a problem adhering to the schedule if: • • • • • 6. the DMO needs to use the car on the days scheduled for the visits, or the DMO cannot give up the car two days in a row, or there is no money for fuel for the car, or one of the supervision days falls on a holiday when health facilities are closed, or he is ill or has an accident.

3. 4. 5.

The District TB Coordinator could inform the DMO of the dates planned for supervisory visits to health facilities to oversee TB control services, so that the DMO can schedule accordingly. The District TB Coordinator could also calculate the cost of fuel each month and make arrangements so that there will be adequate funds available. Other approaches could be for the District TB Coordinator to: • • • • • • • • get a motorcycle for making visits to health facilities, borrow a car or motorcycle from someone else in the district office, combine trips to some towns with the DMO or staff from other programmes, or hire a car if funds are available.

C-4

Exercise B: Written exercise with individual feedback – Updating the District TB Register Watch as participants begin working on this complex exercise. Be sure that they are not confused about what to do. Be sure they fold out pages 53–55 to write on as they read the exercise. Some participants may need a bit of explanation or encouragement to begin the exercise; if necessary, talk a puzzled or hesitant participant through a few steps of reviewing the first TB Treatment Card, Mary Otmani, F-17. When you see a participant has finished the exercise, go to him or her, or ask the participant to come to you. If individual feedback is a new method to the participants, most are likely to wait to see whether and how individual feedback happens. Some may decide they would rather not get individual feedback and may not come for feedback unless you prompt them. Be sure that every participant gets feedback on this exercise. Make sure that this first experience with getting individual feedback is a positive one. Look at each participant’s work carefully. Ask if the participant has questions, and listen attentively to the questions. Answer carefully. Participants will assess whether you are really interested in giving them help and whether feedback is likely to be embarrassing or uncomfortable. It is essential that you build each participant’s confidence that interactions with a facilitator will be helpful or pleasant. When interactions are positive and participants feel that the facilitators are interested in their work, they are more motivated to do the work well. When a participant comes to you for feedback, sit down with him or her and look at the entries that the participant has written in the District TB Register (pages 53–55). Compare the participant’s entries with the answer sheet. If the participant has made errors or omissions, do not simply correct them. Instead, first ask the participant to turn to the relevant TB Treatment Card and look again for anything that should be added to the District TB Register. If the participant has questions, answer them. Try to find out the reason for any misunderstandings and clarify. The purpose of the interaction is to give feedback on what the participant did correctly and to correct any misunderstandings. At the end of the interaction, you should feel that the participant is able to do the task correctly. Give the participant a copy of the answer sheets for this exercise to keep. Thank or congratulate the participant for his or her work. Then ask the participant to go back to page 15 and read until the stop sign on page 25.

C-5

C: Conduct Supervisory Visits for TB Control

Answers to Exercise B These are the entries that should be made in the District TB Register: F-17, Mary Otmani: Enter the 6th month results into the District TB Register under “End of treatment” (30-7-04 // neg // 1399). Also, notice that this patient completed the treatment, that is, 48 doses of continuation-phase treatment. The health worker has marked the treatment outcome on the card, Cure, and dated it 4-8-04. This is correct, since the patient had a negative sputum result in the last month of treatment and on at least one previous occasion. On the District TB Register, the date 4-8-04 should be written in the column for “Cure.” F-63, J.D. Lo: Enter the 4th month results in the District TB Register (2-8-04// neg // 1213). F-64, Rafael Lazare: Enter the 5th month results in the District TB Register (19-8-04 // + // 1530). Because this patient is still positive at the end of 5 months of treatment, his treatment outcome is “Treatment failure.” This treatment outcome should be marked on the card and in the District TB Register. The patient should be informed of the situation and start on Category II treatment at the next visit. A new TB Treatment Card should be opened for the re-treatment. He may be re-registered now or at the next supervisory visit, noting the former District TB number, F-64, under “Remarks” and also on the new TB Treatment Card under “Observations.” The smear examination result to record under “Before treatment” is the one dated 19-8-04. F-84, Eva Peterson: No entry is added in the District TB Register today. F-85, Tara Fleming: No entry is added today. F-127, Felicity Kala: Enter under “Remarks” that the patient has disappeared; last seen on 6 July. No contact person was provided on the card. If the patient does not appear in the next month, she will be a defaulter. For F-150, Olga Goizuetta: No entry is added in the District TB Register. Add two new patients to the District TB Register, including assigning each a District TB number and copying all the information from the card into the register: • • F-172 Alberto Flores F-173 Zoila Aila (Note that treatment has been irregular from the start: 3 doses were missed out of 8. Try to find out why, solve a problem if possible, and motivate the patient. Also obtain the name and address of a contact person to write on the back of the card.)

You should also have written the District TB number on each new patient’s TB Treatment Card (on pages 49 and 50).

C-6

C: Conduct Supervisory Visits for TB Control Answers to Exercise B, continued

Answers to questions on page 51 of module: 3a) Yes, F-150, Olga Goizuetta, is due for a 2-month sputum examination in the next couple of weeks. 3b) Yes, F-64, Rafael Lazare is a treatment failure, as he was still positive at the end of 5 months of treatment. Action should be taken immediately (see below). 3c) The TB Coordinator should consider Rafael Lazare a treatment failure and talk to the health staff about starting this patient on Category II treatment at his next visit. This treatment outcome should be marked on the card and in the District TB Register. A patient who is a treatment failure should be re-registered and given a new District TB number. Record the former District TB number under “Remarks.” (If you wrote this patient on the last page of the register, giving him the District TB number F-172 or F-174, this is correct.) “Date treatment started” should be left blank in the register until the Category II treatment is actually started. The sputum examination result to record under ”Before treatment” is the one from 19-8-04. The health facility should open a new TB Treatment Card; type of patient will be Treatment after failure; note the former District TB number, F-64, on the card under “Observations.”

C-7

Exercise C: Written exercise with individual feedback – Identifying causes of performance problems Review the participant’s answers. If the participant’s answers do not seem reasonable and you think the participant has not understood the process of analysing performance problems, turn to page 25 of the module. Review Figure 3: Analysing a performance problem with the participant, asking the participant the questions about different causes and discussing answers, to help the participant re-analyse Situation A. This can be an important teaching session if done correctly. When you think the participant understands how to analyse a performance problem, ask the participant to work individually on Situation B again and then return to you to review the answers. Give the participant a copy of the answer sheet to keep. Congratulate the participant on his or her work. Then ask the participant to go back to page 26 and read until the stop sign on page 30.

C-8

Exercise D: Written exercise with individual feedback – Identifying training needs Review the participant’s entries on the fold-out chart on page 61. If the entries are significantly different from those on the answer sheet, determine why. Some errors may be made because a participant did not understand that entries should be made at two different visits, on 18 December 2003 and 10 June 2004. The specific words written on the chart do not matter as much as whether the participant understands how to use the chart: • to track staff responsible for TB case detection and control at the health facility, for example, add new staff, write the date of the visit, and record an X for staff who leave; and to keep track of training needs, for example by writing the date of the visit and C (competent, no training needed) or NT (needs training) for each staff; and when any person is trained, writing RT (received training) and the date of the training.

•

Discuss the chart with the participant in sufficient detail so that you believe the participant could use the chart to keep track of training needs of staff in an actual health facility. Give the participant a copy of the answer sheet to keep. Then ask the participant to go back to page 30, read section 8, and work until the end of the module (page 36). This will include writing answers to the self-assessment questions and checking the answers.

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C: Conduct Supervisory Visits for TB Control Possible answers to Exercise D

Training Needs for TB Control Health facility: Bella Health Centre Responsibilities for TB case detection and treatment Date of visit or traininga Enter C (competent), NT (needs training), RT (received training), or X (no longer on staff). Enter comments on the right.

Health worker

Mary Lang

TB case detection, treatment of TB patients, record keepings, drug supplies

18/12/03 Feb 2004 10/6/04

NT RT C

Send to Management of TB course, Feb 2004 Attended Management of TB course

AJ Perera

Treats TB patients when busy and on Saturday

18/12/03 10/6/04

NT X

Send to Management of TB course, July 2004 Transferred to Patanga District

Samia Shiva

Treats TB patients when filling in for Mary Lang

10/6/04

Send to Management of TB course, July 2004

Update on a supervisory visit every 6 months or whenever there are changes in staff who perform TB case detection and treatment. Also update when staff receive training.

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Explanation of self-assessment questions When you have finished giving all participants feedback on Exercise D and they are finishing the reading (pages 29–32), get the group’s attention and explain the purpose of the self-assessment questions and how to do them. A possible explanation is written below. (The self-assessment questions for this module and their answers are on pages 33–35.) Every instructional module has self-assessment questions at the end. “The self-assessment questions address the important tasks taught in the module. Selfassessment questions are a review to help each of you assess for yourself what you have learned and what you have missed or forgotten. They are not a test in the usual sense, because you do not turn them in or receive a grade. Instead, you check your own answers against those in the module. After each answer you will find (in parentheses) the section of the module where that information or step was taught. “If you answer all the self-assessment questions correctly, you can feel satisfied and proud that you have learned the important points that the module taught. If you miss a question, this tells you what you need to study again. Look back to the specified section of the module and reread it. “When you answer the self-assessment questions, work carefully. Do not look ahead at the answers because this will reduce the effectiveness of the review. Also, if you look ahead at the answers, you will not know what you have learned and what you need to study further.”

Concluding the module Note: Allow participants enough time to complete the self-assessment questions at the end of each module. The self-assessment questions at the end of some modules are quicker to complete; some take more time. Observe the participants’ progress, and allow enough time for all or almost all participants to finish. Avoid the temptation to rush at the end of the module. The self-assessment questions are a helpful summary and review, but they can only be effective if participants have time to complete them thoughtfully. Ask the participants how they did on the self-assessment questions. If there are any questions about the answers, or other questions about the module, discuss them. Reinforce that this module has described very important functions of a District TB Coordinator making a visit to a health facility: • Maintaining the District TB Register • Noticing if TB patients are converting by the end of the initial phase of treatment • Reviewing the Register of TB Suspects and how suspects are identified and cases are detected • Assessing performance of health workers doing TB case detection and treatment (Checklist for Supervisory Visits to Health Facilities), as well as drug supplies and the environment • Motivating staff responsible for TB case detection and treatment C-13

• Identifying training needs of these staff (Training Needs for TB Control) Make any additional points from this module that you want to reinforce with these participants. Thank the participants for participating in the group discussion and in individual feedback, a method which may not be familiar to them. Congratulate them on completing this module.

C-14

Facilitator Guidelines for D: Provide Training for TB Control

Procedures 1. Distribute module D: Provide Training for TB Control. Introduce the module. 2. Participants read pages 1–11 of the module and then do Exercise A, pages 22–23. 3. Participants read pages 12–14 of the module and then do Exercise B, pages 24–25. 4. Participants read the summary of important points (page 15) and then do the self-assessment questions. Participants check their own answers against those provided in the module. 5. Conclude the module.

Feedback -----

Group discussion

Self-checked

-----

D-1

Introducing the module Emphasize the main points from the Introduction on page 1 of the module: • • • It is the District TB Coordinator’s responsibility to ensure that health facility staff who provide TB control services are properly trained. The District TB Coordinator may not always train staff, but should be able to recognize good training and arrange appropriate training experiences for staff. Training can be provided in many formats, but it should always include certain basic elements, such as information, examples, and active practice of tasks to be done on the job. The need for training in a district never goes away. After initial training, there is a continuing need to maintain the skills and knowledge of staff.

•

Explain that module D will help participants learn to recognize good training and arrange or conduct appropriate training for staff. Have available a copy of the course Management of Tuberculosis: Training for Health Facility Staff. Tell participants that they may want to refer to this course for health facility staff as they read and work on module D. Ask participants to read the module to page 12 and then do Exercise A individually. After the individual written work, there will be a group discussion. 2. Exercise A: Written exercise followed by group discussion – Planning on-the-job training Be sure that every participant does the written exercise to prepare for the discussion. Use a flipchart or blackboard to record the group’s ideas during the discussion. On one page, write the heading Information; on the next, Examples; and on the next, Practice. First, briefly review the situation: The District TB Coordinator, Dr Oke Karimi, has decided to provide on-the-job training to Nurse Fonki in how to use the Register of TB Suspects. Since he has decided in advance of the supervisory visit, he has the opportunity to plan how to provide the on-the-job training. (Explain that, in some situations, such as immediately solving a problem detected during a visit, there may be no time to make a written training plan, but one should still follow the pattern of providing information, examples, and practice.) Ask participants how they might provide information to Nurse Fonki about how to use the Register of TB Suspects. Use the answer sheet as a guide during the discussion, but recognize that participants may have other good ideas, and focus on their ideas first. If they do not eventually mention the answers given on the answer sheet, then you may mention them yourself. Focus on the essential information to complete the Register of TB Suspects.

D-2

During the discussion, stress that on-the-job training must be simple to implement and suitable for one person or a small group. A lecture or long reading in a textbook would not be appropriate for providing information during on-the-job training. A short oral explanation or a one-page written job aid would be more suitable in this setting. Next, ask participants how they would provide examples to Nurse Fonki. Again, focus on participants’ ideas, and then add any ideas from the answer sheet that they have not mentioned. Discuss the practicality of the ideas in the on-the-job setting. For example, in order to demonstrate making an initial entry in the Register of TB Suspects for a real person, it would be necessary to have a group of adults who can be asked about cough; in addition, at least one of them must have been coughing for 2 weeks or more. This real situation may not always occur during a supervisory visit, so one must be ready to simulate the experience, perhaps by making up a story. Also discuss preparation that might be needed to implement certain ideas. For example, the District TB Coordinator should prepare and bring an example of a correctly completed page from a Register of TB Suspects. Next, ask participants how they would provide practice for Nurse Fonki. Again, focus on participants’ ideas, and then add any ideas from the answer sheet that they have not mentioned. Discuss the practicality of each idea and the preparation that would be needed. For example, if one is going to describe case studies, it is helpful to make them up in advance to make sure that you cover important situations. Stress that practice is the most important part of training because it allows the trainer to see if the learner can actually perform a task. Practice should always be followed by feedback and, if needed, the opportunity to try again. After the group discussion, give participants a copy of the answer sheet. Ask participants to go back to page 12 of the module and continue reading until the next stop sign.

D-3

D: Provide Training for TB Control

Possible Answers to Exercise A On-the-job training to use the Register of TB Suspects To provide: Use the following training methods: Explain what the Register of TB Suspects is. Explain the purpose of the register and why it is useful. Explain when to use the Register of TB Suspects. Explain who is considered a suspect. Explain how to complete each column. Show a correctly completed page from a Register of TB Suspects. Examples Demonstrate asking questions about cough and recording a suspect in the register Show several Requests for Sputum Examination with results recorded; demonstrate how these results would be recorded in the register. Make up several stories of TB suspects. As you tell each story of how the suspect is asked about cough, when sputum samples are sent, what results are received, etc., have the health worker complete a row of the Register of TB Suspects. Practice Play the role of a coughing patient, and have the health worker ask you about cough and record in the Register of TB Suspects. Show several Requests for Sputum Examination with results recorded; have the health worker record these results in the register. Discuss how to interpret the results.

Information

D-4

Exercise B: Written exercise followed by group discussion – Solving problems due to lack of skill or knowledge Be sure that every participant does the written exercise to prepare for the discussion. Begin the discussion by stressing that both situations A and B involve a lack of skill or knowledge, so a training solution is appropriate. Situation A First, briefly review the situation (or ask a participant to describe it): The District TB Coordinator, Dr Elisabeth Amilami, has found that health facilities in her district send only two sputum samples for diagnosis and only one for follow-up because “this is the way it has always been done.” Use the questions given in the exercise to structure the discussion. Record ideas on the flipchart or blackboard. Discuss whether ideas are cost-effective for the situation. For example, since this is a very explicitly defined problem affecting many health workers throughout the district, it would not be cost-effective to send them all to a 5day training course in order to solve this problem. This training can be accomplished in a short time during a meeting or during supervisory visits. Use the answer sheet as a guide during the discussion, but recognize that participants may have other good ideas, and focus on their ideas first. If they do not eventually mention the answers given on the answer sheet, then you may mention them yourself. Discuss the practicality of each idea, given the situation, and any preparation needed. Situation B Briefly review the situation (or ask a participant to describe it): There has been a change in the national guidelines for managing TB. Health workers throughout the district need to know about the new drug regimen for the continuation phase, the implications for directly observed treatment, the treatment schedule, etc. Again, use the questions given in the exercise to structure the discussion. Record ideas on the flipchart or blackboard. Discuss whether ideas are cost-effective for the situation. For example, since all health workers responsible for management of TB cases need the training, it might be more efficient to have one large training session in a central location, rather than repeat a small training session at every health facility. Participants may have different ideas about what would be most efficient in their own districts, and that is fine. Use the answer sheet as a guide during the discussion, but recognize that participants may have other good ideas, and focus on their ideas first. If they do not eventually mention the answers given on the answer sheet, then you may mention them yourself. Discuss the practicality of each idea and any preparation needed. Stress the need for follow-up after training. After the group discussion, give participants a copy of the answer sheet for Exercise B. Ask participants to read the summary of important points (page 15), do the self-assessment questions, and check their own answers. D-5

D: Provide Training for TB Control

Possible Answers to Exercise B Situation A 1. 2. Health workers lack knowledge of what is expected of them. They have not been told how many sputum samples to send. Health workers at all health facilities throughout the district seem to lack this knowledge. Microscopists may also lack the knowedge of how many sputum samples are required. The District TB Coordinator could provide a brief training session for the health workers responsible for TB case detection and management and representatives from the TB microscopy units. A group training session could be held at a regular district meeting. Alternatively, the District TB Coordinator could inform health workers and microscopists individually during supervisory visits. The training should include the following key information, examples, and practice: Information – Explain the number of samples needed for diagnosis and follow-up, and the reasons why they are needed. Distribute the national guidelines regarding the number of samples to be sent and explain them. Examples – Show samples of the Request for Sputum Examination form, correctly completed with results for three samples for diagnosis and two for follow-up. Practice – Discuss any problems that may interfere with sending and testing more samples, and how to solve these problems. Describe several cases requiring diagnosis or follow-up, and ask questions to ensure that everyone understands the number of samples required. Note: It will be important to follow up during supervisory visits after the training to ensure that health workers are sending the correct number of samples.

Situation B 1. Health workers lack knowledge of the new national guidelines (the new drug regimen and how it affects the treatment schedule). They lack knowledge of what old practices to stop, what new practices to begin, and when the changes will take effect. All health workers responsible for management of TB cases in the district lack this knowledge. A training session (perhaps one day or a half day) would be appropriate for all health workers responsible for management of TB cases in the district.

2. 3.

D-6

D: Provide Training for TB Control Answers to Exercise B, continued

The training should be held at a central location in the district.

Note: If there are many health facilities, or if they are widely spread, more than one training session, held in different locations, may be required. 5. The training should include the following key information, examples, and practice: Information – Explain and give a written summary of the new Category I regimen for the continuation phase. Explain reasons for the change and implications of the change (e.g. treatment must be directly observed 3 times a week for 4 months). Explain the importance of directly observing treatment with rifampicin (to be alert for side-effects). Provide written changes in the national guidelines to be posted in every health facility. Describe when the new guidelines will take effect and what to do about patients who are already in the continuation phase of treatment at that point. Examples – Show the new drugs and packaging and a drug kit including the new regimen. Show a sample TB Treatment Card for a patient who has completed the new regimen. Practice – Given a case study, health workers practice completing TB Treatment Cards for a patient on the new regimen. Role play explaining to a patient the need to come 3 times a week for directly observed treatment. Note: It is very important to follow-up after this training. Besides training, the District TB Coordinator will need to order and distribute the new drugs. Careful supervision will be needed during the first months of implementation of the new guidelines.

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4. 5.

Self-assessment questions (self-checked) Concluding the module Ask the group how they did on the self-assessment questions. If there are any questions about the answers, or any other questions about the module, discuss them. Make any important points that you want to reinforce with the participants.

D-8

Facilitator Guidelines for E: Manage Drugs and Supplies for TB Control Procedures 1. Prepare to conduct module E: Manage Drugs and Supplies for TB Control. 2. Distribute module E: Manage Drugs and Supplies for TB Control. Introduce the module. 3. Participants read pages 1–12. When they reach the stop sign on page 12, participants turn to page 32. Participants do Exercise A as individual work. 4. Participants go back to page 12, section 1.3, and read until the stop sign on page 18. Participants do Exercise B on page 35 as individual work. 5. Participants go back to page 18, section 4, to continue reading. They work to the end of the module (page 29), including doing the self-assessment questions. 6. Conclude the module.

Feedback ---------

Individual feedback

Self-checked -----

If participants will use annexes on ordering and distributing separate tablets Alternative procedures Feedback 3. Participants read from page 1 up to the box on page 3. They turn to Annex C, page 42, and continue reading to the stop sign on page 49. Participants do Alternative Exercise A on page 50 as individual work. 4. Participants go back to page 12, section 1.3, and continue reading to the box on page 18. They turn to Annex D, page 54. They read to the stop sign on page 56 and then do Alternative Exercise B on page 57. 5. Participants go back to page 18, section 4, to continue reading. They work to the end of the module (page 29), including doing the self-assessment questions. 6. Conclude the module. Individual feedback (see page E-9 of these guidelines) Individual feedback (see page E-12 of these guidelines)

Self-checked -----

E-1

Prepare to conduct the module How this module is set up

There are two main ways that District TB Coordinators may manage supplies of antiTB drugs. They may count, order and distribute anti-TB drugs as either: • • kits (standard regimens pre-packaged as a complete treatment for one patient) or quantities of separate anti-TB drugs.

This module is written primarily for a District TB Coordinator who manages supplies of anti-TB drugs in kits. The module also includes annexes that provide alternative text, worksheets and exercises for District TB Coordinators who must manage anti-TB drugs as quantities of separate tablets of oral anti-TB drugs, instead of ordering pre-packaged kits. At two specific places in the module, participants are directed to either continue reading the module, or to turn to an annex that presents the alternative version of the text and an exercise. For example, the box below appears on page 3:

→ If you will order anti-TB drugs in pre-packaged kits, continue reading below. → If you will order quantities of separate tablets of oral anti-TB drugs, turn to Annex C, page 42, and read the alternative version of sections 1.1 and 1.2. Then complete Alternative Exercise A.

The alternative text assumes that the country will use fixed-dose combination tablets (FDCs), which are recommended by WHO. If FDCs are not available, District TB Coordinators can use the same procedures to calculate quantities of each of the different tablets required, but will need to adapt the worksheet to include calculations for each of the different drugs and strengths of tablets.1 Determine how you will conduct the module

Find out by asking the course director or the participants in your group (before the day you will do this module) how they receive anti-TB drugs, that is, whether they receive them as pre-packaged kits or as separate tablets. Based on their answer, plan how you will conduct the module. You must have clear in your mind what pages 1

E-2

participants will do and what pages they will skip, so that you can prevent or remedy any confusion. If participants will manage anti-TB drugs in kits, they will: • read pages 1–29 and do Exercises A and B on pages 32–36 when directed, as in any other module. They will not have any need to read Annexes C, D, or E (pages 42–62). If participants will manage supplies of anti-TB drugs as separate tablets, they will: • read pages 1–3 down to the box. • turn to Annex C, page 42, read the alternative version of sections 1.1 and 1.2, and complete Alternative Exercise A (also located in Annex C). • turn back to page 12, section 1.3, and read to the box on page 18. • turn to Annex D, page 54, read the alternative version of sections 3.1–3.3, and complete Alternative Exercise B (located in Annex D). • turn back to page 18, section 4, and read through the end of the module on page 29. (Note: They will not read pages that apply to ordering and distributing kits, bottom of page 3 – box on page 12, page 16 – box on page 18, and Annex B.) Need for calculators

Participants will need to use calculators to complete the mathematical functions (addition and multiplication) in the worksheets. Find out whether the course director will provide calculators for the participants or whether participants should bring their own. You will need to let participants know in advance if they need to bring calculators. 2. Introduce the module Explain that this module describes how to manage drugs and other supplies for TB control, such as sputum containers, forms, and registers. Usually, managing supplies for microscopy units, such as slides and reagents, is the responsibility of the laboratory supervisor, so those supplies are not covered in this module. Review the list of objectives on page 2. Explain that the module is written for District TB Coordinators who are in one of two situations: • • The District TB Coordinator manages anti-TB drugs in kits, that is, anti-TB drugs are counted, ordered, and distributed in pre-packaged kits. The District TB Coordinator manages supplies of anti-TB drugs as quantities of separate tablets of oral anti-TB drugs, instead of pre-packaged kits, for example, quantities of (HRZE) tablets, (HR) tablets, and E tablets. These may be loose tablets or blister packs of tablets, FDCs or separate drugs.

E-3

The participants will read the text and do the exercises that apply only to their situation. Then, based on what you know about the participants’ situation, explain which path they will take through the module. Ask participants to begin reading in the module, beginning at page 1, following the instructions in the box on page 3 to either continue reading below or to turn to Annex C on page 42, and reading until they reach the first stop sign. They should follow the instructions given in the box at the stop sign. 3. Exercise A: Written exercise with individual feedback – Calculating quantities of anti-TB drugs to order for the district When a participant comes to you for feedback, sit down with the participant and look first at the tally sheet completed in the exercise (page 33). Compare it with the answer sheet. (If the participant has different totals, determine why. There may be simple errors in addition, or the participant may have used the wrong quarter in the District TB Register. If necessary, have the participant find the 2nd quarter 2004 in module K and redo the tally sheet. Ask the participant to correct the tally sheet and then redo the Ordering Worksheet on page 34, using the correct numbers.) Then check the Ordering Worksheet by comparing it with the answer sheet and asking the participant about the steps in the worksheet to determine whether the participant understands the steps performed. If the participant has questions, answer them. Try to find out the reason for any misunderstandings and clarify. At the end of the interaction, you should feel that the participant is able to use the worksheet correctly. Give the participant a copy of the answer sheet for this exercise to keep. Thank or congratulate the participant for his or her work. Then ask the participant to go back to page 12 and read to the stop sign on page 18.

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E: Manage Drugs and Supplies for TB Control

Answers to Exercise A 2. Faba District TB cases in 2nd quarter 2004 Health Facility A. Agraville Hospital B. Bella Health Centre D. Denali Health Post G. Gadara Health Post H. High Road Health Post Category I Category II Category III

22 12 3 3 3

3 2

11 4

TOTAL

Ordering Worksheet: Pre-packaged kits of anti-TB drugs to order to treat adult patients in the district during one quarter Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 58 patients 5 patients

Instructions: Complete one worksheet for the district.

• • •

Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients 58 5 B Multiply by 2 for reserve stock Ax2=B 116 10 C Estimated stock on last day of previous quarter 50 6 D Number to order after subtracting current stocks B–C=D 66 kits 4 kits

Kit (or drug) and category of patient who a needs it Category I and III kits Category II kits

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. If injection supplies are not provided in the Category II kit, add injection supplies to the order.

E-5

Exercise B: Written exercise with individual feedback – Calculating quantities of anti-TB drugs to distribute to each health facility for the quarter Review the participant’s worksheet on page 36. Make sure that the participant has done this calculation for one facility only, the Agraville Hospital, and not for the entire district, as in the Ordering Worksheet in Exercise A. If the participant has used the numbers of cases in the entire district, instead of just cases in Agraville Hospital, ask the participant to redo the Distribution Worksheet to calculate quantities to send to Agraville Hospital. Point out that this worksheet would be completed once for each health facility to be supplied with anti-TB drugs. Give the participant a copy of the answer sheet to keep. Congratulate the participant on his or her work. Then ask the participant to go back to page 18 and read and work to the end of the module (page 29). This will include writing answers to the self-assessment questions and checking the answers.

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E: Manage Drugs and Supplies for TB Control

Answers to Exercise B Distribution Worksheet: Kits of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter Agraville Hospital (name of health facility)

Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 :

33 3

patients patients

Instructions: Complete a separate worksheet for each health facility.

• • •

Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients 33 3 B Multiply by 2 for reserve stock Ax2=B 66 6 C Estimated stock on last day of previous quarter 21 5 D Number to distribute after subtracting current stocks B-C=D 45 1

Kit (or drug) and category of patient who needs it Category I and III kits Category II kits

E-7

5. 6.

Self-assessment questions (self-checked) Concluding the module Ask the group about how they did on the self-assessment questions. If there are any questions about the answers, or other questions about the module, discuss them. Point out that there are blank worksheets in Annex B that participants can photocopy and use: • • for ordering anti-TB drug kits for the district, and for calculating numbers of kits to distribute to each health facility in the district.

Make any additional important points from this module that you want to reinforce with these participants. Congratulate the participants on completing this module.

E-8

Alternative facilitator guidelines if participants will use annexes on ordering and distributing separate tablets 3. Alternative Exercise A: Written exercise with individual feedback – Calculating quantities of separate tablets of anti-TB drugs to order for the district Note: On page 50, participants read this paragraph as background information for Exercise A: “In Faba District, anti-TB drugs are provided to health facilities in separate boxes of (HRZE), (HR), and ethambutol, and boxes of vials of streptomycin. The tablets are packaged in blisters of 28 or 12 each. Patient kits are assembled by staff at health facilities for each patient at the time the patient begins treatment.” This paragraph contradicts the information given in module B: Faba District, which says that in Faba District, anti-TB drugs are provided to health facilities in prepackaged kits. If any participant asks about this contradiction, explain that this was changed for purposes of Alternative Exercises A and B, so participants can practice using the worksheets to calculate quantities of separate tablets to order and distribute to health facilities. When a participant comes to you for feedback, sit down with the participant and look first at the tally sheet completed in the exercise (page 51). Compare it with the answer sheet. (If the participant has different totals, determine why. There may be simple errors in addition or it may be that the participant has used the incorrect quarter in the District TB Register. If necessary, have the participant find the 2nd quarter 2004 in module K and redo the tally sheet. Ask the participant to correct the tally sheet and then redo the Ordering Worksheet on page 52, using the correct numbers.) Then check the Ordering Worksheet by comparing it with the answer sheet and asking the participant about the steps in the worksheet to determine whether the participant understands the steps performed. If the participant has questions, answer them. Try to find out the reason for any misunderstandings and clarify. At the end of the interaction, you should feel that the participant would be able to use the worksheet correctly. Give the participant a copy of the answer sheets for this exercise to keep. Thank or congratulate the participant for his or her work. Then ask the participant to go back to page 12, section 1.3, and read to the box on page 18. Then turn to Annex D, page 54, and read. Then do Alternative Exercise B.

E-9

E: Manage Drugs and Supplies for TB Contro

Answers to Alternative Exercise A 2. Faba District TB cases in 2nd quarter 2004 Health Facility A. Agraville Hospital B. Bella Health Centre D. Denali Health Post G. Gadara Health Post H. High Road Health Post Category I Category II Category III

22 12 3 3 3

3 2

11 4

TOTAL

E-10

3. Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter Daily treatment in the initial phase (28 doses per month) and intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 58 5 patients patients

Instructions: Complete one worksheet for the district.

• • •

Drug and category of a patient who needs it

Tablets and vials needed to treat expected patients ( 58 x 168 tablets) + ( _5_ x 252 tablets) = 11 004_ tablets

Combination (HRZE) (Cat I + III) + (Cat II) Combination (HR) (H150 R150 mg) (Cat I + III) + (Cat II)

22 008

9 900

12 108 tablets

( 58_ x 144 tablets) + ( 5 x 180 tablets) = 9 252 tablets 5 x 240 tablets 1 200 tablets 5 = x 56 vials 280 vials

18 504

8 300

10 204 tablets

Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

2 400

1 100

1 300 tablets

560

320

240 vials

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. Supplies for giving streptomycin injections may also be added to the order.

E-11

Alternative Exercise B: Written exercise with individual feedback – Calculating quantities of anti-TB drugs to distribute to each health facility for the quarter Review the participant’s worksheet. Make sure that the participant has done this calculation for one facility only, the Agraville Hospital, and not for the entire district, as was done in the Ordering Worksheet in Exercise A. If the participant has used the numbers of cases in the entire district, instead of just cases in Agraville Hospital, ask the participant to redo the Distribution Worksheet to calculate quantities to distribute to Agraville Hospital. Point out that this worksheet would be completed once for each health facility to be supplied with anti-TB drugs. Give the participant a copy of the answer sheet to keep. Congratulate the participant on his or her work. Then ask the participant to go back to page 18, section 4, and read and work to the end of the module (page 29). This will include writing answers to the self-assessment questions and checking the answers.

E-12

E: Manage Drugs and Supplies for TB Control

Answers to Alternative Exercise B Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter Agraville Hospital (name of health facility)

Daily treatment in the initial phase (28 doses per month) and Intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 33 3 patients patients

Instructions: Complete a separate worksheet for each health facility.

• • •

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A B Multiply by 2 for reserve stock Ax2=B 12 600 C Estimated stock on last day of previous Quarter 4 800 D Amounts to distribute after subtracting current stocks B-C=D

Drug and category of patient who needs it

Tablets and vials needed to treat expected patients ( 33 x 168 tablets) + ( 3 x 252 tablets) = 6 300 tablets

Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

7 800 tablets

( +(

33 x 144 tablets) 3 x 180 tablets) = 5 292 tablets 3 = = x 240 tablets 720 tablets 3 x 56 vials 168 vials

10 584

3 900

6 684 tablets

1 440 336

1 200 275

240 tablets 61 vials

E-13

5. 6. 7.

Participants turn back to page 18 and read to the end of the module Self-assessment questions (self-checked) Concluding the module Ask the group about how they did on the self-assessment questions. If there are any questions about the answers, or other questions about the module, discuss them. Point out that there are blank worksheets in Annex E that participants who manage quantities of separate tablets of anti-TB drugs can photocopy and use: • • for ordering anti-TB drugs for the district, and for calculating quantities to distribute to each health facility in the district.

Make any additional important points from this module that you want to reinforce with these participants. Congratulate the participants on completing this module.

E-14

Facilitator Guidelines for F: Ensure Laboratory Support for TB Control Procedures 1. Distribute module F: Ensure Laboratory Support for TB Control and module L: Tuberculosis Laboratory Register. Introduce the module. 2. Participants read pages 1–4. When they reach the stop sign on page 4, they turn to page 24 and do Exercise A. 3. Participants go back to page 4 and read until the stop sign on page 7. Participants do Exercise B on pages 25–26 as individual work. 4. Participants go back to page 8 and read until the stop sign on page 11. Participants do Exercise C on pages 27–34 as individual work. 5. Participants go back to page 12 and work to the end of the module (page 22) including doing the self-assessment questions. 6. Conclude the module.

Feedback -----

Individual feedback

Self-checked -----

F-1

Introducing the module Explain that this module describes how to ensure laboratory support for TB control services. That means ensuring that all health facilities are able to have sputum samples examined by microscopy for TB case detection (diagnosis) and for monitoring TB treatment (follow-up). Review the list of objectives on page 2 of the module. Mention that participants will use module L: Tuberculosis Laboratory Register in an exercise. Ask participants to read in the module, from page 1 until the first stop sign (on page 4). They should follow the instructions given in the box at the stop sign.

Exercise A: Written Exercise with individual feedback – Assessing access to TB microscopy units Review the participant’s answers and compare them with the answer sheet. If there are significant differences, look at the map of Faba District with the participant. Ask the participant to explain his or her thinking and discuss until you can agree on a reasonable answer. If the participant has questions, answer them. Give the participant a copy of the answer sheet for this exercise to keep. Thank or congratulate the participant for his or her work. Then ask the participant to go back to page 4 and read until the stop sign on page 7.

F-2

F: Ensure Laboratory Support for TB Control

Answers to Exercise A 1. 2. Sputum smear microscopy is performed at the TB microscopy unit at Agraville Hospital. Factors to consider: • Distance from the health facility to the TB microscopy unit. • Transportation of sputum samples to the TB microscopy unit must be regular and reliable. • Transportation of results to the health facility must be regular and reliable. The approximate distance of each health facility that provides TB services from the microscopy unit at Agraville Hospital is: Bella Health Centre = 24 km on paved road Denali Health Post = 36 km on paved road Gadara Health Post = 15 km on paved road High Road Health Post = 48 km on paved road Therefore, each of these health facilities is within a reasonable distance of the TB microscopy unit on a paved road. However, we do not know whether there is regular and reliable transportation. 4. It might be difficult for Emeral Health Post to send sputum samples on a regular basis. From Agraville Hospital to Emeral Health Post = 50 km on paved road plus 12 km on dirt = 62 km. The dirt road may at times be rough, wet, or impassible.

F-3

Exercise B: Written exercise with individual feedback – Assessing the need to increase the capacity of the TB laboratory services When a participant comes to you for feedback, review the participant’s answers to each question. Refer to the answer sheet as needed. Questions 3d) and e) may have a variety of answers, as long as the participants’ answers are reasonable. During your discussion of 3d), refer to the highlights of the plan for 2004 on page 5 of module B: Faba District if needed. Tell the participant that the need to increase TB laboratory capacity and what will be added to increase capacity goes into the District TB Plan for 2005. Module I: Develop the District Plan of Action for TB Control will teach more about making the plan. Give the participant a copy of the answer sheet to keep. Ask the participant to go back to page 8 and read until the next stop sign (page 11).

F-4

F: Ensure Laboratory Support for TB Control

Answers to Exercise B 2. a) How many workdays are in a quarter? 66 b) 1 960 smear examinations performed = 30 examinations per day by the microscopist 66 workdays

3. a) The maximum recommended number of sputum examinations per microscopist per day is 20. b) The minimum recommended number per day is 2–3. c) The workload at the Agraville Hospital microscopy unit averages 30 sputum smears per day, which exceeds the recommended maximum. d) The TB microscopy workload is likely to increase later in 2004 and 2005 as case detection efforts increase. During 2004 more staff are being trained to question adults about cough, and supplies of sputum containers are increasing. Private clinics may also start referring persons who cough. e) Possible ways to improve the capacity of the TB laboratory services include: • • •

adding another microscopist at the Agraville Hospital microscopy unit (increasing capacity to 40 sputum smear examinations per day), and adding a second microscope and a third microscopist at the Agraville Hospital microscopy unit (increasing capacity to 60 sputum examinations per day), or making an additional TB microscopy unit at a health centre (adding a microscope and microscopist at a health centre).

F-5

Exercise C: Written exercise with individual feedback – Confirming registration of all smear-positive cases in the District TB Register This is a long exercise (most groups take approximately 2 hours). Allow plenty of time so that participants will not be rushed. When participants are beginning to work on this exercise, be sure that they understand what to do and the correct materials to use: • • module L: Tuberculosis Laboratory Register and pages from the District TB Register presented in module F on pages 30–34.

Note: Participants should not use module K: District Tuberculosis Register for this exercise, because that module shows the district register as it appears at a later point in time, and the exercise will not work. Watch participants as they start to work, and check over their shoulders that they are proceeding correctly. (It is very frustrating to participants to spend a lot of time doing the wrong thing, so help to prevent that!) If you see a participant making any of the errors listed below, speak with them individually to point out the error so that they may continue correctly: •

A common error is starting from the District TB Register instead of the Tuberculosis Laboratory Register. Remind participants that the Tuberculosis Laboratory Register is the original source of data. Check that participants have begun reviewing in the Tuberculosis Laboratory Register at the correct place. They should not review the most recent month’s entries (4 June – 8 July) but should begin reviewing at 3 June and work backwards. They do not need to confirm registration of follow-up cases. They are confirming registration of cases that had positive results for diagnosis only. They should stop reviewing when they reach cases that were previously confirmed (stop at number 836).

•

• •

When a participant comes to you for feedback, quickly check two things which will indicate whether the participant has done the exercise correctly: • • On page 29, has the participant corrected the sputum results for F-117 and F-125? On page 32, has the participant added two patients?

If so, you can be reasonably sure that the participant has done the exercise correctly. Look at the participant’s copy of module L: Tuberculosis Laboratory Register. Ask the participant to show you the pages reviewed (which should include 3 June and earlier). Refer to the answer sheet and look page by page in the laboratory register to check whether the participant has placed a tick next to each smear-positive case who was already registered or who the participant added to the District TB Register.

F-6

If you realize that the participant has made many errors, try to find out why (before reviewing the entire exercise). If the participant was confused about what to do or how to do it, give help and explanation until the participant understands what to do. Then ask the participant to redo the exercise and return to you when finished. If the participant has made only a few errors, he or she can correct these as you review the exercise together. Give the participant a copy of the answer sheet for this exercise to keep. Thank or congratulate the participant for his or her work. Then ask the participant to go back to page 12 and work until the end of the module (page 22). This will include writing answers to the self-assessment questions and checking the answers.

F-7

F: Ensure Laboratory Support for TB Control

Answers to Exercise C In the Tuberculosis Laboratory Register, a tick should be written next to the following laboratory serial numbers to indicate that these smear-positive cases have been registered in the District TB Register: 1010 Tee Woo 988 Felicity Kala 973 Rashid Jamu. This patient’s results were incorrectly entered into the District TB Register; the correct entry would be ++. The entry should be corrected in the District TB Register (F-125). 971 Ahmed Mokandu 962 Than Van Tra 960 Zora Riat. This patient’s results were incorrectly entered into the District TB Register; the correct entry would be ++. The entry should be corrected in the District TB Register (F-117). (956 Sam Mapasu should not be registered because he does not meet the criteria for a smearpositive case. However, you should make a note to check that he continued the diagnostic process and was assessed by a clinician.) 950 946 938 934 928 915 896 895 883 875 871 863 861 853 Eduardo Lazar Cecil Trang – was not registered, so should be added to the District TB Register Grace Madu Lucy Wana Obed Sayam – was not registered, so should be added to the District TB Register Karina Elo Ayo Nakobi Okul Curanda Imran Shah Ella Wana Andrew Grand Vincent Dondero Rachel Meza Mano Tam

On the previous visit, a line was drawn below the last entry made on 6/5. The smear-positive case detected before that, laboratory serial number 824, Ari Torres, has a tick beside it, indicating that he was previously confirmed to be registered. This means that is not necessary to review entries before this point. Two cases should have been added to the District TB Register, that is, added on page 32 of the module (not on page 30): Cecil Trang and Obed Sayam as F-139 and F-140. Corrections should be made in the sputum examination results recorded in the District TB Register (page 29) for the following TB patients: F-117: change to ++ F-125: change to ++

F-8

F: Ensure Laboratory Support for TB Control Answers to Exercise C, continued

Make a note to: • Check on Cecil Trang and Obed Sayam at Agraville Hospital to determine whether they have been found and have started treatment. (Since you, Dr Karimi, are still at the Agraville Hospital, go now to ask the health worker about these patients. Perhaps the health worker did not include their TB Treatment Cards with the others for some reason. If you find that they have not started treatment, urge the health worker to look for them.) • Check on Sam Mapasu during the next visit to High Road Health Post to determine whether he was referred to a clinician for assessment, and the result of that assessment.

You may also check: −

at Agraville Hospital, why Zora Riat (F-117) had an incorrect sputum result in the District TB Register. It may have been an error of transcription in the laboratory report sent back to the health facility (Request for Sputum Examination form), on the TB Treatment Card, or only in the District TB Register. at Bella Health Centre, why there was an incorrect sputum result in the District TB Register for Rashid Jamu (F-125)

−

You will check whether smear-positive TB cases detected by the microscopy unit on 5 and 6 July are registered in the District TB Register on your next visit to the microscopy unit (about 8 August). By that time, those patients should have started treatment and you will be able to register them from their TB Treatment Cards.

F-9

5. 6.

Self-assessment questions (self-checked) Concluding the module Ask the participants how they did on the self-assessment questions. If there are any questions about the answers, or other questions about the module, discuss them. Reinforce that this module has described how to ensure TB laboratory support. Health facilities must have access to a TB microscopy unit. The microscopy workload must be distributed among microscopy units in the district so that no unit does too few or too many sputum examinations each day. A microscopy unit must have trained staff and adequate equipment and supplies. Reviewing the Tuberculosis Laboratory Register and comparing it with the District TB Register provides an opportunity to identify smear-positive TB cases who are not yet registered and receiving treatment. If you identify any such cases, you should make sure that the health facility is aware of the case and looks for the TB patient, thereby reducing the chance that this case will be lost. In some countries, up to 5% of cases are lost in this way, so this is an important problem to solve. Accurate transcription of sputum examination results by the laboratory to a Request for Sputum Examination form, then by a health worker to a TB Treatment Card, and then by the District TB Coordinator into the District TB Register is very important. If data in the District TB Register are inaccurate, then provincial and national data will be wrong also. The District TB Coordinator has the responsibility to check and ensure that data are correct at the district level. Make any additional points from this module that you want to reinforce with these participants. Thank the participants for their persistence in completing the exercises. Congratulate them on completing this module.

F-10

Facilitator Guidelines for G: Monitor and Evaluate TB Control

Procedures 1. Distribute module G: Monitor and Evaluate TB Control and module K: District Tuberculosis Register. Introduce the modules. 2. Participants read until the stop sign on page 3 of the module and then prepare for Exercise A as instructed on pages 46–47. 3. Participants read pages 3–11 of the module. Explanation to the group: Completing the Quarterly Report on TB Case Registration 4. Participants do written Exercise B, pages 48–51. 5. Participants read pages 13–17 of the module and then do Exercise C, pages 52–55. 6. Participants read pages 19–23 and do Exercise D, pages 56–60. 7. Participants read pages 25–29 of the module and then do Exercise E, which begins on page 61. Participants may ask for feedback after Part I of the exercise or may continue working through Part II and receive feedback at the end of the exercise. 8. Participants read pages 30–33 of the module and do written Exercise F, pages 65–68, in preparation for a group discussion. 9. Participants read pages 34–38 and do written Exercise G, pages 69–70. 10. Participants read the summary of important points (pages 39–40) and do the self-assessment questions. Participants check their own answers against those provided in the module. Note: Participants who finish early may do Optional Exercise H and check their own work. 11. Conclude the module.

Feedback -----

Group discussion

----Individual Individual Individual

Individual

Group discussion

Individual

Self-checked

-----

G-1

Introducing the modules Distribute module G: Monitor and Evaluate TB Control and module K: District Tuberculosis Register. Explain that module K includes District TB Register pages from three quarters in Faba District. Participants will use module K extensively when doing exercises related to monitoring and evaluation in module G. Ask participants what they understand the word “monitor” to mean. They will probably associate monitoring with keeping records, completing reports, making graphs, etc. Explain that monitoring is more than record keeping. It involves reviewing and analysing the records kept. It is an important way to identify successes and problems, such as a low proportion of new smear-positive TB cases having sputum conversion, or a high number of defaulters in the district. If you find problems, you can investigate the causes, and work towards solving them. Differentiate between ongoing monitoring of a district TB control programme and annual evaluation: •

A district TB Coordinator should continually monitor implementation of the District TB Plan to determine whether activities are being completed as planned. On a quarterly basis, monitoring involves completing several Quarterly Reports and calculating and analysing district-level indicators related to case detection, quality of diagnosis, and TB treatment. Annual evaluation involves reviewing the year’s efforts and results, comparing actual achievements with targets, assessing the quality and extent of current TB control services, identifying causes of problems and reasons for success, and determining required and available resources. Evaluation is the basis for planning.

•

Since monitoring and evaluation provide information that is important as a basis for planning, this course presents module G: Monitor and Evaluate TB Control before module I: Develop the district Plan of Action for TB Control. Module I will show how results of monitoring and evaluation are used to develop a plan. Comment that the Quarterly Reports presented in this module should be basically similar to those used in the participants’ districts. However, there may be some differences, as the Quarterly Reports have recently been revised by WHO. Districts should use the reporting forms required by their national TB control programme. Ask participants to read in the module until the stop sign on page 3 and then prepare for the group discussion as instructed in Exercise A, pages 46–47.

G-2

Exercise A: Written exercise followed by group discussion – Monitoring implementation of activities After participants have written brief answers in their modules, lead a group discussion related to each situation in Faba District. Situation 1 Remind participants that, according to the Faba District TB Plan for 2004, staff at all of the health facilities providing TB control services were to be trained in March in use of the Register of TB Suspects, and they were to begin using it on 1 April 2004. Ask a participant to summarize the situation at High Road Health Post when Dr Karimi visits in the 3rd week of April. Then, ask several participants in turn what they think should be done immediately (during the visit) and what should be done later. Finally, ask participants whether plans for the district may need to be revised and, if so, how. Use the possible answers given on the next page as a guide, and mention those answers if participants do not. Stress the importance of monitoring to find problems and solve them, as opposed to just ignoring them. Situation 2 Remind participants that the Faba District TB Plan for 2004 includes a number of activities that should increase the number of sputum samples being received by the Agraville Hospital laboratory. For example, staff at Bella Health Centre and three health posts were to be trained to ask about cough to identify TB suspects in March. More sputum containers were to be ordered and sent to the facilities. Note that Dr Karimi finds this problem, not on a supervisory visit to Bella Health Centre, but while staying in Agraville and reviewing the number of sputum samples received by the hospital laboratory. There are many ways to monitor and find problems. Having found a problem, Dr Karimi must investigate the cause. Ask a participant to describe the cause that is found. Then, ask several participants in turn what they think should be done immediately, and what should be done later. Finally, ask participants whether plans for the district may need to be revised and, if so, how. Use the possible answers given on the next page as a guide, and mention those answers if participants do not. Stress the importance of monitoring to actively find causes of problems and solve them. Point out that the problems in this exercise cannot be solved by “training.” Remind participants that training is not always an appropriate solution, for example, when a problem is related to transportation or supply issues. ***** After the discussion, give participants copies of the answer sheet. Tell participants to go back to page 3, section 2, and read until the next stop sign (page 13). G-3

G: Monitor and Evaluate TB Control

Possible Answers to Exercise A Situation 1: 1. While at High Road Health Post, the District TB Coordinator should: • • • •

Discuss possible options for transporting sputum samples and decide on a plan. Check the supply of sputum containers. Review with staff the procedures for asking about cough, recording in the Register of TB Suspects, and collecting and sending sputum samples. Ask to be informed if there are any problems.

Later, the District TB Coordinator should: • • • •

Contact the hospital laboratory and High Road Health Post to ensure that the transportation plan is working. Consider additional supervisory visits to High Road Health Post. Between visits, check on things frequently by phone call. Check the supply of sputum containers and ask about transportation at every supervisory visit. Review the Register of TB Suspects to ensure that the expected number of TB suspects (adults coughing for more than 2 weeks) are being found and recorded.

It is quite possible that other health facilities lack adequate plans for transporting sputum samples. The District TB Coordinator should discuss transportation options with all facilities offering TB control services, develop specific plans, and put them in writing. The plans may be different for each facility and may involve sharing transportation with the immunization programme or others.

Situation 2: 1. Immediately, the District TB Coordinator should arrange for a supply of sputum containers to be sent to Bella Health Centre. He should also describe suitable alternative containers (e.g. small, clean glass jars that close well) to use in an emergency. The District Coordinator should review with the Bella Health Centre staff the need to ask all adults about cough. Later, follow up to make sure that the supply of sputum containers is received at Bella Health Centre. Ensure that there is a system in place for sending sputum containers from the district storeroom to all health facilities offering TB control services. Be sure to check the supply of sputum containers at all supervisory visits (at Bella Health Centre and other health facilities as well). Plan to increase the order of sputum containers (or adjust where they are sent, based on use) as needed.

G-4

Explanation of Quarterly Report on TB Case Registration This explanation continues the example for Patanga District given on pages 9–11 of the module. Use the overhead projector to demonstrate how to transfer data from the District TB Register to a tally sheet, which can then be used to complete the Quarterly Report on TB Case Registration. This demonstration is critical and should be done very carefully, with emphasis on tallying technique (how to use a blank sheet of paper to keep your place, where to look in the District TB Register, etc.). Similar tallying techniques will be used in completing all of the quarterly reports, so it is worth taking time for a thorough demonstration. Paper copies of the following overheads are provided on white pages at the end of this Facilitator Guide. Photocopy them onto plastic sheets to make overhead transparencies: • •

a District TB Register excerpt that continues the example from Patanga District shown on page 11 of the module (Overhead A); a blank tally sheet, that is, an enlarged copy of the Quarterly Report on TB Case Registration (Overhead B).

Since this demonstration requires handling two overheads, and switching back and forth between them, you will want to practise with the overhead projector in advance. You may ask a co-facilitator or a participant to help you move the overheads on and off of the projector. **** To begin the demonstration, remind participants that the Quarterly Report on TB Case Registration is completed at the beginning of each quarter and includes cases registered in the quarter that just ended. Project the overhead transparency of the District TB Register from Patanga District (Overhead A). This excerpt is from the 1st quarter of 2004. At the beginning of the 2nd quarter of 2004, the District TB Coordinator would tally the cases from the 1st quarter, including the cases shown on this excerpt. Project the overhead transparency of the tally sheet (Overhead B). Using an overhead marker, write the name of the district (Patanga). In the upper right corner, record that patients were registered in the 1st quarter of 2004. Enter a “date of completion of this form” that is early in the 2nd quarter, e.g. 5 April 2004. Put the overhead transparency of the District TB Register back on the projector. Point to the entries in each column as you discuss how to tally each case. Use a blank sheet of paper to obscure the cases not being discussed. Draw participants actively into the discussion by asking them questions about how they would tally a case, for example: •

What type of patient is this? G-5

• • •

Is this case pulmonary smear-positive, smear-negative, or extrapulmonary? Where should this case be tallied in Block 1 or 3? Should this case also be tallied in Block 2 by sex and age?

When it is decided how to tally a case, put up the overhead transparency of the tally sheet and make the appropriate tally mark(s) to demonstrate. Following is a case-by-case explanation. The first five cases are also explained in the module on fold-out page 11. Cases P-6 to P-10 are not presented in the module, so be sure to discuss them slowly and carefully. Cases listed on Overhead A P-1 The first case for the quarter, Manov Pio, is a new male patient (aged 25 years) with pulmonary smear-positive TB. On the tally sheet, put a tally mark for this patient in Block 1, Column 1. Since this is a new smear-positive case (in the bold cell), also make an entry in Block 2. Put a tally mark for a male in age group 25–34 in Block 2. Lana Do, is a female pulmonary smear-positive relapse, aged 40 years. On the tally sheet, put a tally mark for this case in Block 3, in the cell for relapses. Since this case is a relapse, do not make an entry in Block 2. Joma Saka had no sputum smear examination but was diagnosed with pulmonary TB by other means. He should be tallied in Block 1, Column 2 with the smear-negative cases. (Note that the smear-negative column includes cases that were not tested.) Since Joma is 10 years old, make the tally mark in the cell for cases <15 years old. Do not make an entry in Block 2. Munzir Nabi (aged 20 years) is an extrapulmonary case. Put a tally mark for him in Block 1, Column 3, in the cell for cases >15 years old. Do not make an entry in Block 2. Sofia Lee is a new female patient (aged 46 years) with pulmonary smearpositive TB. On the tally sheet, put a tally mark for her in Block 1, Column 1. Since this is a new smear-positive case (in the bold cell), also make a tally mark in Block 2 for a female in age group 45–54. Carlo Moreno is a new smear-positive case, so he is tallied in the bold cell in Block 1. Put a tally mark for him in Block 2 for a male in age group 25–34. Margaret Lo is a “transfer in.” She should have already been reported by the district in which she was originally registered, so she will not be reported on the Quarterly Report from Patanga District. In order to check the completeness of your tallies, however, you may wish to tally this case at the bottom of the tally sheet. Victor Singh is a new smear-positive case, so he is tallied in the bold cell in Block 1. Also put a tally mark in Block 2 for a male in age group 35–44.

P-2

P-3

P-4

P-5

P-6 P-7

P-8

G-6

P-9 P-10

Ram Patel is a “treatment after default.” He should be tallied in Block 3. Do not make an entry in Block 2. Maria Karna (aged 36 years) is an extrapulmonary case. Put a tally mark for her in Block 1, Column 3, in the cell for cases >15 years old. Do not make an entry in Block 2.

After tallying these 10 cases, remind participants this is only one page of a District TB Register. They will have to review all of the pages from a quarter and tally all of the cases before writing total numbers on the actual report. Tallying cases is a painstaking job with potential for counting errors. If there are many register pages to review, it may be helpful to tally each page separately and then total the results. Tell participants to check the completeness of their tallies by adding together the total cases in Blocks 1 and 3, plus the number of “transfers” noted under the form. The total from the tally sheet should equal the total number of cases entered in the District TB Register for the quarter. Remind participants about the purposes of the Quarterly Report on TB Case Registration: •

Some of the data recorded will help them to calculate recommended district-level indicators related to case detection, sputum conversion, and treatment outcomes. Some of the data recorded will be used in later Quarterly Reports completed for this cohort. Reports from all districts will be compiled at higher levels of the TB control programme and used for evaluation purposes.

•

Tell participants that they will now have a chance to complete a Quarterly Report on TB Case Registration for Faba District. Ask them to do Exercise B (pages 48–51) and then see a facilitator for individual feedback. They will need to use module K: District Tuberculosis Register. 4. Exercise B: Written exercise followed by individual feedback – Completing the Quarterly Report on TB Case Registration As participants work, be sure that they are using the correct quarter from module K: District Tuberculosis Register. They should be using pages from the 3rd quarter of 2004 (pages 15–21). Remind participants to use a piece of paper to keep their place. Be sure that participants answer the questions on page 51. These questions will help them see beyond the mechanics of completing the form to the meaning of the entries. When giving individual feedback, ensure that participants know how to check their work. Their totals from Blocks 1 and 3 of the quarterly report, plus transfers in, should equal the total number of cases entered in the District TB Register for the quarter.

G-7

In this exercise: 57 (cases in Block 1) + 9 (cases in Block 3) + 2 (transfers in) = 68 (the total number of cases in the District TB Register) Note that it is easy to count the number of cases in the District TB Register since there are 10 per page. Give the participant a copy of the answer sheet. Tallying errors are likely to be common on this and other exercises in this module. Provide individual feedback to be sure that the participant understands the process. Once the participant understands the process, he or she may look for any tallying errors independently. After providing individual feedback, tell the participant to go back to page 13, section 3.2, and read until the next stop sign.

G-8

G: Monitor and Evaluate TB Control

Answers to Exercise B QUARTERLY REPORT ON TB CASE REGISTRATION Faba Name of district: ____________________ 4 District no.: ___________ Oke Karimi Name of District TB Coordinator: _____________________ Oke Karimi Signature: ______________________________________ Patients registered during 2004 3rd quarter of year______ _____

Date of completion of this form: 4/10/04 _______________________

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

0 0

3 3

16 6

5 1

0 2

0 0

24 12

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

Note: There were 2 “transfers in” not shown in this report. Answers to questions about the Quarterly Report on TB Case Registration: a. b. c. d. 36 patients registered in the 3rd quarter are new smear-positive cases. Of these new smear-positive cases, 24 are men and 12 are women. The largest number of new smear-positive cases is in the age group 25–34 years. 8 cases registered in the 3rd quarter are re-treatments (relapses, treatment after failure, and treatment after default). G-9

Exercise C: Written exercise followed by individual feedback – Completing the Quarterly Report on Sputum Conversion If participants had difficulty with the tallying process in the previous exercise, do the optional demonstration described below to begin Exercise C as a group. If participants had no difficulty with the tallying process, they may begin Exercise C on their own. (Skip to independent work, below.) Optional demonstration: Introduce Exercise C by using the overhead projector to illustrate how to tally new smear-positive cases that have sputum conversion on the tally sheet for the Quarterly Report on Sputum Conversion. Paper copies of the following overheads are provided on white pages at the end of this Facilitator Guide and may be photocopied onto plastic sheets to make overhead transparencies: • •

an excerpt from page 8 of Faba District’s District TB Register (Overhead C) a blank tally sheet, that is, an enlarged copy of the Quarterly Report on Sputum Conversion (Overhead D)

Following the instructions in Exercise C (page 52 of the module), and using the overhead transparencies, demonstrate the process of tallying new pulmonary smearpositive cases, and whether or not they converted, on the tally sheet. Participants may simultaneously make tally marks on their tally sheets in Exercise C (page 53). Be sure to involve participants actively; do not turn the demonstration into a lecture. You will find 6 new smear-positive cases on page 8 of the District TB Register (Overhead C). Of these cases, 5 converted at 2 months and 1 converted at 3 months. Thus the overhead of the tally sheet (at the end of the demonstration) will have no tally marks in the column for “smear not done.” By pointing to the appropriate places on the overhead, show participants where to tally cases that have no test results at 2 or 3 months, or cases that do not convert. After the demonstration, participants should continue Exercise C independently, tallying cases from pages 9–14 of the District TB Register. Independent work: As participants work, be sure that they are using the correct quarter from module K: District Tuberculosis Register. They should be using pages from the 2nd quarter of 2004 (pages 8–14). Be sure that participants understand the reason for waiting to complete the report on sputum conversion, that is, one must wait long enough for conversion to occur (2–3 months). Thus, in the 4th quarter of 2004 in Faba District, it is time to report sputum conversion for cases registered in the 2nd quarter of 2004. Be sure that participants answer the questions on page 55 of the module. These questions will help them see beyond the mechanics of completing the form to the meaning of the entries.

G-10

When giving individual feedback, ensure that participants know how to check their work. The total number of cases that converted at 2 or 3 months, plus those not tested, plus those that did not convert should equal the number of new smear-positive cases recorded in the first column. In this exercise: 35 (converted) + 4 (smear not done) + 2 (did not convert) = 41 (the number of new smear-positive cases in the first column). Point out that, even if a case did not convert at 2 or 3 months, that case can still have a successful treatment outcome. To be “cured” the case must be sputum smear-negative in the last month of treatment and on at least one previous occasion, which could be at 5 months. Give the participant a copy of the answer sheet. Tallying errors are likely to be common in this exercise and other exercises in this module. Provide individual feedback to be sure that the participant understands the tallying process. Once the participant understands the process, he or she may look for any tallying errors independently. After finding and correcting any errors, the participant should go back to page 19, section 3.3, and read until the next stop sign.

G-11

G: Monitor and Evaluate TB Control

Answers to Exercise C QUARTERLY REPORT ON SPUTUM CONVERSION Faba Name of district: _____________________________ 4 District no.: ___________ Oke Karimi Name of District TB Coordinator: ___________________ Oke Karimi Signature: _____________________________________ Number of new smear-positive cases registered in quarter recorded above** Smear not done at either 2 or 3 months Patients registered during 2nd quarter of year______* 2004 _____ Date of completion of this form: ____________________ 4/10/04 Sputum conversion at: 2 months 3 months

Total converted at 2 or 3 months:

* Quarter: This form applies to patients registered (recorded in the District Tuberculosis Register) in the quarter that ended 3 months ago. For example, if completing this form at the beginning of the 3rd quarter, record data on patients registered in the 1st quarter. ** This number should match the number of new smear-positive cases in Block 1, Column 1, of the Quarterly Report on TB Case Registration previously completed for patients registered in this quarter.

Answers to questions on Quarterly Report on Sputum Conversion: a. 4 new sputum smear-positive cases had no smear done at 2 months and no smear done at 3 months. Possible reasons: Patient defaulted before the test. Patient died before the test. Patient transferred out before the test. Staff did not ask for sputum samples or collect them b. c. 35 new sputum smear-positive cases converted at 2 or 3 months. Patient F-83 defaulted after the 2-month test, which was positive. Patient F-125 was still positive at 2 and at 3 months. Presumably he is still being treated and will be tested again at the end of 5 months.

G-12

Exercise D: Written exercise followed by individual feedback – Completing the Quarterly Report on Treatment Outcomes If participants had difficulty with the tallying process in the previous exercises, do the optional demonstration described below to begin Exercise D as a group. If participants had no difficulty with the tallying process, they may begin Exercise D on their own. (Skip to independent work, below.) Optional demonstration: Introduce this exercise by using the overhead projector to illustrate how to complete the Quarterly Report on Treatment Outcomes. Paper copies of the following overheads are provided on white pages at the end of this Facilitator Guide and may be photocopied onto plastic sheets to make overhead transparencies: • • •

the Quarterly Report on TB Case Registration shown in Exercise D of the module, page 57 (Overhead E) a blank tally sheet, that is, an enlarged copy of the Quarterly Report on Treatment Outcomes (Overhead F) excerpts from page 1 of Faba District’s District TB Register (Overhead G)

Using the overhead transparencies, demonstrate the process of transferring data from the Quarterly Report on TB Case Registration (Overhead E) to the left side of the tally sheet for the Quarterly Report on Treatment Outcomes (Overhead F). (This process was pictured on page 21 of the module for a different district and quarter.) Do not lecture. Do involve the participants in the demonstration. For example, while projecting the Quarterly Report on TB Case Registration, ask, “How many new sputum smear-positive cases are entered on this report?” Then project the tally sheet for the Quarterly Report on Treatment Outcomes, and enter the number on that form. After completing the left side of the Quarterly Report on Treatment Outcomes, use the excerpts from page 1 of the District TB Register (Overhead G) to demonstrate how to tally treatment outcomes for cases. There are a variety of outcomes on page 1 of the District TB Register. Remember not to tally the treatment outcome for the extrapulmonary (EP) case. While you are marking on the overhead, participants may simultaneously make tally marks on the tally sheet given in Exercise D (page 58). When you are finished with this demonstration, the overhead of the tally sheet (showing outcomes only for cases on page 1 of the District TB Register) should look like the next page.

G-13

After the demonstration, participants should continue Exercise D independently, tallying outcomes for cases on pages 2–6 of the District TB Register. Independent work: Be available to help participants who may appear confused or have questions. As participants work, be sure that they are using the correct quarter from module K: District Tuberculosis Register. They should be using pages from the 3rd quarter of 2003 (pages 1–6). Be sure that participants understand the reason for waiting 12 months to complete the report on treatment outcomes, that is, one must wait long enough for outcomes to occur. Thus, at the beginning of the 4th quarter of 2004 in Faba District, it is time to report on sputum conversion for cases registered in the 3rd quarter of 2003. Be sure that participants answer the questions on pages 67-68 of the module. These questions will help them understand the meaning of the entries on the report. When giving individual feedback, ensure that participants know how to check their work. Unless there were exclusions or cases with no outcome recorded, the sum of columns 1 to 6 (in the last column) should equal the total in the first column (transferred from the earlier Quarterly Report on TB Case Registration for the cohort). Remind participants that line 1.1 of the Quarterly Report on Treatment Outcomes is the most important, as it provides data to measure treatment outcomes for new pulmonary smear-positive cases and thereby assess the quality of the district TB control programme. Reporting of treatment outcomes for pulmonary smear-negative and re-treatment cases is optional, but encouraged. After individual feedback, give the participant a copy of the answer sheets. After finding any errors, the participant should go back to page 25, section 4, and read until the next stop sign.

G-14

QUARTERLY REPORT ON TREATMENT OUTCOMES

Faba Name of district:_____________

Oke Karimi Name of District TB Coordinator:__________________

Patients registered during 3rd quarter of year 2003 _____ ______* Date of completion of this form: 4/10/04 _____________________

4 District no.:___________ Treatment outcomes Cure Treatment completed (2) (3) (4) (5) Died Treatment failure Default

Oke Karimi Signature: _________________

Type of case

Total number of pulmonary patients registered during the quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1. New

1.1 Smear (+)

32 10 2 2 2 1

3 4

32 15 2 2 1 3

1.2 Smear (–)

2.1 Relapses

2.2 Treatment after failure

* Quarter: This form applies to patients registered (recorded in the District Tuberculosis Register) in the quarter that ended 12 months ago. For example, if completing this form at the beginning of the 3rd quarter, record data on patients registered in the 2nd quarter of the previous year.

G: Monitor and Evaluate TB Control Answers to Exercise D

** These numbers are transferred from the Quarterly Report on TB Case Registration for the above quarter. Of these patients, _______ (number) were excluded from evaluation for the following reasons: _______________________________________________________________________________________________________

*** In areas routinely using culture, a separate form for culture-positive patients should be used.

2. Re-treatment (smear-positive)***

2.3 Treatment after default

G-15

G: Monitor and Evaluate TB Control

Answers to Exercise D, continued Answers to questions about the Quarterly Report on Treatment Outcomes: a. b. Outcomes were recorded for 32 new smear-positive cases. Of these, 22 were cures. These are all new sputum smear-positive cases who did not have a 5-month follow-up sputum examination. However, they had a sputum examination at the end of treatment (as well as one earlier negative examination) and so were proven cures. There may be a problem with Bella Health Centre and the health posts not doing the 5-month examination. Since the final sputum examination is necessary to prove a cure, perhaps health workers are saving their efforts and their sputum containers for the final examination rather than the 5-month examination. c. 54 cases had outcomes recorded on the Quarterly Report on Treatment Outcomes. Of the 60 cases entered in the District TB Register in the 3rd quarter of 2003, those not accounted for on this report are 5 extrapulmonary cases and 1 transfer in.

G-16

Exercise E: Written exercise followed by individual feedback – Calculating and analysing indicators related to case detection and quality of diagnosis Participants may ask for individual feedback after Part I of this exercise, or they may continue working until the end of Part II before seeking feedback. Use the answer sheets as a guide for giving feedback. Refer to the tables about analysis of indicators given on pages 28 and 29 of the module. In discussing Part I of the exercise, point out the footnote on page 28 of the module. This explains that the expected ratio of TB suspects tested to adult outpatients is 3–5% because that is the expected percentage of adults with cough lasting 2 weeks or more. A study could be done to find out a more accurate expected level for a specific area. Possible question: Some participants may wonder why this indicator is called a ratio and not a proportion. It is not technically correct to call it a proportion because some members of the numerator may not necessarily be in the denominator. (For example, the laboratory reports used to determine the numerator may include people who were not referred by public health facilities reporting the number of adult outpatients.) Nevertheless, the numerator and denominator data should be related. If more adult outpatients are asked about cough and have sputum samples examined, the numerator will go up while the denominator stays about the same. In discussing Part II, note that data from the Quarterly Report on TB Case Registration are used to calculate the indicator related to quality of diagnosis in the district. This is just one example of how the Quarterly Reports are useful at district level as well as higher levels. Other indicators will be calculated based on these reports as well. Relate the exercise to the participant’s home district if possible. For example, ask whether the proportion of TB cases that are sputum smear-positive is known for the participant’s district. If known, discuss possible interpretations of that indicator. After providing individual feedback, give the participant a copy of the answer sheet. Tell the participant to go back to page 30, section 4.3, and read until the next stop sign.

G-17

G: Monitor and Evaluate TB Control

Answers to Exercise E, Part I Indicators related to case detection in Faba District, 3rd quarter of 2004 Formula for calculating (numerator ÷ denominator) Number of TB suspects whose sputum was examined Total number of outpatients aged 15 years and older seen for any reason at facilities providing TB control services Number of TB suspects who were sputum smear-positive Number of TB suspects whose sputum was examined Results for Faba District Sources of data Numerator Denominator Ratio or proportion

Indicator

Ratio of TB suspects tested to outpatients aged 15 years and older

Obtain from laboratory reports from district laboratory supervisor Estimate based on outpatient totals from health facilities in previous quarters Obtain from laboratory reports from district laboratory supervisor Obtain from laboratory reports from district laboratory supervisor

600 4% 15 000

Proportion of TB suspects tested who were sputumsmear positive (positivity rate)

42 7% 600

Answers to questions about the indicators: a. The first indicator, the ratio of TB suspects tested to outpatients aged 15 years and older, is in the middle of the expected range of 3–5%. It suggests an improvement above the rate of 2% in 2003. b. The second indicator, the proportion of TB suspects tested who were sputum-smear positive, is in the middle of the expected range of 2–15%. The rate may have decreased to 7% (from 10% one year ago) because of better TB case detection (i.e. health workers may be asking less seriously ill patients about cough).

G-18

G: Monitor and Evaluate TB Control

Answers to Exercise E, Part II Indicator related to quality of diagnosis in Faba District Formula for calculating (numerator ÷ denominator) Results for Faba District Source of data Numerator Denominator Proportion

Indicator

Proportion of TB cases who were sputum smear-positive

Number of TB cases who were sputum smearpositive

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the new sputum smear-positive cases (Block 1, Column 1) and all cases recorded in Block 3.

45 68%

Total TB cases

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the total new cases (Block 1, Column 4) and all cases recorded in Block 3.

Answers to questions about the indicator: a. b. At 68%, this indicator is above the expected level of at least 50%. There does not seem to be a problem with over-reliance on X-ray for diagnosis of TB in Faba District. If there is an increase, however, it may suggest that more clinicians are relying on sputum smear microscopy for diagnosis.

G-19

Exercise F: Written exercise followed by discussion – Calculating and analysing indicators related to TB treatment If participants are uncertain about their answers in the table of indicators on page 66, they may come for individual feedback on this part of the exercise before continuing. If so, check their answers and give them the first page of the answer sheet. When everyone has finished the exercise, distribute the first page of the answer sheet (the table of indicators) to any participants who have not yet collected it. Ask if there are any questions about the mathematics of calculating the indicators. Note that it is very easy to calculate indicators related to sputum conversion and treatment outcomes if one has completed the Quarterly Report on Sputum Conversion and the Quarterly Report on Treatment Outcomes for the appropriate cohorts. Be sure that participants understand why, at a certain reporting time, the sputum conversion rate is calculated for a different (more recent) cohort than the treatment outcome rates. The reason is that sputum conversion can be expected at the end of 2 or 3 months of treatment, while treatment outcomes may take 12 or more months to be achieved. Use the answer sheets as a guide for the discussion. Refer as needed to the table on page 32 of the module about analysis of the indicators. Focus on the interpretation of the indicators more than the mathematics of the exercise. Point out that, with small numbers of new sputum smear-positive cases, one or two cases can make a big difference in the sputum conversion rate or the treatment outcome rates. Therefore one cannot get too excited (or dismayed) by a sudden change in a rate. One must look for sustained changes over a number of quarters. Relate the exercise to the participant’s home districts if possible. For example, ask whether the sputum conversion rate is known for the participants’ districts. If known, discuss possible interpretations of that indicator. After the discussion, give participants copies of the second page of the answer sheets. Tell the participant to go back to page 34, section 5, and read until the next stop sign.

G-20

G: Monitor and Evaluate TB Control

Answers to Exercise F Indicators related to TB treatment in Faba District Indicator Proportion of new sputum smear-positive TB cases who converted at 2 or 3 months (sputum conversion rate) Proportion of new sputum smear-positive TB cases with each treatment outcome: Cure Formula for calculating (numerator ÷ denominator) Number of new sputum smearpositive TB cases who converted at 2 or 3 months Total new sputum smearpositive TB cases Sources of data Results for Faba District Numerator Proportion Denominator

Quarterly Report on Sputum Conversion, bottom row Quarterly Report on Sputum Conversion, first column

35 85% 41 22 69% 32 3 9% 32 2 6% 32 1 3% 32 3 9% 32 1 3% 32

Number of new sputum smearpositive TB cases with outcome cure Total new sputum smearpositive TB cases

Quarterly Report on Treatment Outcomes, line 1.1, column 1 Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Treatment completed

Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 2 treatment completed Quarterly Report on Total new sputum smearTreatment Outcomes, line 1.1, total number positive TB cases evaluated Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 3 died Quarterly Report on Total new sputum smearTreatment Outcomes, line 1.1, total number positive TB cases evaluated Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 4 treatment failure Quarterly Report on Total new sputum smearTreatment Outcomes, positive TB cases line 1.1, total evaluated Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 5 default Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total evaluated

Died

Treatment failure

Default

Transfer out (out of district)

Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 6 transfer out Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total evaluated

G-21

G: Monitor and Evaluate TB Control

Answers to Exercise F, continued a. The sputum conversion rate for patients registered in the 2nd quarter of 2004 is at the desired level of at least 85%. This suggests that TB case management in Faba district is of reasonably good quality where it is offered. The sputum conversion rate should be entered on the graph at 85%. Reasons for the increase in the rate could include improved patient adherence and improved treatment. For the cohort of new smear-positive cases registered in the 3rd quarter of 2003, the rate of “treatment success” (that is, the proportion cured plus the proportion that completed treatment) was 78% (69% plus 9%). According to the graph, the sputum conversion rate for that same cohort was about 81%. “Treatment success” for this cohort seems consistent with its earlier sputum conversion rate. The “treatment success” rate is just a bit lower than the earlier sputum conversion rate. It is likely that one of the converted cases defaulted, died, or transferred out and had no known outcome, while the rest finished treatment. d. Possible reasons for the changes in the cure rate (from 54% to 69%) and completion rate (from 18% to 9%): • •

b. c.

More cases are being proven cured (having final sputum examination) as opposed to just finishing treatment. Overall treatment success (cure plus completion) has also improved, suggesting perhaps fewer defaults. The decrease in the default rate bears this out.

Possible reasons for the changes in the default rate (decrease from 17% to 9%): Although this rate is still too high at 9%, it has improved. Reasons may include improved quality and convenience of services. Perhaps health workers are also informing patients better about the need to continue treatment until cured. e. The numerator of the death rate in Faba District included the 2 new sputum smearpositive cases who died, out of the cohort of cases registered in the 3rd quarter of 2003. These were cases F-157 and F-167. Case F-157 (Mohammed Arata) died of complications from HIV infection, and case F-167 (Lea Chan) died in a car accident. Note: There were 5 deaths in this cohort, but only the 2 who were new sputum smearpositive cases are included in the rate. The other 3 deaths were extrapulmonary or smear-negative cases. One of these was HIV-related and 2 were seriously ill patients. Faba District should be able to reduce the death rate by involving HIV testing sites in asking PLWHA about cough and referring them for sputum examination if they have been coughing for 2 weeks or more. If TB is detected early, more co-infected persons will survive. Note that, if Mohammed Arata had survived, the death rate for new smearpositive cases in this cohort would be only 3%.

G-22

Exercise G: Written Exercise followed by individual feedback – Evaluation of target Note that this exercise jumps ahead to the beginning of 2005, when it is time to determine whether the sputum conversion target of 85% was achieved for Faba District in 2004. Use the answer sheet as a guide for providing individual feedback. Relate the discussion to the participant’s district if possible. For example, ask what could be done to achieve a higher sputum conversion rate in the participant’s district. Point out that, in Faba District as well as other districts, failure to do follow-up testing at 2 or 3 months affects the sputum conversion rate adversely. It is important to analyse why individual cases were not tested at 2 or 3 months to solve this problem. After providing individual feedback, give the participant a copy of the answer sheet. Tell the participant to go back to page 39 and read and work to the end of the module.

G-23

G: Monitor and Evaluate TB Control

Answers to Exercise G 2. The sputum conversion rate for this cohort is calculated as follows: 31 = about 0.86 or 86% 36 3a. This rate is higher than the sputum conversion target of 85% set for Faba District for 2004. Yes, the target was achieved. However, notice the difference that one case can make. If only 30 cases had converted instead of 31, the rate would be 83%.

3b. It will be important to find out why four cases in this cohort were not tested at 2 or 3 months. The reasons will suggest possible ways to achieve even higher sputum conversion in Faba District, which might include: • • • Decreasing defaults by making TB control services more convenient (using community TB treatment supporters or expanding to more health facilities). Making sure that health workers understand the importance of follow-up sputum examinations and know the schedule. Providing more sputum containers and reliable transportation for sputum samples.

G-24

10.

Self-assessment questions (self-checked) Notice whether some participants are finishing the module much earlier than others. If so, suggest that they do optional Exercise H, which is at the end of the exercises in the module. An answer sheet is provided on the next page. When they finish the optional exercise, give them the answer sheet to check their own work.

11.

Concluding the module If participants have any remaining questions about the module or the self-assessment questions, discuss them. Make any important points that you want to reinforce with the participants.

G-25

G: Monitor and Evaluate TB Control

Possible Answers to Optional Exercise H This is an exercise with many possible answers. Some possible answers are as follows: 1. Some possible causes of a low sputum conversion rate are: • • • • •

Patients do not have a follow-up sputum examination at 2 or 3 months. Patients have irregular attendance for treatment and do not convert. Patients default before 2 or 3 months of treatment. Patients die before 2 or 3 months of treatment. TB/HIV patients have a high bacillary load and take longer to convert.

For the first cause listed above, some possible root causes are: • • •

Health workers do not know the schedule for follow-up examinations. There are not enough sputum containers at the health facilities, and those available are reserved for diagnosis. Patients treated by community TB treatment supporters find it inconvenient to bring sputum samples to the health facility.

For the root causes listed in question 2, some possible solutions are as follows: Possible root cause Possible solution

Health workers do not know the schedule for follow-up examinations. There are not enough sputum containers at the health facilities. Patients treated by community TB treatment supporters find it inconvenient to bring sputum samples to the health facility.

Provide on-the-job training or job aids for health workers. Order and provide more sputum containers; explain importance of follow-up sputum examinations at 2 or 3 months. Provide community TB treatment supporters with sputum containers; find ways to pick up sputum samples from community TB treatment supporters.

Similar problem-solving tables could be made for the root causes of other causes listed in question 1.

G-26

Facilitator Guidelines for H: Advocacy and Collaboration for TB Control

Procedures 1. Distribute module H: Advocacy and Collaboration for TB Control. Introduce the module. 2. Participants read pages 1–6 of the module and then do Exercise A, pages 20–21. 3. Participants read pages 7–8 of the module and then do Exercise B, pages 22–23. 4. Participants read pages 9–12 of the module and then do Exercise C, page 24. 5. Participants read the summary of important points (page 13) and then do the self-assessment questions. Participants check their own answers against those provided in the module. 6. Conclude the module.

Feedback -----

Individual

Group discussion

Self-checked

-----

H-1

Introducing the module Explain that advocacy is a word that is commonly used but may have different meanings to different people. As used in this course, it means promoting and gaining support for the DOTS strategy and TB control services. Support may be financial or political. Mention the examples of advocacy listed on page 1 of the module. Ask participants if they can think of other examples, perhaps from their own districts. Explain that advocacy can lead to collaboration, that is, working together towards a common purpose. This module will describe some ways to collaborate with nonpublic health facilities, private practitioners, and with various organizations. Explain that it is particularly important for the district TB control programme to collaborate with the HIV/AIDS programme. Section 5 of this module will describe ways to collaborate with the HIV/AIDS programme. Ask participants to read the module to the stop sign on page 6 and then do Exercise A individually.

Exercise A: Written exercise followed by individual feedback – Collaboration with private physicians Possible answers are given on the answer sheet; each participant’s answers may vary. When giving feedback, discuss the participant’s answers first; then use the answer sheet as a guide to suggest other possible answers. After discussing question 1, ask participants how they could find answers to the questions listed in their areas. Would they talk with a sample of physicians? Visit private clinics? After providing individual feedback, give the participant a copy of the answer sheet. Ask the participants to go back to page 7 of the module and continue reading until the next stop sign.

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H: Advocacy and Collaboration for TB Control

Possible Answers to Exercise A 1. Dr Karimi should attempt to answer questions such as the following. You should have listed several questions of this type. • • • • • • • •

How do most private physicians currently diagnose TB? Where do private patients obtain anti-TB drugs? At what cost? Is their treatment directly observed? To what extent do private physicians follow the national guidelines for TB control? Are treatment records kept? If private physicians do rely on sputum smear microscopy, where are sputum samples examined, and at what cost? Are follow-up sputum examinations done? Are private physicians aware of TB control services being offered free of charge by public health facilities? What is their attitude towards the free services?

Dr Karimi could meet with all of the physicians working at a private clinic together at the end of clinic hours. Perhaps he could make a presentation at a Rotary Club meeting. Support could be obtained to offer refreshments. Examples of points to be made include the following. You may have listed others. •

• • • • •

Sputum smear microscopy is the most cost-effective way to diagnose pulmonary smear-positive TB. (When sputum smear microscopy is inconclusive, public health staff are instructed to refer patients to a clinician.) Sputum smear microscopy is provided free of charge by the public health services. Anti-TB drugs can be provided free of charge by the public health services. Treatment of TB patients must be directly observed. Defaults often occur if patients must pay for drugs and if treatment is not directly observed. Public health facilities offering free TB control services are ____________ (provide names, locations, and hours).

You should have listed two ways to collaborate. Possibilities include the following: The private practitioner could: Refer patients with suspected TB to the public health services for sputum examination. Refer patients diagnosed with TB to the public health services for free anti-TB drugs and directly observed treatment.* Diagnose TB, provide directly observed treatment, and report cases to the district TB control programme. While district public health services could: Provide free sputum smear microscopy; diagnose smear-positive TB; refer the patient back (with results) for other care as needed. Provide free drugs and directly observed treatment for referred TB cases. Provide free drugs, training, and reporting forms. Trace missing patients to ensure continuation of treatment.

* It is critical that patients know where to get free anti-TB drugs. Having to purchase drugs often leads to default.

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Exercise B: Written exercise followed by group discussion – Collaborating with organizations in your district Be sure that every participant does the written exercise to prepare for the discussion. Answers to this exercise will be related to the participants’ own districts and may vary greatly, so there is no printed answer sheet for this exercise. Notice that question 1 of this exercise focuses on associations that are primarily related to health care, while question 2 focuses on other organizations, not related to health care, that may have an interest in collaboration. Use a flipchart or blackboard to record the group’s ideas during the discussion. For example, to discuss question 1, on the left of a flipchart page, write the health-carerelated associations mentioned by the participants. On the right, record possible ways to inform and collaborate with each. On another page, record community organizations on the left. On the right, record possible ways to inform and collaborate with each. Try to include every participant in the discussion. After the discussion, ask participants to go back to page 9 of the module and continue reading until the next stop sign.

Exercise C: Written exercise followed by group discussion – Collaboration of HIV/AIDS and TB control programmes Be sure that every participant does the written exercise to prepare for the discussion. Answers to this exercise will be related to the participants’ own districts and may vary greatly, so there is no printed answer sheet for this exercise. As needed, refer to section 5 of the module for possible ways to collaborate with the HIV/AIDS programme. For example, one very important way to collaborate is to involve HIV testing and care sites in TB case detection (section 5.2). Ask participants if HIV testing and care sites in their districts refer patients who have been coughing for 2 weeks or more for sputum examination. If not, ask whether HIV testing and care sites might be asked to collaborate in this way in the future. Record participants’ ideas on the flipchart or blackboard. Try to include every participant in the discussion. After the discussion, ask participants to go to page 13 and read and work to the end of the module, checking their own answers to the self-assessment questions.

Self-assessment questions (self-checked)

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Concluding the module Ask the group how they did on the self-assessment questions. If there are any questions about the answers, or any other questions about the module, discuss them. Make any important points that you want to reinforce with the participants.

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Facilitator Guidelines for I: Develop the District Plan of Action for TB Control

Procedures 1. Distribute module I: Develop the District Plan of Action for TB Control. Introduce the module. 2. Participants read pages 1–6 of the module and then do Exercise A, page 24. 3. Participants read pages 7–8 of the module and then do Exercise B, page 25. 4. Participants read pages 9–14 of the module and then do Exercise C, pages 26–27. 5. Participants read pages 15–17 of the module and then do Exercise D, pages 28–39. 6. Participants read the summary of important points (page 18) and then do the self-assessment questions. Participants check their own answers against those provided in the module. 7. Conclude the module.

Feedback -----

Individual

Group discussion

Group discussion Individual and Group discussion

Self-checked

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I-1

Introducing the module Explain that this module will describe how to develop a District TB Plan similar to the one shown for Faba District in module B. Participants should have module B: Faba District available to refer to. Participants may use a different format for planning in their own districts, but a good plan should always include some basic elements, such as: targets, activities needed to achieve the targets, and information on who will carry out the activities, when they will be accomplished, and what human and financial resources are needed. Draw attention to the diagram on page 1 of the module. Explain that monitoring and evaluation provide the basis for a good plan. The extent and quality of current TB control services must be assessed before one can plan how to improve, maintain, or expand services. Thus, the first part of this module focuses on assessing the current status of TB control services in the district. Ask participants to read to the stop sign on page 6 of the module and then do Exercise A individually.

Exercise A: Written exercise – Setting a sputum conversion target There is no absolute correct answer to this exercise. Participants may suggest sputum conversion targets that range from 85% to 90%. Participants should be able to describe the reasoning behind their answers. The situation in Faba District, as described on page 24 of the module, is improving in many ways, so it should be possible at least to maintain the current sputum conversion rate of 85%. The rate may increase, but 90% is likely to be the maximum that can be reached. If a participant gives an unusual answer (e.g. 50% or 100%), try to find out what the participant has misunderstood. Give the participant a copy of the answer sheet. Ask the participants to go back to page 7 of the module and continue reading until the next stop sign.

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I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise A Possible answers for the sputum conversion target may range from 85% to 90%. There is no absolutely correct answer. Participants should be able to describe their reasoning.

I-3

Exercise B: Written exercise followed by group discussion – Planning activities to solve a problem Be sure that every participant does the written exercise to prepare for the discussion. First, briefly review the situation (or ask a participant to describe it): Nurse Natore at High Road Health Post needs a better arrangement for transporting sputum samples to the TB microscopy unit at Agraville Hospital. She also needs transportation to visit patients who miss visits and to take drugs to a community TB treatment supporter. Funds for a motorcycle or other vehicle are not readily available. Ask participants what activities should be included in the District TB Plan to help solve the transportation problem at High Road Health Post. Use the answer sheet as a guide during the discussion, but recognize that participants may have other good ideas, and focus on their ideas first. If they do not eventually mention the answers given on the answer sheet, then you may mention them yourself. Use a flipchart or blackboard to record the group’s ideas during the discussion. List activities clearly, as participants will refer to this list when they do Exercise D later. Discuss the practicality of each activity listed on the flipchart. Also discuss any preparation needed and possible ways to obtain resources needed. After the group discussion, give participants a copy of the answer sheet. Ask participants to go back to page 9 of the module and read until the next stop sign.

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I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise B Possible activities to help solve the transportation problem at High Road Health Post include the following: • • Since there is a bus between High Road Health Post and Bella Health Centre, arrange to pay the bus driver to deliver sputum samples to Bella Health Centre. Find out who are regular travellers on the road, and determine whether they can help with transportation of sputum samples. (Regular travellers could include trucks, taxis, or representatives of NGOs or community organizations.) Discuss with Nurse Natore what type of transportation would be most useful and appropriate for her (e.g. When and how would she use the transportation? Could she drive a motorcycle? Would it be socially acceptable? Would she need a licence or training to drive it?) Research availability of new and used motorcycles or vehicles, types, features, fuel, and maintenance costs, etc. Meet with business associations to explore the possibility of a donation or funds for motorcycle or other vehicle. Meet with other health programmes (e.g. immunization) to discuss sharing expense and use of motorcycle or other vehicle. Purchase motorcycle or vehicle (using funds from budget plus funds from other sources).

•

• • • •

The District TB Coordinator would be responsible for these activities. If possible, the first activity (paying the bus driver) should begin as soon as possible, even before the start of 2005. The other activities should take place as soon as possible, preferably early in 2005. Participants may have listed other activities.

I-5

Exercise C: Written exercise followed by group discussion – Expansion of TB control services Note: It will be helpful to have a map of Faba District photocopied on an overhead transparency for use during the discussion of expansion of TB control services. You may make one using Overhead A, printed on a white page at the end of this Facilitator Guide, or simply use the map at the beginning of module B: Faba District. Be sure that every participant does the written exercise to prepare for the discussion. First, briefly review the situation in Faba District (or ask a participant to describe it) based on the information given on page 26 of the module. Next, taking each question (1–4) in turn, ask the participants for their opinions about expansion of TB control services in Faba District. In deciding whether to expand, consider the factors listed on page 9 of the module. Once it is decided to expand TB control services, there are two main issues to decide for Faba District: • • where to expand TB case detection and treatment where to situate the new TB microscopy unit for which funds are available.

Use the answer sheet as a guide during the discussion, but recognize that participants may have other good ideas, and focus on their ideas first. If they do not eventually mention the answers given on the answer sheet, then you may mention them yourself. Discuss the pros and cons of each idea. In selecting health facilities for expansion, refer to the factors listed on page 10 of the module. In determining where to place the TB microscopy unit, consider issues such as transportation (distance, roads) and the number of health facilities that could be served, and their outpatient loads. Participants may have different ideas about what would be most cost-effective, and that is fine. Record on the flipchart the group’s conclusions about where to expand TB case detection and treatment, and where to place the new TB microscopy unit. Participants will refer to these conclusions later, when they do Exercise D. After discussing expansion of TB control services in Faba District, use questions 5 and 6 to change the focus of the discussion to participants’ own districts. Some districts may be ready for expansion only to more public health facilities. Others may be ready for expansion to non-public health facilities. (Criteria are suggested on page 12 of the module in section 3.4.) Encourage the group to think creatively about how to involve non-public health facilities in TB control. They may draw on ideas from module H: Advocacy and Collaboration for TB Control. After the discussion, give participants a copy of the answer sheet. Ask participants to go back to page 15 of the module and read until the next stop sign.

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I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise C 1. Yes, TB control services should be expanded in Faba District. Reasons include: • • • • 2. The sputum conversion rate for health facilities currently providing TB control services is well over 80%. When last measured, it was 85%. Only 5 out of 8 public health facilities now provide TB control services. More of the population can be reached if services are provided at more facilities. The north-west and south-east corners of the district do not currently have convenient access to TB control services. There are resources available for expansion (e.g. resources for training, drugs, and supervisory visits; funds for another TB microscopy unit).

There are several possibilities for expansion, but Dr Karimi’s first choices are Cara Health Centre and Emeral Health Post. Cara Health Centre is already involved in providing treatment, and the nurse there has expressed interest in being trained to do more. Cara Health Centre and Emeral Health Post could both be visited on the same day, which would be convenient for supervision. Ferro Health Post would be somewhat hard to visit for supervisory purposes given the longer distance on a dirt road, and it has a much smaller outpatient load (4 000) than Cara and Emeral combined (16 000 + 6 000). Once services are implemented in Cara and Emeral, it will be debatable whether it is more worthwhile to expand to Ferro Health Post or to some larger non-public health facility. Participants may note that the prison is very close to the District Office and suggest that TB control services should be implemented there. Expanding to non-public health facilities should become a focus only when most public health facilities are providing TB control services according to the national guidelines. However, if resources are available, TB control services could be expanded to the prison, especially since it is so close.

Participants may have considered whether to put the new TB microscopy unit at Bella Health Centre or Cara Health Centre. Dr Karimi decided on Cara Health Centre, for the following reasons: • • Cara Health Centre is farther away from Agraville than Bella Health Centre, so sputum transport to Agraville Hospital would be more difficult. If the new TB microscopy unit is placed in Cara Health Centre, it can serve Emeral Health Post and possibly Denali Health Post as well. (It could serve three facilities, instead of just two if placed at Bella. The outpatient load for Cara, Emeral, and Denali combined is 30 000, which is greater than 27 100 at Bella and High Road combined.) Plans are being made to solve transportation problems at High Road Health Post, so they should be able to send sputum samples to Agraville Hospital more easily.

• 4.

The target should state that 7 out of 8 public health facilities will provide TB control services in 2005.

Answers to 5 and 6 will be based on the participant’s own situation in his or her district. I-7

Exercise D: Written exercise followed by individual feedback and group discussion – Completing a District TB Plan Individual work Participants should follow the instructions given in the module to complete the District TB Plan and Planning Chart for Faba District. Participants will need to refer to the flipchart pages from the discussions in Exercises B and C, so have these available and visible. As participants work on this exercise, watch to be sure that they know where to record activities on the District TB Plan and the Planning Chart. You may need to remind participants that section A of the District TB Plan includes activities to maintain and improve existing TB control services. Section B includes activities related to expansion of TB control services. There are training activities, laboratory activities, etc. in both sections A and B. Participants should obtain individual feedback on steps 1–6 of the exercise. Refer to the first page of the answer sheets for Exercise D, which is based on the answer sheets for the previous Exercises B and C. If participants reached different answers in the previous exercises, then the activities that they list on the District TB Plan may be quite different. That is fine; just be sure that they have thought logically about the activities. Give each participant a copy of the first page of the answer sheets for Exercise D. Discussion After all participants have received individual feedback, lead a brief group discussion of question 7. Encourage participants to thoughtfully consider the practicality of the plan. Use the points for discussion provided on the second page of the answer sheets. Participants may have other ideas as well. Be sure to discuss the pros and cons of different options for supervisory visits to Cara Health Centre, and Denali and Emeral health posts. Be sure that participants understand that it is critical to spend enough time at each health facility to do a proper supervisory visit, as described in module C: Conduct Supervisory Visits for TB Control. It is not acceptable just to collect data from the TB Treatment Cards and then leave. Even if a health facility starts treatment for only one TB case per month, it is important to conduct a proper visit; with a small number of cases, the staff may need even more attention to stay motivated and keep their skills sharp. After the group discussion, give participants the second page of the answer sheets for Exercise D. Ask participants to return to page 18 of the module and read and work until the end of the module.

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I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise D Individual work Section A4: Laboratory support

Some of the following activities (or others listed by the group in Exercise B) should be added to the District TB Plan in section A4: c) d) e) f) g) h) i) Arrange to pay bus driver to deliver sputum samples to Bella Health Centre. Find out who are regular travellers on the road, and determine whether they can help with transportation of sputum samples. (Regular travellers could include trucks, taxis, or representatives of NGOs or community organizations.) Discuss with Nurse Natore what type of transportation would be most useful and appropriate. Research availability of new and used motorcycles or vehicles, types, features, fuel, and maintenance costs, etc. Meet with business associations to request donation or funds for motorcycle or other vehicle. Meet with other health programmes (e.g. immunization) to discuss sharing expense and use of motorcycle or other vehicle. Purchase motorcycle or vehicle (using funds from budget plus funds from other sources).

The persons listed as responsible should be logical, e.g. District TB Coordinator for all, as well as Nurse Natore for “e”, as well as head of the business association or other health programmes in “g” and “h”. Timing should be logical, probably early in the year. Section B2: Training

The following training activities (or others that seem logical based on the group’s decisions on where to expand) should be listed in section B2 of the District TB Plan: a) b) c) Arrange for 2 nurses from Cara HC and Emeral HP to take February course offered by province in Management of Tuberculosis. – TB coord., 7 Jan Health workers attend training above. – 2 nurses, 7–11 Feb Provide on-the-job training of additional staff at Cara and Emeral who will ask about cough. – TB coord., 3rd week of March

Training for a microscopist for Cara Health Centre could be included in section B2 or in section B4 under “laboratory support.” Times for all activities should be plotted on the Planning Chart.

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I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise D, continued

Points for discussion Possible problems that participants may notice with this plan include the following: • The District TB Coordinator really needs to meet with nurses at Cara Health Centre and Emeral Health Post before January in order to discuss plans and get commitment. Otherwise, he is signing them up for training, ordering increased supplies, etc., before getting their commitment. Many activities are planned for January. It will be a very busy month. Perhaps some activities could be moved to another month, or the starting date at Cara Health Centre and Emeral Health Post could be delayed to allow more time for planning, training, and preparation of the TB microscopy unit. Although it is a good idea to start services at Cara Health Centre and Emeral Health Post at the beginning of a quarter (1 April), it will be difficult to devote enough attention to both places at the same time. Consider delaying the start at Emeral Health Post until the next quarter. It is unlikely that Denali Health Post, Cara Health Centre, and Emeral Health Post can all be visited thoroughly in one day for supervisory purposes. It will probably be necessary to devote 2 days to the three facilities. Participants may discuss the pros and cons of different options, such as: – making two separate trips to visit the three facilities, – spending the night in Cara and going to Emeral the next day, – after TB control services are well-established at Emeral, making a long visit to Emeral every 2 months, as opposed to a hurried visit every month. The choice may depend on the availability of transportation and associated costs. For example, if the District TB Coordinator travels independently by motorcycle, an overnight stay would be less costly than if one had to pay and provide lodging for a driver overnight. • The plan does not allow for impact of various holidays, and events such as World TB Day (24 March), on the schedule. Holidays and other time-consuming events should be included in the plan.

•

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6. 7.

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Facilitator Guidelines for J: Field Exercise – Supervisory Visit Procedures 1. Find out about preparations made for the field exercise or make preparations. 2. Before the field exercise, distribute module J: Field Exercise – Supervisory Visit. Participants read pages 1–2 of the module. Introduce the field exercise and make assignments. 3. Participants do the field exercise: They visit a health facility to practise assessing the items on the supervisory checklist and completing Training Needs for TB Control. 4. Lead a discussion to analyse a performance problem observed at the health facility. 5. Conclude the module.

Feedback -----

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Group discussion -----

J-1

Preparations for the field exercise The course director will plan and schedule the visit to a health facility near the training site. (The participants may be divided into two or more groups, with each group visiting a different facility.) The field exercise should occur on the third day of the course or later. The exact timing of the field visit during the course will depend on the health facility or facilities to be visited and the logistics of transporting participants. The visit must take place after participants have completed module C: Conduct Supervisory Visits for TB Control. Participants will be able to assess more of the items on the checklist if they have also completed the following modules: • • E: Manage Drugs and Supplies for TB Control F: Ensure Laboratory Support for TB Control

The course schedule should allow a total of at least 3 hours for the field exercise, including transportation. At least 1.5 hours should be spent at the health facility. Planning should ensure that the visit will not disrupt the work of the health facility. The participants’ activities will depend on how much time health staff can spend to talk with them and guide their activities. In a very busy or crowded clinic, there is little room for participants, and the staff do not have time to answer questions from participants. Therefore, scheduling the visit carefully and limiting the number of participants in the facility at one time is critical. If the group is large (e.g. 8–10 participants), the participants should be divided into two groups to visit in shifts or to visit two different facilities. Thoughtful scheduling and preparation at the facility is important for a successful visit. The participants’ activities will also depend on the records available to them, whether TB patients are receiving treatment during the visit, and whether TB patients are willing to talk with participants. Meeting with the staff in advance to explain the purpose of the visit can greatly increase the willingness of the staff to talk with and help the participants. With advance notice, staff can make any necessary preparations for the participants to review a number of TB Treatment Cards, the Register of TB Suspects, and any recent results of self-monitoring done by the health facility. All the participants will not work on the same section of the checklist at the same time. Instead, they may work in pairs or groups of three on different sections. 2. Introducing the field exercise Distribute the module in advance so that participants have time to read the first 2 pages of the module and understand what they will do. It is best to distribute the module and ask participants to read it on the day before the field exercise.

J-2

When you distribute the module, explain the purpose and review the objectives on page 1. Explain that the module is not an instructional text like the others. Instead, it provides a copy of the Checklist for Supervisory Visits to Health Facilities Providing TB Control Services to use during the visit. It also includes a copy of a District TB Register and the chart, Training Needs for TB Control to complete during the visit. Ask participants to read pages 1–2 of the module and look through the rest of it. Inform the participants of the schedule for travel to the health facility. Making assignments After participants have finished reading the module, describe how the field exercise will be conducted. Explain that participants will take turns (working in pairs or groups of three) assessing different sections of the checklist. For example, one pair will review TB Treatment Cards for sections A and B, while another will examine drugs, supplies and the environment for sections D and K. At the same time, another pair may interview a health worker, observe case detection and treatment, and speak with patients to complete sections F, G, and H. When participants assess each item, they will tick yes or no and make notes on the checklist. Divide the participants into pairs or groups of three. Then assign each pair or group certain sections of the checklist to complete first. (If possible, make this first assignment before arriving at the health facility.) Assign sections together that use the same source of information. Sections that can be done conveniently together are grouped in bold lines in the table on page 2 of the module and listed together on the next page of this guide. Use the Assignment Chart on the next page to keep track of assignments. At the health facility, you will find that some assignments require longer to complete than others. When a pair finishes one assignment, give them another and record it on the Assignment Chart. Keep in mind that you want to spare the staff and patients repetitive interviews. (Participants will learn about any checklist sections that they did not work on themselves when the group discusses its findings after the field exercise.) This is not a formal data collection exercise. The information will not be tallied. Participants will discuss their findings for the purposes of learning. Discuss with the participants that they are practising some of the tasks of supervision at this health facility. They should take care not to offend the staff there. They may need to explain that they are not evaluating but are observing and asking questions in order to learn. Comment about Section A of the Supervisory Checklist: Participants are asked to enter information from 3 or 4 patients’ TB Treatment Cards in the District TB Register. Blank register pages are provided on pages 5 and 6 of this module. Notice that this task is not practised exactly as it would be done on the job, because participants do not have the actual District TB Register book. In the real situation, they would register the new patients and turn back in the book to update information on patients registered previously.

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Assignment Chart Participant name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Sections of Supervisory Checklist assigned 1st assignment 2nd assignment 3rd assignment

Field Exercise: Group activity – Visiting a health facility to practise using the Checklist for Supervisory Visits Travel to the health facility with the participants in your group. On arrival, find the person in charge and introduce yourselves. Ask for help and direction as needed to provide participants with access to the information sources needed to complete their first assigned section of the checklist. Section A, B C, J D, K Information sources needed to complete sections of the checklist TB Treatment Cards (3–4 per participant) Register of TB Suspects (or Tuberculosis Laboratory Register); monitoring results; health worker responsible for monitoring at the health facility Storage areas for supplies of anti-TB drugs; health workers who do TB case detection and treatment; access to areas where patients wait and are treated; access to microscopy unit (if there is one) The health facility supervisor, head nurse or health worker responsible for TB control services (who can provide the names of health workers who do TB case detection and treatment and information about their training); community TB treatment supporters, if available

E, I

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F, G, H

Health worker(s) who do TB case detection and treatment; area where outpatients are seen; interaction of TB patient with health worker while providing directly observed treatment; TB patients who have come for treatment (they will be interviewed after they have received the treatment)

Get the participants started, with each pair or group of participants working on different sections of the checklist. When they finish, make subsequent assignments so that they can move to another area of the health facility and work on other sections. Ensure that the participants are working, and assist when any participant cannot find the information needed or is not sure what to do. If any section is not possible to complete, or if a participant has quickly completed the assignment and has nothing to do, make additional assignments. After participants have been working for an hour or so, gather them together to end the exercise. Thank the staff for their help. 4. Group discussion – Analyse a performance problem observed at the health facility Conduct this discussion whenever you can. You may wait until all the participants meet back in the classroom, or it may be possible to have the discussion at another time when the participants are together, such as on the grounds of the health facility or on the bus. If possible, use a flipchart or blackboard to record the group’s ideas as you lead this discussion. First, allow the participants to comment on significant things that they observed or learned. If some participants completed sections of the checklist that others did not, for example, talking to TB patients, ask them to share their findings with the group. Continue the discussion by telling the participants that they are going to practise analysing a real performance problem, one that they identified in the supervisory visit to this health facility. Remind the participants that a performance problem is stated in the following terms: who is not doing what .

Ask for a volunteer to state a performance problem identified at the health facility. If the problem is not stated in terms of who is not doing what, ask the participants to help rephrase it, so that it is in the correct form for analysis. You may list a few performance problems (and write them on a flipchart if available) and then choose one to analyse. Refer participants to the diagram Analysing a performance problem on page 10 of the module. Ask a participant to consider the first of the causes listed on the left side of the page, and tell whether the cause applies. Repeat this process for each type of cause and, if it applies, ask the participant to state it specifically. For example, if the health worker lacks motivation, ask participants to state this cause more specifically, for

J-5

example, “The health worker does not like to take time to directly observe a TB patient swallowing the medication when there are many other patients waiting.” After listing all the possible causes, go back to each cause and state one or more possible solutions to each (refer to the box to the right of the cause). Ask participants to state a specific solution. For example, if training is needed, ask them to suggest what the training should address and how it might be done. If enough time remains, lead the group through the analysis of another performance problem. Repetition will help participants become accustomed to using this process for analysing performance problems. 5. Concluding the module Thank the participants for their work on the field exercise. Ask whether there are any questions and discuss them. Make any important points that you want to reinforce with these participants.

J-6

Guidelines for All Modules Facilitator Techniques A. Techniques for motivating participants

Encourage interaction

During the first day, you will talk individually with each participant several times (for example, during individual feedback). If you are friendly and helpful during these first interactions, it is likely that the participants: • • •

will overcome their shyness, will realize that you want to talk with them, and will interact with you more openly and productively throughout the course.

Look carefully at each participant’s work. Check to see whether participants are having any problems, even if they do not ask for help. If you show interest and give each participant undivided attention, the participants will feel more eager to do the work. Also, if the participants know that someone is interested in what they are doing, they are more likely to ask for help when they need it. Be available to talk with participants as needed.

Keep participants involved in discussions

Frequently ask questions of participants to check their understanding and to keep them actively thinking and participating. Questions that begin with “what,” “why,” or “how” require more than just a few words to answer. Avoid questions that can be answered with a simple “yes” or “no.” After asking a question, PAUSE. Give participants time to think and volunteer a response. A common mistake is to ask a question and then answer it yourself. If no one answers your question, rephrasing it can help to break the tension of silence. But do not do this repeatedly. Some silence is productive.

Acknowledge all participants’ responses with a comment, a “thank you” or a definite nod. This will make the participants feel valued and encourage participation. If you think a participant has missed the point, ask for clarification, or ask whether another participant has a suggestion. If a comment is ridiculed or ignored, the participant may withdraw from the discussion entirely or not speak voluntarily again. Answer participants’ questions willingly, and encourage participants to ask questions when they have them rather than to hold the questions until a later time. Do not feel compelled to answer every question yourself. Depending on the situation, you may turn the question back to the participant or invite other participants to

6. 7.

All-1

respond. You may need to discuss the question with the course director or another facilitator before answering. Be prepared to say, “I don’t know but I’ll try to find out.” 8. 9. Use names when you call on participants to speak and when you give them credit or thanks. Use the speaker’s name when you refer back to a previous comment. Maintain eye contact with the participants so everyone feels included. Be careful not to always look at the same participants. Looking at a participant for a few seconds will often prompt a reply, even from a shy participant.

Keep the session focused and lively

10.

Keep your presentations lively: • • •

Present information conversationally rather than read it. Speak clearly. Vary the pitch and speed of your voice. Use examples from your own experience, and ask participants for examples from their experience.

11.

Write key ideas on a flipchart as they are offered. (This is a good way to acknowledge responses. The speaker will know that the idea has been heard and will appreciate having it recorded for the entire group to see.) When recording ideas on a flipchart, use the participant’s own words if possible. If you must be more brief, paraphrase the idea and check it with the participant before writing it. You want to be sure the participant feels that you understood and recorded the idea accurately. Do not turn your back to the group for long periods as you write.

12.

At the beginning of a discussion, write the main question on the flipchart. This will help participants stay focused on the subject. As needed, walk to the flipchart and point to the question. Paraphrase and summarize frequently to keep participants focused. Ask participants for clarification of statements as needed. Also encourage other participants to ask speakers to repeat or clarify statements as needed. If the discussion loses focus, first pause to get the group’s attention, and tell them they have gone astray. Restate the original question to the group to get them focused on the main issue again. Do not allow several participants to talk at once. When this occurs, stop the talkers and assign an order for speaking. (For example, say, “Let’s hear Dr Samua’s comment first, then Dr Salvador’s, then Dr Lateau’s.”) People usually will not interrupt if they know they will have a turn to talk. Thank participants whose comments are brief and to the point.

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13.

Try to encourage quieter participants to talk. Ask to hear from a participant in the group who has not spoken before, or walk towards someone to encourage that person to talk.

Manage any problems

14.

Some participants may talk too much. Here are some suggestions on how to handle an overly talkative participant: • •

Do not call on this person first after asking a question. After a participant has gone on for some time say, “You have had an opportunity to express your views. Let’s hear what some of the other participants have to say on this point.” Then rephrase the question and invite other participants to respond, or call on someone else immediately by saying, “Dr Samua, you had your hand up a few minutes ago.” When the participant pauses, break in quickly and ask to hear from another member of the group or ask a question of the group, such as, “What do the rest of you think about this point?” Record the participant’s main idea on the flipchart. As the participant continues to talk about the idea, point to it on the flipchart and say, “Thank you, we have noted your idea.” Then ask the group for another idea. Do not ask the talkative participant any more questions. If the same participant answers all the questions directed to the group, ask for an answer from another individual specifically or from a specific subgroup. (For example, ask, “Does anyone on this side of the table have an idea?”)

•

15.

Try to identify participants who have difficulty understanding or speaking the course language. Speak slowly and distinctly so you can be more easily understood, and encourage the participant’s efforts to communicate. Discuss with the course director any language problems that seriously impair the ability of a participant to understand the written material or the discussions. It may be possible to arrange help for the participant. Discuss disruptive participants with your co-facilitator or with the course director. (The course director may be able to discuss matters privately with the disruptive individual.)

Reinforce participants’ efforts

16.

As a facilitator, you will have your own style of interacting with participants. However, a few techniques for reinforcing participants’ efforts include: •

avoiding use of facial expressions or comments that could cause participants to feel embarrassed,

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• • • •

sitting or bending down to be on the same level as participants when talking to them, answering questions thoughtfully, rather than hurriedly, encouraging participants to speak to you by allowing them time, appearing interested, saying, “That’s a good question/suggestion.”

17.

Reinforce participants who: • • • • •

try hard, ask for an explanation of a confusing point, do a good job on an exercise, participate in group discussions, or help other participants (without distracting them by talking at length about irrelevant matters).

B. 1. 2.

Techniques for relating modules to participants’ jobs Discuss the use of procedures taught in the modules in participants’ own districts. This will help participants begin to think about how to apply what they are learning. Reinforce participants who discuss or ask questions about using the procedures in their own districts. Acknowledge and respond to their concerns.

C. 1.

Techniques for co-facilitators to work together Spend some time with the co-facilitator when assignments are first made. Exchange information about prior teaching experiences and individual strengths, weaknesses and preferences. Agree on roles and responsibilities and how you can work together as a team. Assist one another in providing individual feedback and conducting group discussions. For example, one facilitator may lead a group discussion, and the other may record the important ideas on the flipchart. The second facilitator could also check the Facilitator Guide and add any points that have been omitted. Each day, review the teaching activities that will occur the next day and agree who will do what (lead the discussion, collect the supplies, present an example using the overhead projector, etc.). Work together on each module rather than taking turns having sole responsibility for a module.

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Guidelines for All Modules

When participants are working: • •

Look available, interested and ready to help. Watch the participants as they work, and offer individual help if you see a participant looking troubled, staring into space, not writing answers, or not turning pages. These are clues that the participant may need help. Encourage participants to ask you questions whenever they need some help. If important issues or questions arise when you are talking with an individual, make note of them to discuss later with the entire group. If a question arises that you cannot answer adequately, obtain assistance as soon as possible from another facilitator or the course director. Review the points in this Facilitator Guide so you will be prepared to discuss the next exercise with the participants.

• •

•

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Guidelines for All Modules

When providing individual feedback: •

Before giving individual feedback, refer to the appropriate notes in this guide to remind yourself of the major points to make. Compare the participant’s answers to the answer sheet. If the participant’s answer to any exercise is incorrect or is unreasonable, ask questions to determine why the error was made. There may be many reasons for an incorrect answer. For example, a participant may not understand the question, may not understand certain terms used in the exercise, or may not understand a basic process being taught. Once you have identified the reason(s) for the incorrect answer to the exercise, help the participant correct the problem. For example, you may only need to clarify the instructions. However, if the participant has difficulty understanding the process itself, you might try using a specific example to explain. After explaining, ask questions to be sure that the participant understands. Give the participant a copy of the answer sheet, if one is provided. Always reinforce the participant for good work by (for example): – – – – commenting on how well the participant understands, showing enthusiasm for the participant’s ideas for application of the skill in the job setting, mentioning that you enjoy discussing exercises with the participant, commenting that the participant’s hard work is appreciated.

• •

•

• •

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Guidelines for All Modules

When leading a group discussion: •

Plan to conduct the group discussion at a time when you are sure that all participants will have completed the preceding work. Wait to announce this time until most participants are ready, so that others will not hurry. Before beginning the discussion, refer to the appropriate notes in this guide to remind yourself of the purpose of the discussion and the major points to make. Begin the group discussion by telling the participants the purpose of the discussion. Often there is no single correct answer that needs to be agreed on in a discussion. Just be sure the conclusions of the group are reasonable and that all participants understand how the conclusions were reached. Try to get most of the group members involved in the discussion. Record key ideas on a flipchart as they are mentioned. Keep your participation to a minimum, but ask questions to keep the discussion active and on track. At the end of the discussion, summarize the group’s conclusions or important points that were made. Give participants a copy of the answer sheet, if one is provided. Reinforce the participants for their good work by (for example): – praising them for the list they compiled, – commenting on their understanding of the exercise, – commenting on their creative or useful suggestions for using the skills on the job, – praising them for their ability to work together as a group.

•

• •

•

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Schedule for the course This schedule should provide enough time to do all the work in the classroom setting. Homework is discouraged. If some participants get very far ahead while working at home, they may be bored in class the next day. Also, it is best if facilitators are present while participants are working in order to answer questions.

Activity Registration and opening presentation Day 1 Module A: Introduction Module B: Faba District Module C: Conduct Supervisory Visits for TB Control Module D: Provide Training for TB Control Day 2 Module E: Manage Drugs and Supplies for TB Control Prepare for field exercise Module F: Ensure Laboratory Support for TB Control Day 3 Module J: Field Exercise–Supervisory Visit* Module G: Monitor and Evaluate TB Control Discussion of field exercise Module H: Advocacy and Collaboration for TB Control Day 5 Module I: Develop the District Plan of Action for TB Control Closing session

Time 0.5 hour 1.5 hours 5 hours 3 hours 3.5 hours 0.5 hour 4 hours 3 hours 7 hours 0.5 hour 2.5 hours 4 hours 0.5 hour

Day 4

* Timing of the field exercise may depend upon local circumstances, the locations and hours of health facilities to be visited, etc.

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Overhead transparencies for Modules B, G, and I

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Overhead A

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Overhead B TALLY SHEET: QUARTERLY REPORT ON TB CASE REGISTRATION Name of district: ____________________ District no.: ___________ Name of District TB Coordinator: _____________________ Signature: ______________________________________ Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) or not tested (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Patients registered during _____ quarter of year______

Date of completion of this form: _______________________

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

F Block 3. PREVIOUSLY TREATED CASES (Smear-positive) Relapse Treatment after failure Treatment after default Other

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Overhead C

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Overhead D

TALLY SHEET: QUARTERLY REPORT ON SPUTUM CONVERSION Name of district: _____________________________ Faba District no.: ___________ 4 Patients registered during 2004 _____ 2nd quarter of year______* Date of completion of this form: 4/10/04 ____________________ Sputum conversion at: 2 months 3 months

Name of District TB Coordinator: ___________________

Oke Karimi

Oke Karimi Signature: _____________________________________ Number of new smear-positive cases Smear not done at registered in quarter either 2 or 3 months recorded above**

Did not convert:

Total converted at 2 or 3 months:

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Overhead E

QUARTERLY REPORT ON TB CASE REGISTRATION

Faba Name of district: ____________________ 4 District no.: ___________ Oke Karimi Name of District TB Coordinator: _____________________ Oke Karimi Signature: ______________________________________

Patients registered during 3rd quarter of year______ 2003 _____

Date of completion of this form: _______________________ 6/10/03

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

4 3

13 6

2 2

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

* In areas routinely using culture, a separate form for reporting culture-positive patients should be used. ** Other cases may include patients with unknown history of previous treatment.

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Overhead F Tally sheet: Quarterly Report on Treatment Outcomes Oke Karimi Name of District TB Coordinator:__________________ Signature: _________________ Oke Karimi Date of completion of this form: _____________________ 4/10/04 Treatment outcomes Cure Treatment completed (2) (3) (4) (5) Died Treatment failure Default Patients registered during 3rd quarter of year ______* 2003 ______

Faba Name of district:_____________

District no.:___________ 4

Type of case

Total number of pulmonary patients registered during quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1.1 Smear (+)

1. New

1.2 Smear (–)

2.1 Relapses

2. Re-treatment (smear-positive)***

2.2 Treatment after failure

2.3 Treatment after default

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Overhead H FABA DISTRICT Population of Faba District: 150 000 Population of Agraville: 45 000 1 cm _____ = 4 km F = private clinic = paved road = dirt road

Ferro Health Post

Ferro River bed

Irini village

H* B* Bella Health Centre

High Road Health Post

Prison

A* Agraville

Agraville Hospital

G* Gadara Health Post

Denali Health Post

Cara Health Centre

Emeral Health Post

Health facility A*

Type MOH

Services provided

Outpatient load (2003) 52 800 21 100 16 000 8 000 6 000 4 000 8 000 6 000

TB cases (2003) 132 72 17 12 7

inpatient and outpatient, physician, microscopy unit, X-ray B* MOH outpatient, physician C MOH outpatient, nurse D* MOH outpatient, nurse E MOH outpatient, nurse F MOH outpatient, nurse G* MOH outpatient, nurse H* MOH outpatient, nurse * providing TB services in 2004 MOH = ministry of health

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WHO/HTM/TB/2005.347m

Management of Tuberculosis Training for District TB Coordinators

ANSWER SHEETS

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

C: Conduct Supervisory Visits for TB Control

3. 4. 5.

C: Conduct Supervisory Visits for TB Control

You should also have written the District TB number on each new patient’s TB Treatment Card (on pages 49 and 50).

C: Conduct Supervisory Visits for TB Control Answers to Exercise B, continued

Answers to questions on page 51 of module: 3a) Yes, F-150, Olga Goizuetta, is due for a 2-month sputum examination in the next couple of weeks. 3b) Yes, F-64, Rafael Lazare is a treatment failure, as he was still positive at the end of 5 months of treatment. Action should be taken immediately (see below). 3c) The TB Coordinator should consider Rafael Lazare a treatment failure and talk to the health staff about starting this patient on Category II treatment at his next visit. This treatment outcome should be marked on the card and in the District TB Register. A patient who is a treatment failure should be re-registered and given a new District TB number. Record the former District TB number under “Remarks.” (If you wrote this patient on the last page of the register, giving him the District TB number F-172 or F-174, this is correct.) “Date treatment started” should be left blank in the register until the Category II treatment is actually started. The sputum examination result to record under “Before treatment” is the one from 19-8-04. The health facility should open a new TB Treatment Card; type of patient will be Treatment after failure; note the former District TB number, F-64, on the card under “Observations.”

C: Conduct Supervisory Visits for TB Control Possible answers to Exercise D

Health worker

Mary Lang

TB case detection, treatment of TB patients, recordkeepings, drug supplies

18/12/03 Feb 2004 10/6/04

NT RT C

Send to Management of TB course, Feb 2004 Attended Management of TB course

AJ Perera

Treats TB patients when busy and on Saturday

18/12/03 10/6/04

NT X

Send to Management of TB course, July 2004 Transferred to Patanga District

Samia Shiva

Treats TB patients when filling in for Mary Lang

10/6/04

Send to Management of TB course, July 2004

Update on a supervisory visit every 6 months or whenever there are changes in staff who perform TB case detection and treatment. Also update when staff receive training.

D: Provide Training for TB Control

Information

D: Provide Training for TB Control

2. 3.

D: Provide Training for TB Control Answers to Exercise B, continued

The training should be held at a central location in the district.

E: Manage Drugs and Supplies for TB Control

22 12 3 3 3

3 2

11 4

TOTAL

Ordering Worksheet: Pre-packaged kits of anti-TB drugs to order to treat adult patients in the district during one quarter Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: • • • 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 58 patients 5 patients

Instructions: Complete one worksheet for the district. Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients 58 5 B Multiply by 2 for reserve stock Ax2=B 116 10 C Estimated stock on last day of previous quarter 50 6 D Number to order after subtracting current stocks B–C=D 66 kits 4 kits

Kit (or drug) and category of patient who a needs it Category I and III kits Category II kits

E: Manage Drugs and Supplies for TB Control

Answers to Exercise B Distribution Worksheet: Kits of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter Agraville Hospital (name of health facility)

Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: • • • 2(HRZE)S / 1(HRZE) /5(HR)3E3 :

33 3

patients patients

Instructions: Complete a separate worksheet for each health facility. Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients 33 3 B Multiply by 2 for reserve stock Ax2=B 66 6 C Estimated stock on last day of previous quarter 21 5 D Number to distribute after subtracting current stocks B-C=D 45 1

Kit (or drug) and category of patient who needs it Category I and III kits Category II kits

E: Manage Drugs and Supplies for TB Contro

22 12 3 3 3

3 2

11 4

TOTAL

E: Manage Drugs and Supplies for TB Control Answers to Alternative Exercise A, continued

Instructions: Complete one worksheet for the district.

• • •

Drug and category of a patient who needs it

Tablets and vials needed to treat expected patients ( 58 x 168 tablets) + ( _5_ x 252 tablets) = 11 004_ tablets

Combination (HRZE) (Cat I + III) + (Cat II) Combination (HR) (H150 R150 mg) (Cat I + III) + (Cat II)

22 008

9 900

12 108 tablets

( 58_ x 144 tablets) + ( 5 x 180 tablets) = 9 252 tablets 5 x 240 tablets 1 200 tablets 5 = x 56 vials 280 vials

18 504

8 300

10 204 tablets

Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

2 400

1 100

1 300 tablets

560

320

240 vials

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. Supplies for giving streptomycin injections may also be added to the order.

E: Manage Drugs and Supplies for TB Control

Daily treatment in the initial phase (28 doses per month) and Intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: • • • 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 33 3 patients patients

Instructions: Complete a separate worksheet for each health facility. Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Drug and category of patient who needs it Tablets and vials needed to treat expected patients ( 33 x 168 tablets) + ( 3 x 252 tablets) = 6 300 tablets B Multiply by 2 for reserve stock Ax2=B 12 600 C Estimated stock on last day of previous quarter 4 800 D Amounts to distribute after subtracting current stocks B-C=D

Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

7 800 tablets

( +(

33 x 144 tablets) 3 x 180 tablets) = 5 292 tablets 3 = = x 240 tablets 720 tablets 3 x 56 vials 168 vials

10 584

3 900

6 684 tablets

1 440 336

1 200 275

240 tablets 61 vials

F: Ensure Laboratory Support for TB Control

Answers to Exercise B 2. a) How many workdays are in a quarter? 66 b) 1 960 smear examinations performed = 30 examinations per day by the microscopist 66 workdays

F: Ensure Laboratory Support for TB Control

F: Ensure Laboratory Support for TB Control Answers to Exercise C, continued

You may also check: −

−

G: Monitor and Evaluate TB Control

Possible Answers to Exercise A Situation 1: 1. While at High Road Health Post, the District TB Coordinator should: • • • •

Later, the District TB Coordinator should: • • • •

G: Monitor and Evaluate TB Control

Date of completion of this form: 4/10/04 _______________________

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

0 0

3 3

16 6

5 1

0 2

0 0

24 12

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

G: Monitor and Evaluate TB Control

Total converted at 2 or 3 months:

QUARTERLY REPORT ON TREATMENT OUTCOMES

Faba Name of district:_____________

Oke Karimi Name of District TB Coordinator:__________________

Patients registered during 3rd quarter of year 2003 _____ ______* Date of completion of this form: 4/10/04 _____________________

4 District no.:___________ Treatment outcomes Cure Treatment completed (2) (3) (4) (5) Died Treatment failure Default

Oke Karimi Signature: _________________

Type of case

Total number of pulmonary patients registered during the quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1. New

1.1 Smear (+)

32 10 2 2 2 1

3 4

32 15 2 2 1 3

1.2 Smear (–)

2.1 Relapses

2.2 Treatment after failure

G: Monitor and Evaluate TB Control Answers to Exercise D

*** In areas routinely using culture, a separate form for culture-positive patients should be used.

2. Re-treatment (smear-positive)***

2.3 Treatment after default

G: Monitor and Evaluate TB Control

Indicator

Ratio of TB suspects tested to outpatients aged 15 years and older

600 4% 15 000

Proportion of TB suspects tested who were sputumsmear positive (positivity rate)

42 7% 600

G: Monitor and Evaluate TB Control

Indicator

Proportion of TB cases who were sputum smear-positive

Number of TB cases who were sputum smearpositive

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the new sputum smear-positive cases (Block 1, Column 1) and all cases recorded in Block 3.

45 68%

Total TB cases

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the total new cases (Block 1, Column 4) and all cases recorded in Block 3.

G: Monitor and Evaluate TB Control

Quarterly Report on Sputum Conversion, bottom row Quarterly Report on Sputum Conversion, first column

35 85% 41 22 69% 32 3 9% 32 2 6% 32 1 3% 32 3 9% 32 1 3% 32

Number of new sputum smearpositive TB cases with outcome cure Total new sputum smearpositive TB cases

Quarterly Report on Treatment Outcomes, line 1.1, column 1 Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Treatment completed

Died

Treatment failure

Default

Transfer out (out of district)

G: Monitor and Evaluate TB Control

b. c.

G: Monitor and Evaluate TB Control

For the first cause listed above, some possible root causes are: • • •

For the root causes listed in question 2, some possible solutions are as follows: Possible root cause Possible solution

Similar problem-solving tables could be made for the root causes of other causes listed in question 1.

H: Advocacy and Collaboration for TB Control

Possible Answers to Exercise A 1. Dr Karimi should attempt to answer questions such as the following. You should have listed several questions of this type. • • • • • • • •

• • • • •

* It is critical that patients know where to get free anti-TB drugs. Having to purchase drugs often leads to default.

I: Develop the District Plan of Action for TB Control

•

• • • •

I: Develop the District Plan of Action for TB Control

• 4.

The target should state that 7 out of 8 public health facilities will provide TB control services in 2005.

Answers to 5 and 6 will be based on the participant’s own situation in his or her district. 33

I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise D Individual work Section A4: Laboratory support

Training for a microscopist for Cara Health Centre could be included in section B2 or in section B4 under “laboratory support.” Times for all activities should be plotted on the Planning Chart.

I: Develop the District Plan of Action for TB Control

Possible Answers to Exercise D, continued

•

WHO/HTM/TB/2005.347l

Management of Tuberculosis Training for District TB Coordinators

L TUBERCULOSIS LABORATORY REGISTER

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Tuberculosis Laboratory Register for TB Microscopy Unit at Agraville Hospital 2004

Note: Entries begin on 12 April 2004 (1 January – 11 April 2004 not included)

WHO/HTM/TB/2005.347k

Management of Tuberculosis Training for District TB Coordinators

DISTRICT TUBERCULOSIS REGISTER

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators This set of training modules has been prepared by the Stop TB Department, World Health Organization, Geneva. The project was coordinated by Karin Bergström. Malgosia Grzemska and Fabio Luelmo were the main technical advisers. The modules were designed and developed by Florence C. Johnson and Patricia Whitesell Shirey of ACT International, Atlanta, Georgia, USA. The American Thoracic Society (ATS), the Centers for Disease Control and Prevention (CDC), Atlanta and the Royal Netherlands Tuberculosis Association (KNCV) have all contributed to the development of the modules through the Task Force Training (TFT) of the Tuberculosis Coalition for Technical Assistance (TBCTA). The modules were field-tested in South Africa through the support of the National Tuberculosis Control Programme of South Africa.

District Tuberculosis Register for Faba District: 3rd Quarter of 2003 2nd Quarter of 2004 3rd Quarter of 2004

The 4th quarter of 2003 and 1st quarter of 2004 are not shown. The next excerpts are from the 2004 Faba District Tuberculosis Register: 2nd Quarter of 2004 3rd Quarter of 2004

DISTRICT

WHO/HTM/TB/2005.347j

Management of Tuberculosis Training for District TB Coordinators

J FIELD EXERCISE – SUPERVISORY VISIT

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Field Exercise – Supervisory Visit Contents Page Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................1 How the field exercise will be conducted ............................................................................2 Checklist for Supervisory Visits to Heath Facilities Providing TB Control Services..........3 District TB Register .............................................................................................................6 Training Needs for TB Control ............................................................................................8 Discussion after the visit......................................................................................................9 Analysing a performance problem.....................................................................................10

Field Exercise – Supervisory Visit Introduction For the field exercise you will visit a health facility or hospital outpatient department where TB case detection and treatment are ongoing. The field exercise is an opportunity to practise some of the steps that you have learned in this course, Management of Tuberculosis: Training for District TB Coordinators. The field exercise is important to help you transfer what you have learned into a real-world setting. This module includes the Checklist for Supervisory Visits to Health Facilities Providing TB Control Services, which was taught in module C: Conduct Supervisory Visits for TB Control. This checklist includes questions to answer and items to observe. You will assess as many of the items on the checklist as possible during the field exercise and make notes on the checklist. This will include making entries in a District TB Register and completing the chart Training Needs for TB Control for the health facility you visit.

Objectives of this module Participants will visit a health facility to: • • • • Complete the Checklist for Supervisory Visits to Health Facilities Providing TB Control Services while visiting a real health facility. Make entries in a District TB Register. Complete the chart, Training Needs for TB Control, for this health facility. Analyse a performance problem observed at the health facility.

On return to the classroom, participants will:

How the field exercise will be conducted The Checklist for Supervisory Visits to Health Facilities Providing TB Control Services includes 12 sections. The number of sections that you are able to complete will depend on the agreement the course director has made with the officer in charge at the health facility and the specific assignments given to you by your facilitator. Your facilitator may assign different sections of the checklist to different participants. Your activities will also depend on the records available, whether TB patients are present during the visit, how much time health staff can talk with you, and whether TB patients are willing to talk with you. During the visit you will use the checklist that begins on the next page and is summarized in the table below. Sections/activities that can be conveniently done together are grouped in bold lines. You will write on the supervisory checklist, so be sure to bring this module with you. After the visit, you will refer to your notes for a discussion in the classroom.

Section

Participant’s activity to complete checklist section Given 3 or 4 TB Treatment Cards of current TB patients and patients who have recently completed treatment, enter each patient’s information in a District TB Register (pages 5 and 6 in this module). Examine the TB Treatment Cards to assess how TB cases are provided treatment. Review the Register of TB Suspects and/or Tuberculosis Laboratory Register to assess TB case detection and recording of results. Ask the health worker responsible for TB control services to review with you any recent monitoring results. Examine supplies of anti-TB drugs, where they are stored, as well as sputum containers, needles, syringes, diluent, sterilizer, and TB forms. Ask health workers whether quantities of supplies are adequate. Look at the work environment to assess ventilation, patient flow, organization, etc. Ask health facility supervisor, senior nurse, or health worker responsible for TB control services about the staff who do TB case detection and treatment. Also fill out a chart, Training Needs for TB Control. Talk to community TB treatment supporters, if available, to assess their training, supervision, and performance. Ask health workers who do TB case detection and treatment whether they have any questions or problems. In the area where outpatients are seen, observe whether all adults are asked about cough and TB suspects are identified. When TB patients come for treatment, observe how the health worker carries out the steps of TB treatment. Talk to TB patients to assess what they know about their disease and its treatment (after they have completed their interaction with the health worker). Complete this section after the visit.

A B C J D K E I F G H L

Your facilitator will make some assignments before the field exercise and give more instructions on arrival at the health facility.

Checklist for Supervisory Visits to Health Facilities Providing TB Control Services Health facility .............................. District TB Coordinator................................... Health worker responsible for TB control .............................................. Date ............................

Review TB Treatment Cards for all current TB patients and those who recently completed treatment. Register all newly-detected cases. Update the District TB Register for other patients. Also check TB Treatment Cards: 1. Is each patient on the correct treatment regimen? 2. Are sputum examination results recorded correctly? 3. Do TB Treatment Cards indicate that all patients are receiving directly observed treatment? Is treatment regular and correctly recorded? 4. Are patients undergoing smear examination at 2 months (3 months if Category II)? 5. Are patients undergoing smear examination at 5 months and during the last month of treatment? 6. Are patients who are smear-positive at 2 months (at 3 months for Category II) receiving 1 more month of initial-phase drugs? 7. For each patient who has completed treatment, is the information on the TB Treatment Card sufficient to determine treatment outcome? Review Register of TB Suspects and/or TB Laboratory Register (if available): 1. Does the facility have a Register of TB Suspects? 2. If yes, are the results of sputum smear microscopy written in the Register of TB Suspects? 3. Is there only a reasonable delay between sending sputum to receiving microscopy results? 4. If the facility has both a Register of TB Suspects and a TB Laboratory Register in the facility, do the microscopy results recorded in them match? 5. Do results in the Register of TB Suspects match the results recorded on the TB Treatment Card? 6. Have all the smear-positive patients started treatment? Examine and ask about supplies. Is there: 1. An adequate supply of anti-TB drugs? Are anti-TB drugs well-maintained, not expired? Note quantities in stock: ………………………………………………. 2. An adequate supply of needles, syringes and diluent for injections? 3. A system for safe disposal of needles and syringes? 4. An adequate supply of co-trimoxazole for TB/HIV patients? 5. An adequate supply of sputum containers? Number in stock: ………………. 6. A sterilizer in good working condition (if required)? 7. An adequate supply of: – TB Treatment Cards? – Request for Sputum Examination Forms? – Tuberculosis Referral/Transfer Forms? Page 1 * Tick YES or NO for each question. Any NO answer indicates a problem that should be addressed. For each problem, investigate to determine causes of the problem and possible solutions. YES* NO*

YES

Update the chart when there are changes.

Observe health workers with patients if possible. Do they: 1. Ask all adult outpatients about cough and correctly identify TB suspects? 2. Send TB suspects to laboratory or collect sputum samples for examination? 3. Collect sputum outdoors or in a well-ventilated area? 4. Administer the correct drugs for the treatment regimen? 5. Watch patients swallow the tablets? 6. Tick the TB Treatment Card after watching the patient swallow the tablets? 7. Correctly give a streptomycin injection after the tablets have been swallowed? (if applicable) 8. Give each injection with a sterile syringe and needle? (if applicable) 9. Inform TB suspects/patients about TB in a considerate and appropriate manner? 10.Inform TB patients about HIV testing? Provide or refer patients to HIV testing services? Talk to TB patients, if available. Do patients know: 1. What disease they are suffering from? 2. The number of tablets per day to take? 3. When to come back for the next appointment? 4. The duration of treatment? 5. What to do when they experience problems (side-effects)? 6. Why sputum examinations are needed? 7. How TB spreads? 8. Who else in the household should be examined or tested for TB? Ask whether the patient has any problems that may prevent completing treatment. Talk to community TB treatment supporters, if available. Ask: 1. How many TB patients do you currently support? 2. Examine each patient’s TB Treatment Card, if available. Is it marked correctly? 3. Did you receive sufficient training to prepare you to be a TB treatment supporter? 4. How often does a supervisor from the health facility check your work and your patients’ TB Treatment Cards? 5. Have you ever run out of drugs to treat your TB patients? 6. What do you do when a TB patient interrupts (stops coming for) TB treatment? Answer any questions from the TB treatment supporter. P1

YES

TS 1

TS 2

TS 3

Page 2

Quarterly Ask the health worker responsible for TB control about recent monitoring results. Has the health worker calculated the following for appropriate quarters? If so, what are the results? 1. The total number of TB cases currently on treatment? 2. The proportion of outpatients aged 15 years and older who were identified as TB suspects? 3. The proportion of TB suspects tested who were sputum smear-positive? 4. The proportion of new sputum smear-positive TB cases that converted at 2 or 3 months (sputum conversion rate)? 5. The proportion of new sputum smear-positive cases that – were cured? – completed treatment? Look at the work environment. 1. Is there good ventilation in the waiting area, in patient care areas, and where treatment of TB patients is directly observed? 2. Is the patient flow arranged to minimize the time that TB suspects and TB patients are with or pass by other patients? 3. If there is a microscopy unit, does it have good air flow? Are the work area, slides, and supplies well organized and maintained? Observations from this supervisory visit:

Write the figures below

YES

Describe problems identified during this visit:

Possible causes of the problems:

Actions and recommendations:

Page 3

DISTRICT TUBERCULOSIS REGISTER – LEFT SIDE OF THE REGISTER BOOK Sex Age M/F Complete Address R F D T Health Facility Type of Patient** O Date Disease Treatment Treatment Site Category* N Started P/EP

Date of Registration

District TB No.

Name

*Enter the treatment category:

**Enter only one code:

CAT I: New smear-positive case, or New case (seriously ill smear-negative or seriously ill EP), e.g. 2(HRZE)/4(HR)3

CAT II: Re-treatment, e.g. 2(HRZES)/1HRZE/5(HR)3E3

CAT III: New case (smear-negative or EP), e.g. 2(HRZ)/4(HR) 3

N: New – A patient who has never had treatment for TB or who has taken anti-TB drugs for less than 1 month R: Relapse – A patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB F: Treatment after failure – A patient who is started on a re-treatment regimen after having failed previous treatment D: Treatment after default – A patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more T: Transfer in – A patient who has been transferred from another TB register to continue treatment O: Other – All cases that do not fit the above definitions. (This group includes chronic case, a patient who is sputumpositive at the end of a re-treatment regimen.)

DISTRICT TUBERCULOSIS REGISTER – RIGHT SIDE OF THE REGISTER BOOK Outcome of Treatment and Date †† End of treatment Date Result Lab No. Cure Failure Died Default Transfer out Completed

Results of Sputum Examination Remarks Date 5 months Result Lab No.

Before treatment Date Result Lab No.

2 or 3 months † Date Result Lab No.

† CAT I patients have follow-up sputum examination at 2 months; CAT II patients have follow-up sputum examination at 3 months.

†† Enter date in the appropriate column: Cure……………Sputum smear-positive patient who is sputum smear-negative in the last month of treatment and on at least one previous occasion Treatment completed…….Patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure Treatment failure…………Patient who is sputum smear-positive at 5 months or later during treatment (also a patient who was initially smearnegative and became smear-positive at 2 months) Died……………Patient who dies for any reason during the course of treatment Default………...Patient whose treatment was interrupted for 2 consecutive months or more Transfer out….Patient who 7 has been transferred to another recording and reporting unit and for whom treatment outcome is not known

Training Needs for TB Control Health facility: ______________________ Responsibilities for TB case detection and treatment Date of visit or a training Enter C (competent), NT (needs training), RT (received training), or X (no longer on staff). Enter comments on the right.

Health worker

Update information every 6 months, or whenever there are changes in staff who perform TB case detection and treatment. Also update when staff receive training.

• • •

Discussion after the visit – Analysing a performance problem

On return to the classroom, be prepared to: Report to the rest of the participants what you observed and discussed with health staff. You can use the notes you have made in this module. In a discussion, analyse a performance problem observed at the health facility. Your facilitator will lead the discussion. The figure, analysing a performance problem, appears on the next page for your reference. Discuss whether you can use the supervisory checklist when you conduct supervisory visits in your district.

Analysing a performance problem State a problem. Describe the problem, if possible, in terms of who is not doing what. Ask: Is it important? If not, describe a different problem to analyse. If the problem is important, analyse the causes of the problem in order to find a solution. A problem may have several causes, so consider them all.

Consider all these causes Has the task been clearly described and assigned?

Then plan solutions to address the causes • Clearly describe and assign the

If not, assign it

task to one or more health workers.

• If the health worker used to do

Does the health worker lack the skill or knowledge to do the task?

If yes, training is needed

the task, arrange for him or her to have brief refresher training with practice and feedback. • If the task is new to the health worker, arrange for training to provide the skill and knowledge.

• If there is a disadvantage to the

Does the health worker lack motivation to do the task (e.g. it is difficult, distasteful, less rewarding than other tasks, brings ridicule)?

If yes, positive consequences are needed

health worker for doing this task, remove the disadvantage. • If there is an advantage to doing this task poorly or not at all, arrange a positive consequence for doing the job well. • If the performance is not important to the health worker, make it important.

Are there obstacles that prevent or hinder the health worker from doing the task (e.g. lack of time, supplies, authority)?

If yes, obstacles should be removed

• Remove the obstacles or decrease

their effect.

WHO/HTM/TB/2005.347g

Management of Tuberculosis Training for District TB Coordinators

MONITOR AND EVALUATE TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Monitor and Evaluate TB Control Contents Page

Calculate and analyse indicators...............................................................................25 4.1 4.2 4.3 4.4 Calculate and analyse indicators related to case detection ..............................26 Calculate and analyse indicator related to quality of diagnosis.......................29 Calculate and analyse indicators related to TB treatment................................30 Graph progress towards district target for sputum conversion ........................33

5. 6. 7.

If monitoring reveals problems, investigate the causes and try to solve the problems..............................................................................................................34 Conduct periodic district meetings of health facility staff responsible for TB control services ..........................................................................36 Evaluate achievement of annual district targets........................................................36 7.1 Evaluate achievement of sputum conversion target.........................................37 7.2 Evaluate achievement of target for expansion of TB control services ............37 7.3 Summarize evaluation results and recommendations ......................................38

Summary of important points ............................................................................................39 Self-assessment questions..................................................................................................41 Answers to self-assessment questions ...............................................................................43

Exercises ............................................................................................................................45 Exercise A.................................................................................................................46 Exercise B .................................................................................................................48 Exercise C .................................................................................................................52 Exercise D.................................................................................................................56 Exercise E .................................................................................................................61 Exercise F..................................................................................................................65 Exercise G.................................................................................................................69 Optional Exercise H..................................................................................................71 Annexes A: Quarterly Report on TB Case Registration .........................................................74 B: Quarterly Report on Sputum Conversion.............................................................76 C: Quarterly Report on Treatment Outcomes...........................................................77

Monitor and Evaluate TB control Introduction To monitor is to “watch closely.” Monitoring TB control activities in the district is an important part of your job as a District TB Coordinator. By collecting, compiling, and analysing data from health facilities and TB microscopy units, you can monitor the district’s progress in controlling TB. Monitoring is much more than just completing reports. Monitoring is important to: x x x x x find out whether activities in the district are being implemented as planned, measure key indicators related to case detection, quality of diagnosis, and TB treatment, identify problems, their causes, and possible solutions, obtain data needed for annual evaluation of the district’s TB control programme, and use findings to improve future plans.

You have already learned how to enter data in the District TB Register when you make supervisory visits. In this module you will learn to use this data to complete reports and monitor indicators on a quarterly basis. Evaluation of the district’s TB control programme should be done annually. Evaluation involves reviewing the year’s efforts and results, comparing what was achieved with what was planned, assessing the extent and quality of current TB control services, and identifying the causes of any problems as well as reasons for successes. This module will focus on evaluation of achievement of annual targets. Module I: Develop the District Plan of Action for TB Control will describe how to assess the extent and quality of current TB control services as an important basis for planning.

Objectives of this module Participants will learn how to: x x x x x x x x Refer to section: 1 3.1 3.2 3.3 3 and 4 4 5 7

Monitor implementation of the District Plan of Action for TB Control Complete the Quarterly Report on TB Case Registration Complete the Quarterly Report on Sputum Conversion Complete the Quarterly Report on Treatment Outcomes Understand and apply principles of cohort analysis Calculate and analyse five recommended district-level indicators Identify causes and solutions of problems identified through monitoring Evaluate achievement of annual targets for sputum conversion and expansion of TB control services

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

Monitor implementation of the District Plan of Action for TB Control

It is not necessary to wait until the end of a quarter to monitor activities in your district and discover any problems. Throughout the year, refer to the District Plan of Action for TB Control (hereafter called District TB Plan). Determine whether planned activities are being implemented appropriately and on schedule. If you find out early about problems, you may be able to solve them before they have a large impact. An example of a District TB Plan for Faba District for the year 2004 is given in module B on pages 7–13. Study the example and note that activities planned for Faba District for 2004 are listed along with dates for achievement. As District TB Coordinator, you will refer to your District TB Plan when setting dates on your own calendar. Mark dates for completion of activities on a calendar, as well as dates for milestones leading up to completion. As these dates approach, review records and communicate with others to find out about progress. Ask what has been done; give reminders on what must still be done and feedback on what was done well. If activities are not completed as planned, find out why and attempt to correct problems. If activities cannot be completed, or will be significantly delayed, it may be necessary to adjust plans for the rest of the year.

Example 1

The District TB Plan for Faba District for the year 2004 lists the following activity to be accomplished in February 2004: D1 a) Meet with TB/HIV coordinating committee to discuss plans and possibilities for collaboration. If this meeting does not take place, collaboration between the HIV and TB control programmes could be delayed. To ensure that this meeting takes place, the District TB Coordinator will need to schedule a date, time, and place for the meeting; mark it on a calendar; and prepare notes for discussion. To monitor progress towards the meeting, the District TB Coordinator could list these tasks and tick them off as they are completed.

Example 2

The District TB Plan for Faba District for the year 2004 also states that the District TB Coordinator will order a supply of Registers of TB Suspects in January 2004 and provide training as needed in use of these registers during supervisory visits in March 2004. The plan lists the following activity to be accomplished by 1 April 2004: A1 d) Initiate use of the Register of TB Suspects at all facilities offering TB control services.

The District TB Coordinator could monitor this activity in the following ways: x During supervisory visits in March, ask to see the Register of TB Suspects to be used starting 1 April. Confirm that someone has been given responsibility for recording suspects in the register and has been trained to do so. Ask where the register will be kept. x Also during March visits, observe staff complete the register for several example TB suspects. (Give feedback; solve problems; and provide on-the-spot training as needed.) x Several days before 1 April, contact each health facility with a reminder to start using the register officially on 1 April. x During April supervisory visits, review the Register of TB Suspects.

STOP Now do Exercise A – Written Exercise and Discussion Turn to page 46 and follow the instructions for Exercise A.

Review the District TB Register for completeness

At least once a quarter, before completing required quarterly reports, review your District TB Register with a critical eye to see whether it is as complete as possible. Look for the following: x Are cases from all health facilities offering TB control services included in the register for that quarter? If not, why not? x Are there gaps (empty areas) on the register where there should be entries? For example: – For cases registered 3 months ago, are there follow-up sputum examination results, or blanks in that column? – For cases registered 6 months ago, are there more follow-up sputum examination results, or blanks in that column? – For cases registered 12 months ago, are there treatment outcomes, or gaps in that area of the register? x Are there cases who were registered based on positive sputum examination results recorded in the Tuberculosis Laboratory Register, but who never started treatment? These cases would have blanks in the columns for date treatment started, treatment category, and type of patient. x Are there too many treatment outcomes recorded as “transfer out”? (Should be <5%, or no more than 1 out of 20 outcomes.) Did these patients transfer within the district or out of the district? Was an effort made to determine the actual outcome? Try to obtain information that is missing from the District TB Register. For example, if there is no data from certain facilities, make a full supervisory visit to the facilities and obtain the data. Encourage health workers to find any smear-positive cases who have not started treatment. If patients have transferred out of the district, contact the District TB Coordinator in other districts to determine the treatment outcomes and update the register. 3

Compile data from the district in quarterly reports

In this section you will learn to complete quarterly reports. In completing these reports, you will compile data that will help you to monitor the district-level indicators listed on page 25. Shortly after the beginning of each quarter, complete two copies of each quarterly report: one to be sent to the provincial TB coordinator and one to be kept in your files in the district. Two quarterly reports are required by the national TB control programme.1 These reports from all of the districts will be compiled at the provincial level and the national level. The findings from these compiled reports will be used to plan and manage the national TB control programme more efficiently: x Quarterly Report on TB Case Registration x Quarterly Report on Treatment Outcomes A third report may not be required by the national TB control programme, but it is recommended for compiling data to monitor and evaluate sputum conversion as an early indicator of treatment outcome: x Quarterly Report on Sputum Conversion At the beginning of each quarter, each of these reports is used to compile data on a different group, or cohort, of patients. For the purpose of these reports, a cohort is a group of patients who were registered (recorded in the District TB Register) in the same quarter. Think of a cohort as a group of students who begin school together. Those who start together at the same time will be assessed together at the end of each school year, and when it is time to graduate. Other students, who start earlier or later, are in a different grade level, and graduate at a different time. Like students who are at different points in their education, different groups of patients are at different points in their treatment. Those recently registered have just started treatment. Others have received treatment for 2 or 3 months and have results of follow-up sputum examinations. Others have been cured or reached other treatment outcomes. Thus, when you complete quarterly reports, you will use data on three different cohorts of patients, as follows. To complete the: Quarterly Report on TB Case Registration Quarterly Report on Sputum Conversion Quarterly Report on Treatment Outcomes Use data on patients registered in the: Quarter that just ended Quarter that ended 3 months ago Quarter that ended 12 months ago

The national TB control programme may require another form, the Quarterly Report on Programme Management, which includes the number of treatments used by regimen, the number of cases that converted, amounts of drugs and supplies used and remaining in stock, supervisory activities completed, and sputum examinations performed. The Quarterly Report on Sputum Conversion described in this module includes a modified version of part of this report.

It is helpful to keep quarterly reports on the same cohort together in a file labelled with the quarter in which the patients were registered. After a year, you will have all three quarterly reports on that cohort collected in the file.

Example The following timeline summarizes the cohorts covered in reports at a given point in time. In this example, it is July 2004. The 2nd quarter of 2004 has just ended. It is now time to prepare quarterly reports using data on cohorts of patients registered in the quarters shown. Time of completing reports in this example: July 2004

A new cohort of patients was registered in each quarter shown below:

2003 quarters and months

2004 quarters and months

2005

1 J F M

2 A M J Quarterly Report on Treatment Outcomes done for this cohort in July 2004

3 J A S

4 O N D

1 J F M Quarterly Report on Sputum Conversion done for this cohort in July 2004

2 A M J

3 J A S

4 O N D

1 J F M

Quarterly Report on TB Case Registration done for this cohort in July 2004

3.1 Complete the Quarterly Report on TB Case Registration This report is completed at the beginning of each quarter for patients entered in the District TB Register in the quarter that just ended. To complete the report, first find the appropriate pages to review in the District TB Register. For example, if it is now the 4th quarter, look for the pages that show cases registered in the 3rd quarter. (It is helpful if you have started each new quarter on a new page.) There may be many pages in the District TB Register for the quarter. If the pages are not already numbered, write a number in the bottom corner of each right-hand page. These page numbers will be helpful when you are compiling data, now and in the months to come.

Study the Quarterly Report on TB Case Registration on the next page. Read the explanations on the page after the form.

QUARTERLY REPORT ON TB CASE REGISTRATION Name of district: ____________________ District no.: ___________ Name of District TB Coordinator: _____________________ Signature: ______________________________________

Patients registered during _____ quarter of year______

Date of completion of this form: _______________________

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

* In areas routinely using culture, a separate form for reporting culture-positive patients should be used. ** Other cases may include patients with unknown history of previous treatment.

Explanations of how to fill the Quarterly Report on TB Case Registration: District Information: Enter the name and identification number of the district. Enter the name of the District TB Coordinator. When the report is complete, sign it and enter the date of completion. Quarter: This report applies to patients registered (recorded in the District Tuberculosis Register) in the quarter that just ended. Fill in the number of the quarter and the year: 1st quarter – January, February, March 2nd quarter – April, May, June 3rd quarter – July, August, September 4th quarter – October, November, December Block 1: Refer to the pages of the District Tuberculosis Register showing cases registered in the quarter recorded at the top of the report. Of these cases, enter the number of new cases fitting the description in each column (1, 2, and 3). Enter the total new cases in column 4. Column (1): Smear-positive new case – a patient with pulmonary TB, sputum smear-positive, who has never had treatment for TB or who has taken anti-TB drugs for less than 1 month. (Note: These cases will also be recorded by sex and age group in Block 2, below.) Column (2): Smear-negative case – a patient with pulmonary TB that does not meet the definition for smear-positive TB. (This case may be smear-negative or have no smear result but have been diagnosed with pulmonary TB by culture or other means.) Record smear-negative cases in separate cells according to age group (<15 or >15 years). Column (3): Extrapulmonary TB – a patient with TB of organs other than the lungs. Record extrapulmonary cases in separate cells according to age group (<15 or >15 years). Block 2: In this block enter the new pulmonary smear-positive cases (already recorded in Block 1, Column 1) according to sex and age group. Block 3: Enter the number of patients fitting the description in each cell:

– – – –

Relapse: A patient previously treated for TB, who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB. Treatment after failure: A patient who is started on a re-treatment regimen after having failed previous treatment. Treatment after default: A patient who returns to treatment, bacteriologically positive, following interruption of treatment for 2 months or more. Other: All cases that do not meet the definitions (given in the District Tuberculosis Register) of new, relapse, treatment after failure, treatment after default, or transfer in. This group includes chronic case (a patient who is sputum-positive at the end of a re-treatment regimen), as well as smear-positive cases with unknown history of previous treatment.

In order to complete the Quarterly Report on TB Case Registration, first tally data from the District TB Register on a sheet of paper or an enlarged copy of the report. See the example tally sheet on the next page. It shows tally marks from the District TB Register excerpt that folds out on page 11. To use the tally sheet, review each page of the District TB Register one at a time. Move a sheet of paper down the page so that you cover the rows beneath the one that you are reviewing. For each case, look at the columns of the register for Sex, Disease Site, Type of Patient, and Results of Sputum Examination before Treatment. Based on the entries, draw a tally mark (/) in the appropriate block and column of the tally sheet. Note that, in Block 1 of the Quarterly Report on TB Case Registration, you will tally only cases that are New (N). Tally cases registered as Relapses (R), Treatment after failure (F), or Treatment after default (D) in Block 3. Also in Block 3, tally cases registered as Other (O), that is, cases that did not fit in the categories defined on the District TB Register. Do not record cases registered as Transfer in (T) on this report. (These cases have been or should be reported by the district in which they were originally registered.) Block 2 is used only for the new smear-positive cases counted in the bold cell of Block 1. For these cases only, you will tally the number of males and females in each age group. When you have tallied the cases from all pages of the District TB Register for the quarter, transfer the totals to the appropriate cells of the Quarterly Report on TB Case Registration. Then complete the totals for Blocks 1 and 2 of the quarterly report, as directed in the explanations following the report. When you send the quarterly report, attach any supplementary comments that seem necessary. For example, if the totals for Block 2 do not equal the number of new smear-positive cases because sex or age was not recorded for some cases, explain.

Example for Patanga District Tally sheet to complete Quarterly Report on TB Case Registration Note: This is the actual quarterly report with Block 1 enlarged. If there are many pages to be reviewed in the District TB Register, enter the page numbers in the left margin and draw lines across the tally sheet to separate rows for each page. For the sake of checking completeness, “transfers in” may be tallied below the form.

QUARTERLY REPORT ON TB CASE REGISTRATION Name of district: ___Patanga_________________ District no.: ___________ Name of District TB Coordinator: ________________________ Signature: ______________________________________ Date of completion of this form: Patients registered during 1st quarter of year 2004

5 April 2004 __________________

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) or not tested (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

// These marks are for Manov Pio and Sofia Lee.

/ This mark is for Joma Saka.

/ This mark is for Munzir Nabi.

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Sex M F This mark is also for Manov Pio. 0–14 15–24 Age group in years 25–34 35–44 45–54 55–64 >65 Total

/ / This mark is also for Sofia Lee.

Block 3. PREVIOUSLY TREATED CASES (Smear-positive) Relapse Treatment after failure Treatment after default Other

This mark is for Lana Do.

Tally of transfers in:

STOP Explanation of Quarterly Report on TB Case Registration Tell a facilitator when you have reached this point in the module. There will be an explanation of how to transfer data from the District TB Register to a tally sheet and then to the Quarterly Report.

Now do Exercise B – Written Exercise When you have reached this point in the module, turn to page 48 and follow the instructions for Exercise B. When you have finished the exercise, review your answers with a facilitator.

3.2

Complete the Quarterly Report on Sputum Conversion

Treatment success is defined as the sum of the proportion of new smear-positive TB cases who were cured, plus the proportion who completed treatment. Sputum conversion is a good early predictor of treatment success. The sputum conversion rate is thus an important indicator to monitor at the district level. Completing the Quarterly Report on Sputum Conversion (shown on the next page) will help you compile data needed to measure this indicator. This quarterly report is completed at the beginning of each quarter for patients entered in the District TB Register in the quarter that ended 3 months ago. (Count back 1 quarter from the quarter that just ended.) For example, if the 3rd quarter just ended, you will review and record data on patients registered in the 2nd quarter. Find the pages for the appropriate quarter in the District TB Register. Tally the data from those pages on an enlarged copy of the Quarterly Report on Sputum Conversion or on a piece of paper. After tallying, complete the report itself.

Study the Quarterly Report on Sputum Conversion on the next page.

QUARTERLY REPORT ON SPUTUM CONVERSION Name of district: _____________________________ District no.: ___________ Name of District TB Coordinator: ___________________ Signature: _____________________________________ Number of new smear-positive cases registered in quarter recorded above** Smear not done at either 2 or 3 months Date of completion of this form: ____________________ Sputum conversion at: 2 months 3 months Patients registered during _____ quarter of year____*

Total converted at 2 or 3 months: * Quarter: This form applies to patients registered (recorded in the District Tuberculosis Register) in the quarter that ended 3 months ago. For example, if completing this form at the beginning of the 3rd quarter, record data on patients registered in the 1st quarter. ** This number should match the number of new smear-positive cases in Block 1, Column 1, of the Quarterly Report on TB Case Registration previously completed for patients registered in this quarter.

Notice that only new smear-positive cases are recorded on this report. These cases are identified in the District TB Register with P (for Pulmonary), N (for New), and a positive sputum examination result before treatment, that is, +, ++, +++, or a number. To be counted as converted, the case must have a negative sputum examination result (neg) recorded on the District TB Register at 2 or 3 months. There is a separate column to record cases who have no results recorded at 2 or 3 months. Cases with no results recorded may have died, defaulted, transferred out of the district, or simply not been tested. If there are many cases with no results recorded, it will be important to find out why and solve problems. There is no place on the Quarterly Report on Sputum Conversion to record cases who were tested and remained positive (did not convert), although this number can easily be obtained by subtracting. For the sake of checking completeness, you may wish to tally somewhere on your tally sheet the cases that did not convert. Following is an example of how to tally cases recorded in the District TB Register on the Quarterly Report on Sputum Conversion.

Example for Patanga District

In this example, it is April 2004, the beginning of the 2nd quarter of 2004 in Patanga District. Below is a tally sheet for the Quarterly Report on Sputum Conversion, as completed for the cohort registered in the 4th quarter of 2003. The example shows tally marks for the first six cases registered in the quarter. The relevant parts of the corresponding District TB Register are shown on fold-out page 17. Fold it out now and look at the tally sheet and District TB Register together. TALLY SHEET: QUARTERLY REPORT ON SPUTUM CONVERSION Name of district: _____________________________ District no.: ___________ Name of District TB Coordinator: ___________________ Signature: _____________________________________ Number of new smear-positive cases Smear not done at registered in quarter either 2 or 3 months recorded above** Date of completion of this form: 5 April 2004 ____________________ Sputum conversion at: 2 months 3 months

Patanga

Patients registered during 2003 _____ 4th quarter of year______*

Did not convert:

35 This number was copied from the Quarterly Report on TB Case Registration previously completed for this cohort.

// These marks are for Wilma Pule and Rose Bela.

This tally mark is for J.L. Malay.

This mark is for Bathabile Sithole.

This mark is for José Poma, who did not convert. The total that did not convert is not used on the final report, but tallying these cases will help you check your work.

Total converted at 2 or 3 months:

STOP Now do Exercise C – Written Exercise When you have reached this point in the module, turn to page 52 and follow the instructions for Exercise C. When you have finished the exercise, review your answers with a facilitator.

3.3 Complete the Quarterly Report on Treatment Outcomes The Quarterly Report on Treatment Outcomes (shown on the next page) is required for compiling data to measure treatment outcome indicators for the district. This report is completed at the beginning of each quarter for patients entered in the District TB Register in the quarter that ended 12 months ago. (Count back one year from the quarter that just ended.) For example, if it is now the beginning of the 4th quarter of 2004, you will review and record data on patients registered in the 3rd quarter of 2003. Waiting a year to report on treatment outcomes allows time for cases to complete treatment. Find the appropriate pages to review in the District TB Register. Also find the Quarterly Report on TB Case Registration that you completed for this cohort 12 months ago, when they had just begun treatment. (It is helpful to keep reports on the same cohort together in a file labelled with the quarter in which they were registered.) Use the Quarterly Report on TB Case Registration to complete the left section of the Quarterly Report on Treatment Outcomes (example page 21).

Study the Quarterly Report on Treatment Outcomes on the next page. Also study the example on page 21 that shows how to complete the left section of the report.

QUARTERLY REPORT ON TREATMENT OUTCOMES

Name of district:_____________ Name of District TB Coordinator:__________________ Signature: _________________ Date of completion of this form: _____________________ Treatment outcomes Cure Treatment completed (2) (3) (4) (5) Died Treatment failure Default

Patients registered during _____ quarter of year ______*

District no.:___________

Type of case

Total number of pulmonary patients registered during the quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1. New

1.1 Smear (+)

1.2 Smear (–)

2.1 Relapses

2. Re-treatment (smear-positive)***

2.2 Treatment after failure

2.3 Treatment after default

*** In areas routinely using culture, a separate form for culture-positive patients should be used.

After completing the left side of the Quarterly Report on Treatment Outcomes, tally the outcomes for the types of cases listed on the form. To do this, review the appropriate pages in the District TB Register and tally the treatment outcomes on a sheet of paper or an enlarged copy of the form. Then transfer totals from the tally sheet to complete the quarterly report. Note that line 1.1 of the report is the most important, as it provides data to measure treatment outcomes for new pulmonary smear-positive cases and thereby assess the quality of the district TB control programme. As you complete the Quarterly Report on Treatment Outcomes, notice whether the totals in the last column correspond to those in the left section (which were based on data transferred from the Quarterly Report on TB Case Registration). If they do not correspond, it may be because of counting or addition errors, or it may be because of exclusion of certain cases from evaluation. It is rare to have cases to exclude. Rarely, a case may be excluded because the patient is still being treated and does not yet have an outcome. Another possibility is a wrong diagnosis; for example, if a case was registered as pulmonary TB, and was later found to be a case of pneumonia, exclude it from the tally of cases. Explain any exclusions at the bottom of the quarterly report. Study the example opposite of how to tally treatment outcomes.

STOP Now do Exercise D – Written Exercise After studying the example opposite, turn to page 56 and follow the instructions for Exercise D. When you have finished the exercise, review your answers with a facilitator.

Calculate and analyse indicators

By completing quarterly reports, you will have compiled much of the data needed to calculate indicators for the district. An indicator is a measurable number, proportion, percentage, ratio, or rate that suggests the extent of achievement of a programme, or the level of some condition in the population. It is recommended that the indicators listed below be monitored at the district level on a quarterly basis. The expected or desired levels are shown. If the level in the district differs, it will be important to find out why and solve any problems. By monitoring indicators on a quarterly basis, one can also see improvements and track progress towards annual targets. Main indicators for quarterly monitoring at district level Indicators related to case detection: x x Ratio of TB suspects tested to outpatients aged 15 years and older (3–5% expected) Proportion of TB suspects tested who were sputum smear-positive (2–15% expected)

Indicator related to quality of diagnosis: x Proportion of TB cases who were sputum smear-positive (Should be at least 50%. If <50%, there are too many diagnoses of pulmonary TB by X-ray without smears, or there are too many extrapulmonary cases, or there is high prevalence of TB/HIV.)

Indicators related to TB treatment: x x Proportion of new sputum smear-positive TB cases who converted at 2 or 3 months (desired is at least 85%) Proportion of new sputum smear-positive cases with each treatment outcome: Cure Treatment completed Cure plus completed (“treatment success”) should be at least 85%; cure should be close to 85% if all follow-up examinations are done.

Treatment failure (should be <2%) Died (usually <2%; in areas with high prevalence of HIV, may be 6–8%) Default (should be <5%) Transfer out (usually <5%)

The indicators in the box above are the main indicators recommended for the district level. Other indicators related to programme quality could be measured based on data available from the District TB Register and Quarterly Reports (e.g. age and sex distribution of cases over time, proportion of cases that are extrapulmonary, and proportion that are children). Additional indicators could also be measured through special studies (e.g. proportion of smear-positive cases who started or did not start treatment, proportion of cases diagnosed by private practitioners, or proportion of TB cases who are HIV positive). Data to measure the main indicators (in the box) can be obtained from health facility reports on numbers of outpatients, the District TB Register, district laboratory reports, the Quarterly

Report on Sputum Conversion, and the Quarterly Report on Treatment Outcomes. The next sections of this module will describe, for each of the main indicators: x x x x the cohort for the indicator (i.e. the group of patients considered), the formula for calculating the indicator (numerator and denominator), data sources (i.e. where to obtain numerator and denominator data), and possible implications of results.

Most of the indicators to be measured at district level are proportions (calculated by dividing a numerator by a denominator). In an indicator that is a proportion, the cohort (or group of patients considered) corresponds to the denominator. Some of the cohorts for indicators are defined differently than the cohorts used to complete quarterly reports. For example, instead of including all of the patients registered in a quarter, the cohort may be limited to those patients who were new sputum smear-positive cases. Limiting the cohort in this way can be compared with a school examination in which the students’ results are not only grouped by grade level, but also by other characteristics, such as age or sex. For example, you might consider as a group all boys in grade 5. You might want to see what proportion of these boys scored above 90 in the examination. To be consistent, you will only count students in this group (or cohort) of boys; you will not include any girls, or anyone at a different grade level. The proportion could be expressed as follows: Number of boys in grade 5 who scored above 90 in the examination Number of boys in grade 5

Proportion of boys in grade 5 who scored above 90 in the examination

Notice that all of the boys included in the numerator are from the group in the denominator. The same must be true when measuring indicators for TB control in your district; that is, individuals included in the numerator must be part of the cohort in the denominator. If you want to follow a certain cohort over time, you must be careful to look at the same cohort every time. For example, if you want to compare the results of these boys after 4 weeks of additional study, you must look at the results of the same boys when they take the examination again. Likewise, if you want to compare the sputum conversion rate of a group of new smear-positive cases (at 3 months) to their cure rate (after 12 months), you should look at the same group of cases. 4.1 Calculate and analyse indicators related to case detection

Calculating and analysing the indicators listed in the chart on the next page will help you to monitor TB case detection in the district. Specifically, these indicators will help you determine whether health facilities are adequately: x identifying pulmonary TB suspects by asking adult outpatients (aged 15 years and older) whether they have had cough for 2 weeks or more, and x collecting and sending sputum samples of TB suspects for examination.

Indicators related to case detection in the district Indicator Time frame for cohort Formula for calculatinga Number of TB suspects whose sputum was examined Quarter that just ended Sources of data Obtain from laboratory reports from district laboratory supervisor Estimate based on outpatient totals from health facilities in previous quarters

Ratio of TB suspects tested to outpatients aged 15 years and older

Total number of outpatients aged 15 years and older seen for any reason at facilities providing TB control services Number of TB suspects who were sputum smear-positive Number of TB suspects whose sputum was examined

Proportion of TB suspects tested who were sputum smear-positive (positivity rate)

Quarter that just ended

Obtain from laboratory reports from district laboratory supervisor Obtain from laboratory reports from district laboratory supervisor

The numerator is above the dashed line and the denominator below it. Formulae for the indicators can be expressed as follows: Numerator u 100 = percentage Denominator In each formula, a numerator is divided by a denominator to obtain a ratio or proportion. If you use a calculator, the result is usually expressed as a decimal fraction, for example, 0.94. You may wish to express the result as a percentage. To do this, multiply by 100 (move the decimal point two places to the right). Thus, the decimal fraction 0.94 can be expressed as 94%.

Example

In Patanga district, in the quarter that just ended, laboratory reports show that 720 people had sputum examinations for diagnosis (i.e. were TB suspects whose sputum was examined). Of those TB suspects, 72 were found to be sputum smear-positive. The District TB Coordinator calculated the second indicator above (the positivity rate) as follows: 72 = 0.10 u 100 = 10% positivity 720 This means that, according to laboratory reports, 10% of TB suspects (persons with sputum examined for diagnosis) were found to be positive.

The following table shows expected levels of the indicators related to case detection. (Expected levels are based on results from well organized TB control programmes worldwide.) Compare the results in your district with these levels. If they are different, it will be important to find out why and take appropriate action. Also compare levels with results from previous quarters to see whether changes have occurred and, if so, investigate. Analysis of indicators related to case detection Indicator Compare: Possible interpretation, or investigation needed: If lower than 3%, it is possible that: – patients are not routinely being asked about cough, and/or – sputum samples of TB suspects are not being sent for testing. Ratio of TB suspects tested to outpatients aged 15 years and older Expected level: 3–5%a If higher than 5%, consider whether patients with cough of less than 2 weeks are being identified as TB suspects. If higher than 5%, another possibility is that, in addition to TB suspects identified by health facilities known to provide TB control services, the numerator includes other individuals referred for testing (e.g. patients referred by private physicians). Results from previous quarters If there is a large change in this indicator, investigate whether there have been changes in staff, procedures or reporting that affect the indicator. If higher, monitor procedures used by health facilities to identify TB suspects. It is possible that the only persons who have sputum samples sent for testing are those with severe respiratory symptoms, or those who describe cough as their reason for seeking care, or those who have abnormal X-rays. If the proportion varies greatly from one quarter to the next, check procedures used to identify TB suspects and send sputum samples. Also check quality control procedures in the laboratories. Over a longer period of time, a gradual increase or decrease could indicate a change in the actual level of TB in the district.

Expected level: 2–15% Proportion of TB suspects tested who were sputum smear-positive Results from previous quarters

The expected level is the proportion of adults with cough lasting 2 weeks or more. To determine a more accurate expected level for your area, a simple low-cost study can be done in a few weeks. A sample protocol for a study of prevalence of cough in adults attending health facilities is provided in Annex B of module I: Develop the District Plan of Action for TB Control.

4.2 Calculate and analyse indicators related to quality of diagnosis An important component of the DOTS strategy is to improve the quality of diagnosis of TB by providing access to sputum smear microscopy. It is expected that more than half of the TB cases in the district should be diagnosed (found sputum smear-positive) by sputum smear microscopy. If many cases are not sputum smear-positive, but have been diagnosed by other methods, there may be a problem. The following indicator will help you to roughly assess the quality of diagnosis in the district.1 Indicator related to quality of diagnosis in the district Indicator Time frame for cohort Formula for calculatinga Sources of data

Number of TB cases who were sputum smear-positive Proportion of TB cases who were sputum smearpositive Quarter that just ended

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the new sputum smear-positive cases (Block 1, Column 1) and all cases recorded in Block 3.

Total number of TB cases

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the total new cases (Block 1, Column 4) and all cases recorded in Block 3.

The numerator is above the dashed line and the denominator below it.

Compare the result in your district with the expected level and with results from previous quarters, as shown in the following table. Analysis of the indicator related to quality of diagnosis Indicator Compare: Expected level: Proportion of TB cases who were sputum smearpositive Should be at least 50% Results from previous quarters

Possible interpretation, or investigation needed: If less than 50%, it is likely that: – there are too many diagnoses by X-ray, – there are too many extrapulmonary cases, and/or – TB/HIV prevalence is high. If there is an increase, possibly more clinicians are relying on sputum smear microscopy for diagnosis. A decrease may result from increased identification of TB suspects among adults attending general health facilities.

Other indicators of the quality of diagnosis may be found through quality control of sputum examinations coordinated by the district laboratory supervisor.

STOP Now do Exercise E – Written Exercise When you have reached this point in the module, turn to page 61 and follow the instructions for Exercise E. When you have finished the exercise, review your answers with a facilitator.

4.3 Calculate and analyse indicators related to TB treatment An important indicator for monitoring the quality of TB treatment services in the district is the proportion of new smear-positive cases that convert to smear-negative at the end of 2 or 3 months of treatment. This indicator is a good early predictor of “treatment success,” which requires a delay of 12 months before it can be measured. It will be easy to calculate this indicator, since you have already compiled the necessary data on the Quarterly Report on Sputum Conversion. It is also important to monitor treatment outcomes every quarter, even though these outcomes reflect the quality of services provided over the past year. It is best to look at outcome indicators in two ways: 1. Look at outcome indicators for a given cohort in relation to that same cohort’s earlier conversion rate. The conversion rate should be similar to the rate of treatment success (cases with outcomes of “cure” or “treatment completed”). Look at outcome indicators for successive cohorts (measured in successive quarters) to see whether treatment outcomes, in general, are improving (approaching desired or expected levels). If there are problems (such as an increase in the percentage of cases defaulting), remember that these problems may have been caused months ago. You will have to look into the past to determine the causes.

Indicators for monitoring treatment outcomes are described in the table on the next page. Although there are six treatment outcome indicators, they will be very easy to calculate since you have already compiled the necessary data on the Quarterly Report on Treatment Outcomes.

Indicators related to TB treatment in the district Indicator Proportion of new sputum smearpositive TB cases who converted at 2 or 3 months (sputum conversion rate) Proportion of new sputum smearpositive TB cases with each treatment outcome: Cure Time frame for cohort Formula for calculatinga Number of new sputum smearpositive TB cases who converted at 2 or 3 months Total new sputum smearpositive TB cases Sources of data Quarterly Report on Sputum Conversion, bottom row Quarterly Report on Sputum Conversion, first column

Quarter that ended 3 months ago

Quarter that ended 12 months ago

Number of new sputum smearpositive TB cases with outcome cure Total new sputum smearpositive TB cases

Quarterly Report on Treatment Outcomes, line 1.1, column 1 Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Treatment completed

Quarter that ended 12 months ago

Number of new sputum smearQuarterly Report on Treatment positive TB cases with outcome Outcomes, line 1.1, column 2 treatment completed Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Died

Quarter that ended 12 months ago

Number of new sputum smearQuarterly Report on Treatment positive TB cases with outcome Outcomes, line 1.1, column 3 died Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Treatment failure

Quarter that ended 12 months ago

Number of new sputum smearQuarterly Report on Treatment positive TB cases with outcome Outcomes, line 1.1, column 4 treatment failure Quarterly Report on Treatment Total new sputum smearOutcomes, line 1.1, total number positive TB cases evaluated Number of new sputum smearQuarterly Report on Treatment positive TB cases with outcome Outcomes, line 1.1, column 5 default Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Default

Quarter that ended 12 months ago

Transfer out (out of district) a

Quarter that ended 12 months ago

Number of new sputum smearQuarterly Report on Treatment positive TB cases with outcome Outcomes, line 1.1, column 6 transfer out Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

The numerator is above the dashed line and the denominator below it.

Compare the results in your district with the expected or desired levels and with results from previous quarters, as shown in the following table. Expected levels are based on results from well organized TB control programmes worldwide. Analysis of indicators related to TB treatment Indicator Proportion of new sputum smearpositive TB cases who converted at 2 or 3 months (conversion rate)

Compare: Desired level: at least 85%

Possible interpretation, or investigation needed: If patient adherence is high, and treatment is consistently done correctly, 85% or more should convert. If the proportion is lower, look for reasons (e.g. follow-up sputum examinations not done, defaults, problems with patient adherence or treatment services, or high drug resistance.) An increase in this proportion suggests that patient adherence and treatment are improving. A decrease suggests problems, as above. The cure rate should be close to the earlier sputum conversion rate for this cohort. If the cure rate is lower, consider why by looking at rates of other outcomes. For example, is the proportion of cases with outcome “treatment completed” relatively high (suggesting that final sputum examinations are not done to confirm cures)? Is the default rate high (suggesting there are many defaults after the first 3 months of treatment)? If cure rate is much lower than 85%, consider why by looking at rates of other outcomes, as above. Look for increases in cure rate over successive quarters as a sign that services are improving. Added together, the proportion cured plus the proportion that completed treatment (called “treatment success”) should increase towards 100% and reach at least 85% with good case management. The proportion that completed treatment should be much lower than the proportion cured. Otherwise, it is likely that final followup sputum examinations are not being done to confirm cures. On the other hand, it is better to have a high rate of cases with the outcome “treatment completed” than outcomes such as treatment failure and default. If higher than 2%, it is possible that treatment is not being directly observed as it should be. Another possibility is drug resistance. If the death rate is higher than 2% (or 6–8% in areas with HIV), it is possible that patients are coming very late for diagnosis. If more than 5%, look for problems related to patient adherence, quality and convenience of treatment services, etc. Remember that patients who transfer within the district should all have outcomes. (If they never reported to the new facility, they are defaults.) If more than 5% have the outcome “transfer out,” you may need to try harder to get outcomes of transferred patients from other District TB Coordinators.

Results from previous quarters Sputum conversion rate for same cohort (measured 9 months ago) Desired level: Cure should be close to 85%. Proportion cured plus treatment completed should be at least 85%.

Proportion of new sputum smearpositive TB cases with each treatment outcome: Cure

Treatment completed

Proportion of cases with other outcomes

Treatment failure

Expected level: less than 2% Expected level: less than 2% (In areas with HIV, may be 6–8%) Desired level: less than 5% Expected level: less than 5%

Died

Default

Transfer out (out of district)

Example In Patanga district, the cohort registered in the 3rd quarter of 2004 had a sputum conversion rate of 80%. Ultimately, the “treatment success” rate for this cohort was 77% (50% cure and 27% treatment completed). It is typical that the “treatment success” rate may be a bit lower than a cohort’s earlier conversion rate, since some of the cases who converted may die, default, or transfer out with no known outcome. In Patanga district, the sputum conversion rate for subsequent cohorts steadily increased to 85%. The rate of treatment success, measured later for the same cohorts, increased to 83% (65% cure and 18% treatment completed). The cure rate increased relative to the rate of cases that completed treatment, suggesting that more cases had final sputum examinations. 4.4 Graph progress towards district target for sputum conversion Use a line graph to show your district’s progress in improving the sputum conversion rate. Post the graph on the wall in your office. Show it to health facility staff so that they can see the progress of the district as a whole. Remember that, since the number of TB cases in the district is relatively small, just a few failures can impact the sputum conversion rate greatly. Do not be too discouraged by a short-term drop in the rate, or overly optimistic about a sudden increase. Look for a sustained increase in the sputum conversion rate as evidence of good treatment.

Example The following graph shows the sputum conversion rate in Faba District for cohorts registered from the 1st quarter of 2003 through the 1st quarter of 2004.

STOP Now do Exercise F – Written Exercise and Discussion When you have reached this point in the module, turn to page 65 and follow the instructions for Exercise F. There will be a group discussion after the exercise.

If monitoring reveals problems, investigate the causes and try to solve the problems

Monitoring will help you to identify successes in your district, but you are likely to find some problems as well. For example, you may find that the default rate is increasing. Or you may find that the cure rate is remaining steady rather than increasing as you had hoped. Both of these problems could have many causes. When you identify a problem, it is important to: x Describe the problem in as much detail as possible. Specify when, where, and with whom the problem occurred. Remember that some indicators may reveal problems that actually occurred months ago. You will need to determine whether the problem is still occurring. x Investigate the causes of the problem. Different causes require different solutions. Keep asking “why” until you find the root causes of the problem. (In some cases it may be helpful to conduct or participate in a special study to investigate the causes of a problem. Special studies will be discussed in Annex B of module I: Develop the District Plan of Action for TB Control.) x Identify solutions appropriate for the causes of the problem. For example, if health workers do not know how to do a task, a solution may be training. However, if the cause is a lack of equipment or supplies, a different solution is needed. Solutions should: – – – remove the cause of the problem (or reduce its effects), be feasible (affordable, practical, realistic), not create another problem.

If a problem has several root causes, it may be necessary to implement several solutions to address all of the causes. For example, if there is a lack of both equipment and training, you will need to provide both to solve the problem.

Example Problem: It is now the 4th quarter of 2004 in Bastida District. The default rate in Bastida District has increased from 4% to 6% to 10% when measured at the end of the past 3 quarters. The cohorts for these outcome rates were patients registered more than a year ago, during the 1st, 2nd, and 3rd quarters of 2003. Possible cause: A health facility closed, and patients find it inconvenient or impossible to travel further for directly observed treatment. Possible solution: Identify and train more community TB treatment supporters to make treatment more convenient. Stress the importance of finding patients. Try to arrange schedules so home visits can be made during working hours without understaffing the health facility. For staff who make home visits after working hours, offer an equivalent amount of time off on another day. Another possibility is to find community volunteers who are willing to make visits. Patients are moving from the area without a completed Tuberculosis Referral/Transfer Form. Health facility staff do not know how to use this form. Provide a brief training session on how to use the form, adapting relevant sections of module G: Ensure Continuation of TB Treatment from the course Management of Tuberculosis: Training for Health Facility Staff.

Staff are making fewer home visits to patients who miss visits, because visits are difficult and time-consuming.

Notice that possible causes of this problem are varied and could be affecting just one health facility or several. More than one cause could apply. If causes of this problem are not evident, an investigation to identify the timing of defaults, and the reasons for defaults, could be useful in identifying the causes.

Conduct periodic district meetings of health facility staff responsible for TB control services

Periodically, at least every 6 months, plan a meeting of staff from health facilities providing TB control services throughout the district. Include the person responsible for TB control services at each facility. It is also helpful to include the district laboratory supervisor or one or two microscopists. These meetings may have a number of purposes: x x x x x x x to motivate health facility staff responsible for TB control services to allow staff to share results of their monitoring of indicators at the health facility level1 to increase understanding of what indicators can show and how to interpret them to present results of district-level monitoring to provide brief training or updates on procedures to discuss common problems, causes, and possible solutions to identify priorities for improvements and changes.

Before each meeting, set objectives for the meeting and make an agenda. If you want participants to be prepared to discuss indicators that they have monitored at the health facility level, instruct them to bring information on these indicators. At the meeting, encourage everyone to participate. Give positive feedback for achievements of the health facilities. Congratulate health facility personnel on improvements as well as rates that are at desired levels. Do not allow the meeting to focus on complaints about problems that cannot be solved. Focus the discussion on issues that health facilities can do something about, such as increasing follow-up sputum examinations or decreasing defaults.

Evaluate achievement of annual district targets

Annual evaluation of the district’s TB control programme involves reviewing the year’s efforts and results, comparing what was achieved with what was planned, assessing the extent and quality of current TB control services, and identifying the causes of any problems as well as reasons for successes. This section of this module will focus only on evaluation of achievement of annual targets. Module I: Develop the District Plan of Action for TB Control will describe how to evaluate the extent and quality of current TB control services as an important basis for planning. If indicators have been monitored on a quarterly basis, evaluation of achievement of targets involves little additional work, simply looking to see whether the district targets were reached by the end of the year, and why or why not. When 4th-quarter monitoring data are available, you can determine whether or not annual targets were achieved.

Indicators measured at the health facility level are described in module H: Monitor TB Case Detection and Treatment of the course Management of Tuberculosis: Training for Health Facility Staff.

7.1 Evaluate achievement of sputum conversion target The district sets an annual target for maintaining and improving existing TB control services in the following format: By the end of 200__, the quarterly sputum conversion rate in the district will reach at least __%.

As you have learned, the sputum conversion rate is the proportion of new sputum smearpositive TB cases that convert at 2 or 3 months. This rate is a predictor of treatment success but has the advantage that it can be measured earlier than treatment success. As part of monitoring indicators, the sputum conversion rate is measured at the beginning of each quarter for cases registered in the quarter that ended 3 months ago. (See section 4.3.) In January or February, review the sputum conversion rate achieved in the 4th quarter as the most recent evidence of the sputum conversion rate in the district. Compare this rate with the rate predicted in the annual target. (This rate should increase until it reaches and possibly exceeds a level of 85%, but the target may have been set lower to be realistic while the district continues to make improvements.) If the actual rate is lower than the target, look for reasons (e.g. follow-up sputum examinations not done, defaults, problems with patient adherence or treatment services.) 7.2 Evaluate achievement of target for expansion of TB control services Depending on the stage of TB control efforts in your district, there may or may not yet be an annual district target for expanding TB control services to more public health facilities. If there is such a target, it should be in the following format: By the end of 200__, __ out of __ public health facilities in the district will provide TB control services.

In some districts, a target may also be set for non-public health facilities, such as private, NGO, military, or prison health facilities. Facilities “providing TB control services” are those that are continuously supplied with antiTB drugs and supplies, have at least one health worker trained in TB case detection and treatment, have microscopy support, and have started detecting and treating cases. If there is a target for expanding TB control services in your district, you will have been collecting information all year about activities leading up to its achievement, as described in section 1 of this module. After the 4th quarter, compare the actual situation at the end of the year with the target. Use the results of monitoring activities throughout the year to identify reasons for success or to determine why the target was not reached.

7.3

Summarize evaluation results and recommendations

It is important to communicate evaluation results to others. Be sure to recognize achievements and progress and describe them to health facilities and to your own supervisors. Typically, the District TB Plan for the coming year has already been written before evaluation of annual targets is complete. Nevertheless, it is important to examine evaluation results for implications for future district planning; for example, note problems that need to be investigated and solved, and recommendations to improve or expand TB control services. Following is a suggested format for summarizing results of the end-of-year evaluation of district targets. It is not a required form but a way to keep track of results and recommendations.

Evaluation of annual district targets Targets set for ___________district for the year _________: By the end of 200__, the quarterly sputum conversion rate in the district will reach at least _____%. By the end of 200__, __ out of __ public health facilities in the district will provide TB control services. Actual achievement as measured on ________________________ (date): Sputum conversion rate measured after 4th quarter of 200__ (for patients registered in 3rd quarter of 200__): ________________ Total number of public health facilities providing TB control services: ________ Total number of public health facilities in the district:______ Reasons for successes: Reasons for non-achievement (problems and likely causes): Recommendations:

STOP Now do Exercise G – Written Exercise When you have reached this point in the module, turn to page 69 and follow the instructions for Exercise G. When you have finished the exercise, review your answers with a facilitator.

Summary of important points x Throughout the year, refer to the District Plan of Action for TB Control and monitor whether planned activities are being implemented correctly and on schedule. If you find out early about problems, you may be able to solve them before they have a large impact. x Maintain the District TB Register carefully by registering cases and updating information on their treatment at regular supervisory visits to health facilities. The District TB Register is an important source of data for completing quarterly reports and monitoring district-level indicators. x At the beginning of each quarter, complete three quarterly reports. Each report will provide information on a different cohort of patients, as shown below: To complete the: Quarterly Report on TB Case Registration Quarterly Report on Sputum Conversion Quarterly Report on Treatment Outcomes Use data on patients registered in the: Quarter that just ended Quarter that ended 3 months ago Quarter that ended 12 months ago

x The Quarterly Report on TB Case Registration and Quarterly Report on Treatment Outcomes are required by the national TB control programme. The Quarterly Report on Sputum Conversion is highly recommended because sputum conversion is a good early predictor of treatment success. x The following indicators are recommended for quarterly monitoring at the district level. Indicators related to case detection:

– –

Ratio of TB suspects tested to outpatients aged 15 years and older (3–5% expected) Proportion of TB suspects tested who were sputum smear-positive (2–15% expected)

Indicator related to quality of diagnosis:

– Proportion of TB cases who were sputum smear-positive (Should be at least 50%. If

<50%, there are too many diagnoses of pulmonary TB by X-ray without smears, or there are too many extrapulmonary cases, or there is high prevalence of TB/HIV.)

Indicators related to TB treatment:

– Proportion of new sputum smear-positive TB cases who converted at 2 or 3 months (desired is at least 85%) – Proportion of new sputum smear-positive cases with each treatment outcome:

Cure Cure plus completed (“treatment success”) should be at least 85%; cure should be close to 85% if all follow-up examinations are done. Treatment completed Treatment failure (should be <2%) Died (usually <2%; in areas with high prevalence of HIV, may be 6–8%) Default (should be <5%) Transfer out (usually <5%)

x Data to measure these indicators can be obtained from health facility reports on numbers of outpatients, the District TB Register, district laboratory reports, and quarterly reports. Sections 4.1–4.3 of this module describe how to calculate and analyse the indicators. x Use a line graph to show your district’s progress in improving the sputum conversion rate. Look for a sustained increase in the sputum conversion rate (to a level of at least 85%) as evidence of good treatment. x If monitoring reveals problems, investigate the causes and try to solve the problems. Problems may have many causes, and different causes require different solutions. Keep asking “why” until you find the root causes of a problem. Then identify solutions appropriate for the causes. For example, if health workers do not know how to do a task, a solution may be training. However, if the cause is a lack of equipment or supplies, a different solution is needed. x At the end of each year, when 4th quarter monitoring data are available, evaluate achievement of annual targets such as the following: By the end of 200__, the quarterly sputum conversion rate in the district will reach at least ___%. By the end of 200__, __ out of __ health facilities (specify type) in the district will provide TB control services.

x Summarize evaluation results and communicate them to others. Evaluation results have important implications for planning. Module I: Develop the District Plan of Action for TB Control will describe how to evaluate the extent and quality of TB control services as a basis for planning.

Self-assessment questions Answer the self-assessment questions below to check what you have learned. Then compare your answers with those on pages 43–44. 1. The Quarterly Report on _____ _______ _______________ is completed for the ____________ of patients registered in the quarter that just ended. The bold cell in Block 1 of this report shows the number of new smear-positive cases registered in the quarter.

The Quarterly Report on ___________ ________________ is completed for patients registered in the quarter that ended ____ months ago. This report shows the number of new smear-positive cases who had sputum conversion at _____ or ______ months.

The Quarterly Report on ___________ ________________ is completed for patients registered in the quarter that ended ____ months ago. This report shows the number of new and re-treatment cases with each of six possible _____________ _____________.

Assume that it is now 6 July 2005 in Bastida district, that is, the beginning of the 3rd quarter of 2005. The District TB Coordinator is ready to complete quarterly reports. For each report, which cohort will be reported on? (Fill in the table.) Name of report Quarter in which cohort was registered

Quarterly Report on TB Case Registration Quarterly Report on Sputum Conversion Quarterly Report on Treatment Outcomes

_____ quarter of 200__ _____ quarter of 200__ _____ quarter of 200__

Laboratory reports in a certain district show that 800 people had sputum examinations for diagnosis in the quarter that just ended (i.e. were TB suspects whose sputum was examined). Of those, 64 were found to be sputum smear-positive. What is the positivity rate (i.e. proportion of TB suspects tested who were sputum smear-positive)? Is this indicator in the expected range?

In a certain district, in the quarter that just ended, the proportion of all TB cases who were sputum smear-positive was 45%. This is lower than the expected level of at least 50%. What are three possible reasons?

In a certain district, in the quarter that ended 3 months ago, 48 new sputum smearpositive TB cases were registered. Of these, 36 converted at 2 or 3 months. What is the sputum conversion rate?

How does this compare with the desired level?

In a certain district, in the quarter that ended 12 months ago, 40 new sputum smearpositive TB cases were registered. Of these, 20 had an outcome of “cure” and 14 had an outcome of “treatment completed.” What is the rate of each of the following: x x x

Cure? Treatment completed? Treatment success?

How does each of the above rates compare with the desired level?

In a certain district, the death rate for new sputum smear-positive TB cases is high at 5%. Which of the following are possible causes of this problem? (Tick all that could apply.) a. ___ TB cases are detected late, after they become more serious and likely to die. b. ___ HIV-related deaths are occurring among TB patients. c. ___ Health facility staff are not asking all adults about cough. d. ___ HIV testing and care sites do not refer patients coughing longer than 2 weeks for sputum examination. What is one example of a “root cause” of “d” above? What could you do about this cause?

Now compare your answers with those on the next page.

Answers to self-assessment questions If you had difficulty answering any question, turn back and study the section indicated. If you do not understand something, discuss it with a facilitator. 1. The Quarterly Report on TB Case Registration is completed for the cohort of patients registered in the quarter that just ended. The bold cell in Block 1 of this report shows the number of new smear-positive cases registered in the quarter. (See sections 3 and 3.1) The Quarterly Report on Sputum Conversion is completed for patients registered in the quarter that ended 3 months ago. This report shows the number of new smear-positive cases who had sputum conversion at 2 or 3 months. (See section 3.2) The Quarterly Report on Treatment Outcomes is completed for patients registered in the quarter that ended 12 months ago. This report shows the number of new and re-treatment cases with each of six possible treatment outcomes . (See section 3.3) On 5 April 2005, cohorts reported on would be as follows: Name of report

(See section 3)

Quarter in which cohort was registered

Quarterly Report on TB Case Registration Quarterly Report on Sputum Conversion Quarterly Report on Treatment Outcomes 5.

2nd_ quarter of 2005 1st quarter of 2005 2nd quarter of 2004

The positivity rate (i.e. proportion of TB suspects tested who were sputum smearpositive) is calculated as follows: (See section 4.1) 64 = 0.08 u 100 = 8% positivity 800 This indicator is in the expected range of 2–15%.

Three possible reasons: (See section 4.2) – – – there are too many diagnoses by X-ray, there are too many extrapulmonary cases, and/or TB/HIV prevalence is high.

The sputum conversion rate is: (See section 4.3) 36 = 0.75 u 100 = 75% 48 This is less than the desired level of at least 85%.

50% + 35% = 85% 14 = 0.35 u 100 = 35% 40 Although the rate of treatment success is good at 85%, the cure rate should be a higher proportion of treatment success. If more final follow-up sputum examinations are done, the cure rate should increase towards 85%, while the proportion that completed treatment should decrease. (See section 4.3) 9. All are possible causes of a high death rate: a. b. c. d.

Cure: 20 = 0.40 u 100 = 50% 40

Treatment completed:

Treatment success:

9 9 9 9

TB cases are detected late, after they become more serious and likely to die. HIV-related deaths are occurring among TB patients. Health facility staff are not asking all adults about cough. HIV testing and care sites do not refer patients coughing longer than 2 weeks for sputum examination.

Answer “c” applies because it is a cause of “a.” If health facility staff do not ask all adults about cough, they will only identify TB suspects who have serious cough or who self-report. These TB suspects are likely to include the more advanced TB cases. Answer “d” applies because it is one of many possible causes of “b.” If HIV testing and care sites do not refer coughing patients, their TB may not be diagnosed until it is advanced. There is a much better chance of curing TB in PLWHA if it is identified early. Several examples of “root causes” of “d” are listed below, with possible solutions: x Staff of HIV testing and care sites do not know to ask all PLWHA about cough, or do not know what questions to ask, or do not know where to refer patients for sputum examinations. Possible solution: Provide training to staff. x Staff of HIV testing and care sites are not motivated to ask about cough because their job is already complicated; they want to focus on HIV, which is their patients’ main problem. Possible solution: Explain to staff that TB can be treated and cured in PLWHA. TB treatment will improve co-infected patients’ chances of surviving. x There is a lack of resources; specifically, there is no TB microscopy unit for sputum examinations near the HIV testing and care site. Possible solution: Add a microscopy unit near the HIV testing and care site; or arrange transportation for sputum samples to the nearest microscopy unit, and train HIV testing and care staff to collect and send samples. If you listed a different “root cause,” be sure that the solution that you identified is appropriate for the cause. (See section 5)

The End Congratulations on finishing this module!

Exercises for Module G: Monitor and Evaluate TB Control

Exercise A Written Exercise and Discussion – Monitoring implementation of activities

In this exercise you will discuss the following situations with your group. Both situations are related to monitoring implementation of the District TB Plan for Faba for 2004. Situation 1 During supervisory visits in April 2004, the Faba District TB Coordinator, Dr Oke Karimi, discovers that all but one of the health facilities providing TB control services have begun to use the Register of TB Suspects as planned. When visited in the 3rd week of April, High Road Health Post has recorded nothing in the register. Dr Karimi asks why nothing is recorded and is told that no TB suspects have been found. The outpatient register shows that 260 patients have visited the health post during the first weeks of April. By enquiring further, Dr Karimi finds that health post staff are not asking all adults about cough because they have not organized transportation for sputum samples and would not have a way to send them to the hospital. To prepare for the group discussion, write brief answers to the following questions: 1. What should the District TB Coordinator do about this problem immediately, during the supervisory visit?

What should be done later?

Should plans for activities in the district be adjusted, and if so, how?

Situation 2 Starting in April of 2004, Dr Karimi expects to see an increase in the number of sputum samples being received by the Agraville Hospital laboratory. However, the number does not increase in April. Dr Karimi investigates and finds that, at Bella Health Centre, there are not enough sputum containers, so the staff have collected sputum only for the very ill TB suspects. Although Dr. Karimi increased the order of sputum containers in January, the supplies were not received until March, and then were held in the district storeroom by mistake because the boxes were not labelled properly. To prepare for the group discussion, write brief answers to the following questions: 1. What should the District TB Coordinator do about this problem immediately?

What should be done later?

Should plans for activities in the district be adjusted? If so, how?

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 3, section 2, and read until the next stop sign.

Exercise B Written Exercise – Completing the Quarterly Report on TB Case Registration

In this exercise you will complete a Quarterly Report on TB Case Registration for Faba District. You will use the following materials: x module K: District Tuberculosis Register for Faba District (pages 15–21); x a tally sheet (an enlarged copy of the Quarterly Report on TB Case Registration, given on the next page of this module); and x a blank Quarterly Report on TB Case Registration (given on page 50 of this module). As noted on the tally sheet and quarterly report, it is now 4 October 2004 in Faba District. The Quarterly Report on TB Case Registration will be completed for the cohort registered in the quarter that has just ended, that is, the 3rd quarter of 2004. Instructions: 1. Tally the cases registered in the 3rd quarter of 2004 (pages 15–21 of K: District Tuberculosis Register) on the tally sheet on the next page. Also refer to instructions on pages 7–9 of this module as needed. Remember these hints: – – – – When tallying from the District TB Register, use a blank piece of paper to keep your place and to mask the rows that you are not looking at. When you tally a new smear-positive case in Block 1, also tally the case according to sex and age group in Block 2. Tally patients whose sputum was not tested in the column for smear-negative patients (Block 1, Column 2). Do not tally cases who transferred into the district (T).

TALLY SHEET: QUARTERLY REPORT ON TB CASE REGISTRATION Name of district: ____________________ Faba Patients registered during 2004 _____ 3rd quarter of year______

4 District no.: ___________ Oke Karimi Name of District TB Coordinator: _____________________ Oke Karimi Signature: ______________________________________ Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) or not tested (2) <15 years >15 years

Date of completion of this form: 4/10/04 _______________________

Extrapulmonary (3) <15 years >15 years

Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

F Block 3. PREVIOUSLY TREATED CASES (Smear-positive) Relapse Treatment after failure Treatment after default Other

Exercise continued on next page

Complete the quarterly report below. To do this, refer to the tally sheet on the previous page, count up the totals and write them on the report.

QUARTERLY REPORT ON TB CASE REGISTRATION Faba Name of district: ____________________ 4 District no.: ___________ Oke Karimi Name of District TB Coordinator: _____________________ Oke Karimi Signature: ______________________________________ Patients registered during 3rd quarter of year______ 2004 _____

Date of completion of this form: _______________________ 4/10/04

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

* In areas routinely using culture, a separate form for reporting culture-positive patients should be used. ** Other cases may include patients with unknown history of previous treatment.

Answer the following questions about the Quarterly Report on TB Case Registration that you just completed: a. How many patients registered in the 3rd quarter are new smear-positive cases?

b. Of these new smear-positive cases, how many are men? How many are women?

c. What age group has the largest number of new smear-positive cases?

d. How many cases registered in the 3rd quarter are re-treatments? (Re-treatments include relapses, treatment after failure, and treatment after default.)

When you have finished this exercise, review your answers with a facilitator.

GO BACK to page 13, section 3.2, and read until the next stop sign.

Exercise C Written Exercise – Completing the Quarterly Report on Sputum Conversion

In this exercise you will complete a Quarterly Report on Sputum Conversion for Faba District. You will use the following materials: x module K: District Tuberculosis Register for Faba District (pages 8–14); x a tally sheet (an enlarged copy of the Quarterly Report on Sputum Conversion, given on the next page of this module); and x a blank Quarterly Report on Sputum Conversion (given on page 54 of this module). As in the previous exercise, it is now 4 October 2004 in Faba District. The Quarterly Report on Sputum Conversion will be completed for the cohort registered in the quarter that ended 3 months ago, that is, the 2nd quarter of 2004. Instructions: 1. On the tally sheet on the next page, tally cases registered in the 2nd quarter of 2004 (pages 8–14 of module K: District Tuberculosis Register) according to their sputum conversion status at 2 or 3 months. Refer to instructions on page 14 of this module as needed. Remember these hints: – – – When tallying from the District TB Register, use a blank piece of paper to keep your place and mask the rows that you are not looking at. Do not tally cases who transferred into the district (T). Tally only new (N) smear-positive cases in the first column. The total should match the number of new smear-positive cases on the Quarterly Report on TB Case Registration previously completed for this cohort, which was 41. If a new smear-positive case was still positive at the last recorded 2- or 3-month test, that case did not convert. For the sake of completeness, you may tally the cases that did not convert in the right margin of the tally sheet. (These cases will not be recorded on the quarterly report, however.)

–

TALLY SHEET: QUARTERLY REPORT ON SPUTUM CONVERSION Faba Name of district: _____________________________ District no.: ___________ 4 Name of District TB Coordinator: ___________________ Oke Karimi Signature: _____________________________________ Oke Karimi Number of new smear-positive cases Smear not done at registered in quarter either 2 or 3 months recorded above** Patients registered during 2004 _____ 2nd quarter of year______* Date of completion of this form: 4/10/04 ____________________ Sputum conversion at: 2 months 3 months

Did not convert:

Total converted at 2 or 3 months:

Exercise continued on next page

Complete the quarterly report below. To do this, refer to the tally sheet on the previous page, count up the totals, and write them on the report.

QUARTERLY REPORT ON SPUTUM CONVERSION Name of district: _____________________________ Faba District no.: ___________ 4 Patients registered during 2nd quarter of year______* 2004 _____ Date of completion of this form: ____________________ 4/10/04 Sputum conversion at: Smear not done at either 2 or 3 months 2 months 3 months

Oke Karimi Name of District TB Coordinator: ___________________ Oke Karimi Signature: _____________________________________ Number of new smear-positive cases registered in quarter recorded above**

Answer the following questions about the Quarterly Report on Sputum Conversion: a. How many new smear-positive cases did not have a smear done at either 2 or 3 months? What could be the reasons that these smears were not done?

Of the new smear-positive cases registered in this quarter, how many converted at 2 or 3 months? This number will be used to calculate a sputum conversion rate (the proportion of smear-positive cases that convert at 2 or 3 months).

Of the new smear-positive cases registered in this quarter, which patients were still positive when last tested at 2 or 3 months? (Write the District TB numbers.)

In October 2004, when this report is being completed, what are the circumstances with these cases?

When you have finished this exercise, review your answers with facilitator.

GO BACK to page 19, section 3.3, and read until the next stop sign.

Exercise D Written Exercise – Completing the Quarterly Report on Treatment Outcomes

In this exercise you will complete a Quarterly Report on Treatment Outcomes for Faba District. You will use the following materials: x module K: District Tuberculosis Register for Faba District (pages 1–6); x a Quarterly Report on TB Case Registration (given on the next page), which was completed last year for the same cohort for which you will now complete the Quarterly Report on Treatment Outcomes; x a tally sheet (an enlarged copy of the Quarterly Report on Treatment Outcomes) given on page 58 of this module; and x a blank Quarterly Report on Treatment Outcomes (given on page 59 of this module). As in the previous exercises, it is now 4 October 2004 in Faba District. The Quarterly Report on Treatment Outcomes will be completed for the cohort registered in the quarter that ended 12 months ago, that is, the 3rd quarter of 2003. Instructions: 1. Use the Quarterly Report on TB Case Registration for this cohort to complete the left side of the tally sheet and Quarterly Report on Treatment Outcomes. 2. Tally the treatment outcomes of cases registered in the 3rd quarter of 2003 (pages 1–6 of module K: District Tuberculosis Register) on the rest of the tally sheet. Remember these hints: – – When tallying from the District TB Register, use a blank piece of paper to keep your place and to mask the rows that you are not looking at. First look at the type of case. Was the case new (N) or a re-treatment (R, F or D)? If new, was the case smear-positive or smear-negative before treatment? Answers to these questions will indicate the row (1.1, 1.2, 2.1, 2.2, or 2.3) on which to tally the case’s treatment outcome. Find the case’s treatment outcome, and make a tally mark on the appropriate row. Do not tally outcomes for extrapulmonary cases (EP), for cases who transferred into the district (T), or for those who were registered as other (O).

– –

3. Complete the quarterly report on page 59.

QUARTERLY REPORT ON TB CASE REGISTRATION

Faba Name of district: ____________________ 4 District no.: ___________ Oke Karimi Name of District TB Coordinator: _____________________ Oke Karimi Signature: ______________________________________

Patients registered during 3rd quarter of year______ 2003 _____

Date of completion of this form: _______________________ 6/10/03

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

4 3

13 6

2 2

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

* In areas routinely using culture, a separate form for reporting culture-positive patients should be used. ** Other cases may include patients with unknown history of previous treatment.

Exercise continued on next page

Tally sheet: Quarterly Report on Treatment Outcomes Oke Karimi Name of District TB Coordinator:__________________ Signature: _________________ Oke Karimi Date of completion of this form: 4/10/04 _____________________ Treatment outcomes Cure Treatment completed (2) (3) (4) (5) Died Treatment failure Default Patients registered during ______ 3rd quarter of year ______* 2003

Faba Name of district:_____________

District no.:___________ 4

Type of case

Total number of pulmonary patients registered during quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1.1 Smear (+)

1. New

1.2 Smear (–)

2.1 Relapses

2. Re-treatment (smear-positive)***

2.2 Treatment after failure

2.3 Treatment after default

QUARTERLY REPORT ON TREATMENT OUTCOMES

Name of district:_____________ Faba

Oke Karimi Name of District TB Coordinator:__________________ Oke Karimi Signature: _________________ Date of completion of this form: 4/10/04 _____________________ Treatment outcomes Cure Treatment completed (2) (3) (4) (5) Died Treatment failure Default

Patients registered during 3rd quarter of year ______* _____ 2003

District no.:___________ 4

Type of case

Total number of pulmonary patients registered during quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1. New

1.1 Smear (+)

1.2 Smear (–)

2.1 Relapses

2.2 Treatment after failure

*** In areas routinely using culture, a separate form for culture-positive patients should be used.

2. Re-treatment (smear-positive)***

2.3 Treatment after default

Exercise continued on next page

Answer the following questions about the Quarterly Report on Treatment Outcomes: a. For how many new pulmonary smear-positive cases were outcomes recorded? How many of these cases had the outcome “cure”?

Looking at the sputum examination results for cases F-135, F-136, F-154, F-171, and F-173, what do these cases have in common?

Do you think that this suggests a problem? If so, what is the problem?

What are some possible causes of the problem?

A total of 60 cases were entered in the District TB Register in the 3rd quarter of 2003. For how many of these cases were outcomes recorded on the Quarterly Report on Treatment Outcomes? (Total the last column.)

Of the cases entered in the District TB Register in the 3rd quarter of 2003, which kinds of cases are not accounted for on the Quarterly Report on Treatment Outcomes?

When you have finished this exercise, review your answers with facilitator.

GO BACK to page 25, section 4, and read until the next stop sign.

Exercise E Written Exercise – Calculating and analysing indicators related to case detection and quality of diagnosis Part I (case detection): In the first part of this exercise you will calculate the following indicators related to case detection in the quarter that just ended in Faba District (3rd quarter of 2004): x Ratio of TB suspects tested to outpatients aged 15 years and older x Proportion of TB suspects tested who were sputum smear-positive. Instructions: 1. Read the information below. This information will be used to calculate the indicators. Health facility reports from previous quarters show that the average number of adult outpatients (aged 15 and older, seen for any reason) per quarter is as follows: Agraville Hospital: Bella Health Centre: Denali Health Post: Gadara Health Post: High Road Health Post: 9 000 3 200 1 000 1 000 800 15 000

Monthly laboratory reports from the district laboratory supervisor, summarized by the District TB Coordinator, show the following: Month of 2004 July August September Total for 3rd quarter Number of TB suspects whose sputum was examined 180 200 220 600 Number of TB suspects who were sputum smear-positive 13 15 14 42

Exercise continued on next page

The table below shows the formula and data needed to calculate the indicators related to case detection. Use the information from health facility reports and laboratory reports (on the previous page) to fill in the numerator and denominator in the fourth column. Indicators related to case detection in Faba District, 3rd quarter of 2004 Results for Faba District Formula for calculatinga Number of TB suspects whose sputum was examined Total number of outpatients aged 15 years and older seen for any reason at facilities providing TB services Number of TB suspects who were sputum smear-positive Number of TB suspects whose sputum was examined

Indicator

Sources of data

Numerator Denominator

Ratio or proportion

Ratio of TB suspects tested to outpatients aged 15 years and older

Obtain from laboratory reports from district laboratory supervisor Estimate based on outpatient totals from health facilities in previous quarters

Proportion of TB suspects tested who were sputum smear-positive (positivity rate) a

Obtain from laboratory reports from district laboratory supervisor Obtain from laboratory reports from district laboratory supervisor

The numerator is above the dashed line and the denominator below it.

3. 4.

Calculate the indicators and enter them in the last column of the table above. Answer the following questions about the indicators that you have calculated. Refer to page 28 of the module as needed: a. How does first indicator, the ratio of TB suspects tested to outpatients aged 15 years and older, compare with the expected level of 3–5%? In 2003 this ratio was usually about 2%. Does the current ratio suggest that there has been an improvement since 2003? b. How does the second indicator, the proportion of TB suspects tested who were sputum-smear positive, compare with the expected level of 2–15%?

One year ago, the positivity rate for the district in the 3rd quarter of 2003 was 10%. Does the new rate suggest an improvement? Why or why not?

When you have finished Part I of this exercise, you may review your answers with a facilitator, or you may continue with Part II and receive feedback at the end of the entire exercise.

Part II (quality of diagnosis): In this part of the exercise you will calculate an indicator related to quality of diagnosis, that is, the proportion of TB cases registered in the 3rd quarter of 2004 who were sputum smearpositive. Instructions: 1. Find the answer sheet for Exercise B of this module. The answer sheet shows the Quarterly Report on TB Case Registration for cases registered in the 3rd quarter of 2004. Refer to the Quarterly Report on TB Case Registration (answer sheet) to fill in the numerator and denominator data in the fourth column of the table below. Indicator related to quality of diagnosis in Faba District Results for Faba District Indicator Formula for calculatinga Source of data Numerator Denominator Proportion

Proportion of TB cases who were sputum smearpositive

Number of TB cases who were sputum smear-positive

Refer to the Quarterly Report on TB Case Registration for the cohort. Add the new sputum smear-positive cases (Block 1, Column 1) and all cases recorded in Block 3. Refer to the Quarterly Report on TB Case Registration for the cohort. Add the total new cases (Block 1, Column 4) and all cases recorded in Block 3.

Total TB cases

The numerator is above the dashed line and the denominator below it.

Calculate the indicator and enter it in the last column above.

Exercise continued on next page

Answer the following questions about the indicator that you have calculated. Refer to page 29 of the module as needed: a. How does the indicator compare with the expected level?

Does there seem to be a problem with over-reliance on X-ray for diagnosis of TB in Faba District?

When you have finished this exercise, review your answers with facilitator.

GO BACK to page 30, section 4.3, and read until the next stop sign.

Exercise F Written Exercise and Discussion – Calculating and analysing indicators related to TB treatment

In this exercise you will calculate the following indicators for Faba District: x the sputum conversion rate for cases registered in the 2nd quarter of 2004 x treatment outcome indicators for cases registered in the 3rd quarter of 2003. In previous exercises you have completed quarterly reports that you will use in order to calculate the indicators. Instructions: 1. Get out the answer sheets for Exercises C and D of this module. These show: x the Quarterly Report on Sputum Conversion for patients registered in the 2nd quarter of 2004 and x the Quarterly Report on Treatment Outcomes for patients registered in the 3rd quarter of 2003. 2. 3. Refer to these quarterly reports (answer sheets) to fill in the numerator and denominator data in the fourth column of the table on the next page. Calculate the sputum conversion and outcome indicators, and enter them in the last column of the table.

Exercise continued on next page

Indicators related to TB treatment in Faba District Results for Faba District Numerator Proportion Denominator

Indicator Proportion of new sputum smear-positive TB cases who converted at 2 or 3 months (sputum conversion rate) Proportion of new sputum smear-positive TB cases with each treatment outcome: Cure

Formula for calculating

Sources of data

Number of new sputum smearpositive TB cases who converted at 2 or 3 months Total new sputum smearpositive TB cases

Quarterly Report on Sputum Conversion, bottom row Quarterly Report on Sputum Conversion, first column

Number of new sputum smearpositive TB cases with outcome cure Total new sputum smearpositive TB cases

Quarterly Report on Treatment Outcomes, line 1.1, column 1 Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated

Treatment completed

Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 2 treatment completed Quarterly Report on Treatment Outcomes, line 1.1, total number evaluated Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 3 died Quarterly Report on Treatment Outcomes, Total new sputum smearpositive TB cases line 1.1, total number evaluated Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 4 treatment failure Quarterly Report on Total new sputum smearTreatment Outcomes, positive TB cases line 1.1, total evaluated Total new sputum smearpositive TB cases Number of new sputum smear- Quarterly Report on positive TB cases with outcome Treatment Outcomes, line 1.1, column 5 default Total new sputum smearpositive TB cases Quarterly Report on Treatment Outcomes, line 1.1, total evaluated

Died

Treatment failure

Default

Transfer out (out of district)

If you are not confident of your answers in the table, check with a facilitator before continuing this exercise below.

To prepare for a group discussion, answer the following questions about the indicators that you have just calculated. Refer to page 31 of the module as needed. a. How does the sputum conversion rate for patients registered in the 2nd quarter of 2004 compare with the desired level of at least 85%? What does this suggest about the quality of TB treatment in Faba district?

Enter the sputum conversion rate for the 2nd quarter of 2004 on the graph below:

How does the rate for the 2nd quarter of 2004 compare with previous rates?

What are possible reasons for changes in the sputum conversion rate?

Exercise continued on next page

Look back at the table of indicators that you calculated on page 66. For the cohort of cases registered in the 3rd quarter of 2003, what was the rate of “treatment success” (that is, the proportion cured plus the proportion that completed treatment)? According to the graph on page 67, what was the approximate sputum conversion rate, measured earlier, for that cohort (cases registered in the 3rd quarter of 2003)? Does “treatment success” for that cohort seem consistent with its earlier sputum conversion rate? Why or why not?

When outcome rates were calculated a year ago, selected outcome rates for the cohort registered in the 3rd quarter of 2002 were: Cure 54% Treatment completed 18% Treatment success 72% Default 17% Compare the above rates with those which you just calculated for the cohort registered in the 3rd quarter of 2003. What are some possible reasons for the changes in the: Cure and completion rates?

Default rate? e. The 6% death rate in Faba District is higher than expected. What were the causes of the 2 deaths that resulted in this rate? (Look in the District TB Register to find out.) How could the death rate possibly be reduced?

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 34, section 5, and read until the next stop sign. 68

Exercise G Written Exercise – Evaluation of target

Time has passed in Faba District, and it is now the beginning of the new year (2005). In this exercise you will determine whether the sputum conversion target set for Faba District for 2004 was achieved. This target of 85% was presented in the District TB Plan for 2004 shown in module B. Instructions: 1. Study the Quarterly Report on Sputum Conversion below, which has just been completed for the cohort of patients registered in the 3rd quarter of 2004. QUARTERLY REPORT ON SPUTUM CONVERSION Name of district: _____________________________ Faba District no.: ___________ 4 Patients registered during 3rd quarter of year______* 2004 _____ Date of completion of this form: ____________________ 5/01/05 Sputum conversion at: Smear not done at either 2 or 3 months 2 months 3 months

Oke Karimi Name of District TB Coordinator: ___________________ Oke Karimi Signature: _____________________________________ Number of new smear-positive cases registered in quarter recorded above**

Total converted at 2 or 3 months:

Exercise continued on next page

Use the Quarterly Report on Sputum Conversion (on the previous page) to calculate a sputum conversion rate for the cohort registered in the 3rd quarter of 2004. (See page 31 of this module if you need a reminder of how to calculate this rate.) Write your calculations and result below:

Answer the following questions: a. How does the rate compare with the sputum conversion target of 85% set for Faba District for 2004? Was the target achieved?

b. Based on what you know about Faba District, what else do you think can be done to achieve an even higher sputum conversion rate?

When you have finished this exercise, review your answers with a facilitator.

GO BACK to page 39. Read and work until the end of the module (page 44).

Optional Exercise H Written Exercise – Problems, causes, and solutions

If you finish this module before the rest of your group, you may do this optional exercise while others are finishing.

In this exercise you will identify possible causes of and solutions to a problem that could be found by monitoring indicators. When listing possible causes and solutions, think about the situation in your own district or other districts with which you are familiar. Problem: Over the past year, a district has begun monitoring indicators. When measured after the past 3 quarters, the sputum conversion rate has consistently been about 70%. The District TB Coordinator is concerned about this low rate. Answer the following questions: 1. What are three possible causes of a low sputum conversion rate?

For one of the causes that you listed above, what are two or three possible “root causes”? To identify “root causes,” keep asking “Why?” repeatedly until you identify causes for which there are solutions.

Exercise continued on next page

For each “root cause,” what is a possible appropriate solution? Root causes Possible solutions

Ask a facilitator for an answer sheet when you have finished.

Annexes

A. Quarterly Report on TB Case Registration ............................................. 74 B. Quarterly Report on Sputum Conversion ................................................. 76 C. Quarterly Report on Treatment Outcomes............................................... 77

Annex A QUARTERLY REPORT ON TB CASE REGISTRATION Name of district: ____________________ District no.: ___________ Name of District TB Coordinator: _____________________ Signature: ______________________________________

Patients registered during _____ quarter of year______

Date of completion of this form: _______________________

Block 1. NEW CASES Pulmonary Smear (+) (1) Smear (–) (2) <15 years >15 years Extrapulmonary (3) <15 years >15 years Total (4)

Block 2. NEW PULMONARY SMEAR (+) CASES ONLY, FROM BLOCK 1 ABOVE, BY SEX AND AGE GROUP Age group in years Sex M F 0–14 15–24 25–34 35–44 45–54 55–64 >65 Total

Block 3. PREVIOUSLY TREATED CASES (Smear-positive)* Relapse Treatment after failure Treatment after default Other**

* In areas routinely using culture, a separate form for reporting culture-positive patients should be used. ** Other cases may include patients with unknown history of previous treatment.

Annex A, continued Explanations of how to fill the Quarterly Report on TB Case Registration:

District Information: Enter the name and identification number of the district. Enter the name of the District TB Coordinator. When the report is complete, sign it and enter the date of completion. Quarter: This report applies to patients registered (recorded in the District Tuberculosis Register) in the quarter that just ended. Fill in the number of the quarter and the year: 1st quarter – January, February, March 2nd quarter – April, May, June 3rd quarter – July, August, September 4th quarter – October, November, December Block 1: Refer to the pages of the District Tuberculosis Register showing cases registered in the quarter recorded at the top of the report. Of these cases, enter the number of new cases fitting the description in each column (1, 2, and 3). Enter the total new cases in column 4. Column (1): Smear-positive new case – a patient with pulmonary TB, sputum smear-positive, who has never had treatment for TB or who has taken anti-TB drugs for less than 1 month. (Note: These cases will also be recorded by sex and age group in Block 2, below.) Column (2): Smear-negative case – a patient with pulmonary TB that does not meet the definition for smear-positive TB. (This case may be smear-negative or have no smear result but have been diagnosed with pulmonary TB by culture or other means.) Record smear-negative cases in separate cells according to age group (<15 or >15 years). Column (3): Extrapulmonary TB – a patient with TB of organs other than the lungs. Record extrapulmonary cases in separate cells according to age group (<15 or >15 years). Block 2: In this block enter the new pulmonary smear-positive cases (already recorded in Block 1, Column 1) according to sex and age group. Block 3: Enter the number of patients fitting the description in each cell:

– – – –

Annex B QUARTERLY REPORT ON SPUTUM CONVERSION Name of district: _____________________________ District no.: ___________ Name of District TB Coordinator: ___________________ Signature: _____________________________________ Number of new smear-positive cases registered in quarter recorded above** Smear not done at either 2 or 3 months Date of completion of this form: ____________________ Sputum conversion at: 2 months 3 months Patients registered during _____ quarter of year____*

QUARTERLY REPORT ON TREATMENT OUTCOMES

Patients registered during _____ quarter of year ______*

District no.:___________

Type of case

Total number of pulmonary patients registered during quarter reported on** (1)

Total number evaluated for Transfer out outcomes: (and outcome Sum of columns unknown) 1 to 6 (6)

1. New

1.1 Smear (+)

1.2 Smear (–)

2.1 Relapses

2.2 Treatment after failure

Annex C

*** In areas routinely using culture, a separate form for culture-positive patients should be used.

2. Re-treatment (smear-positive)***

2.3 Treatment after default

WHO/HTM/TB/2005.347f

Management of Tuberculosis Training for District TB Coordinators

F ENSURE LABORATORY SUPPORT FOR TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Ensure Laboratory Support for TB Control Contents Page Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................2 1. Collaborate with the district TB laboratory supervisor to ensure sufficient TB laboratory services.......................................................................................................3 1.1 1.2 1.3 1.4 1.5 2. What tasks are performed at a TB microscopy unit?.........................................3 Assess whether every health facility has access to a TB microscopy unit ........3 Annually assess the TB microscopy workload ..................................................4 Assess distribution of the TB microscopy workload in the district ...................5 Determine whether there is a need to increase the capacity of the TB laboratory services .............................................................................................6

Visit TB microscopy units in the district.....................................................................8 2.1 Confirm that all smear-positive TB cases are registered in the District TB Register and that sputum examination results are entered correctly..................8 2.2 Confirm sputum examination results from a sample of follow-up sputum examinations .......................................................................................12 2.3 Review the Tuberculosis Laboratory Register to identify problems...............14 2.4 Use laboratory data to assess how health facilities are identifying TB suspects ...........................................................................................................15 2.5 Check whether microscopists keep slides for quality assurance by the provincial laboratory supervisor. .....................................................................15 2.6 Check equipment and supplies at the TB microscopy unit..............................16 2.7 Check whether the TB microscopy unit has trained staff. ...............................16

Keep notes of items to follow up after visits to TB microscopy units......................17

Summary of important points ............................................................................................19 Self-assessment questions..................................................................................................20

Answers to self-assessment questions ...............................................................................22 Exercises Exercise A .................................................................................................................24 Exercise B..................................................................................................................25 Exercise C..................................................................................................................27 Annex.................................................................................................................................35 Request for Sputum Examination Tuberculosis Laboratory Register

Ensure Laboratory Support for TB Control Introduction The diagnosis of tuberculosis at health facilities relies on sputum microscopy to detect infectious cases of pulmonary TB. A TB microscopy unit is a site with at least one microscope suitable for doing sputum smear examination for TB and at least one trained microscopist.1 The microscopist performs direct microscopic examination of stained sputum smears for tubercle bacilli, using the Ziehl–Neelsen technique. The most important function of a TB microscopy unit is the diagnosis of infectious cases of pulmonary TB by examination of sputum smears. Health facilities submit sputum samples for diagnosis of TB suspects, that is, an adult who has been coughing for 2 weeks or more or a person with symptoms or signs suggestive of pulmonary TB upon medical examination. TB microscopy units also examine follow-up sputum smears to: • • monitor at certain times during treatment whether a patient is smear-positive or smearnegative, and document cure at the end of treatment for patients who initially had smear-positive pulmonary TB.

The TB laboratory network in a country should include in each district one or more TB microscopy units that perform sputum smear microscopy. The network should also include technical expertise and additional laboratory services at higher levels for training and supervision of staff in TB microscopy units. A TB microscopy unit may be located at a health facility or the district hospital or any hospital at the first referral level. The TB microscopy units are the most important part of the TB laboratory network. TB microscopy units should receive supervision and support from the district TB laboratory supervisor and also from the provincial laboratory supervisor. The technical expertise in the laboratory network is very important for quality control of TB microscopy and the safety of personnel in TB microscopy units. The laboratory supervisor at the provincial level is responsible for quality assessment of how slides are prepared and read. A provincial-level laboratory should be able to perform culture for diagnostic purposes if needed or isolate mycobacteria to send to a reference laboratory at the national level for drug susceptibility testing. Every health facility providing TB control services must have reasonable access to a TB microscopy unit. If the TB microscopy unit is not in the same facility, the TB microscopy unit should be located near the TB control services, and there should be regular and reliable transportation of sputum samples and results between the health facility and the TB microscopy unit.

This module uses the term microscopist for the individual who is trained to perform the tasks of the TB microscopy unit, which include preparing and reading sputum slides. This individual may or may not have broader training in laboratory skills.

As District TB Coordinator, you should collaborate with the district laboratory supervisor to assess the TB microscopy workload and its distribution, using information on the number of sputum smear examinations performed at TB microscopy units and the number of microscopes and microscopists at each. Stay informed of the locations of all TB microscopy units to confirm that each health facility has reasonable access to TB sputum smear microscopy. Also assess whether TB microscopy units are providing timely microscopy results to health workers for diagnosis and management of TB patients.

Objectives of this module Participants will learn how to: • • • • • • Refer to section: 1.2 1.3–1.4 1.5 2.1 2.3 2.5–2.7

Assess whether health facilities have access to a TB microscopy unit Assess the TB microscopy workload and how it is distributed in the district Determine whether there is a need to increase the capacity of the TB laboratory services Review the Tuberculosis Laboratory Register and verify that all smear-positive cases are registered accurately in the District TB Register Review the Tuberculosis Laboratory Register to identify problems Check briefly whether microscopists keep slides for quality assurance and have sufficient equipment and supplies, and trained staff

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

Collaborate with the district TB laboratory supervisor to ensure sufficient TB laboratory services

1.1 What tasks are performed at a TB microscopy unit? When sputum samples are received at a TB microscopy unit, the microscopist: • • • • • logs in the sputum samples, prepares sputum smear microscopy slides for Ziehl–Neelsen staining, stains, dries and reads microscopy slides, when the set of slides has been read, records the results on the Request for Sputum Examination form as well as in the Tuberculosis Laboratory Register (see Annex), and sends the results back to the health facility.

Samples should be processed and results reported within 24 hours of receipt at the laboratory.

The TB microscopy unit must perform these steps accurately and within a reasonable time. When the results are received at the health facility, the health worker records the results in the Register of TB Suspects and/or on the TB Treatment Card and informs the TB suspect or TB patient. The health worker must ensure that any smear-positive patient starts treatment. In addition, each TB microscopy unit: • • • • • stores all negative and positive slides for quality assurance under proper storage conditions, maintains the microscope and microscopy supplies under proper storage conditions, follows safety measures for handling, smearing and fixing sputum samples including disinfection of bench, assuring proper ventilation and hand washing, monitors supplies and reagents stocks and informs supervisor regularly, and sends sputum samples for culture to the provincial laboratory, when requested.

1.2 Assess whether every health facility has access to a TB microscopy unit Every health facility that provides TB control services must have access to a TB microscopy unit. A TB microscopy unit may be a room in the same facility that does TB case detection and treatment or in a different location. If there is no TB microscopy unit in the health facility, a TB microscopy unit should be located nearby, and there should be regular and reliable transportation of sputum samples and results between the health facility and the TB microscopy unit.

Study the locations of the TB microscopy units on the map of the district. Consider whether every health facility has reasonable access to a TB microscopy unit, given the transportation available for sending sputum samples to a TB microscopy unit and for sending results back to the health facility. Reasonable access would mean that all sputum samples can be transported to the TB microscopy unit within 24–48 hours. The time from collection of a TB suspect’s first sputum sample until the suspect’s three samples reach the TB microscopy unit should be less than 1 week.

STOP Now do Exercise A – Written Exercise When you have reached this point in the module, turn to Exercise A on page 24 and follow the instructions. When you have finished writing answers to the questions, review your work with a facilitator.

1.3 Annually assess the TB microscopy workload A direct relationship exists between the workload of the microscopists and the quality of microscopy. The number of smears examined per microscopist per day should not exceed 20. If more examinations are attempted by one individual, visual fatigue will lead to a deterioration of reading quality. Reading 20 sputum slides takes a microscopist about 2.5 hours. The microscopist can do other work in the laboratory during the day, including preparing TB slides, or examining other samples such as blood or urine, or doing HIV testing. However, proficiency in reading smears can only be maintained by examining at least 10–15 smears per week, that is, a minimum of 2–3 smears per day. It is therefore important to assess periodically whether the workload of each microscopist is too much or too little. This is done by determining the average number of sputum smear examinations performed by each TB microscopy unit and microscopist per day. (Note that 2 microscopists can use one microscope in a day. A unit with 3 microscopists would require two microscopes.)

The recommended range of TB sputum smears to be read by a microscopist is: • at least 2–3 per day to maintain proficiency, and • not more than 20 per day to avoid visual fatigue and deterioration of quality.

Once a year, meet with the district laboratory supervisor to assess the TB microscopy workload. The district laboratory supervisor will have records of the number of sputum smears examined at each TB microscopy unit and in the district as a whole during the past month, quarter, or year.1 (Note: A month usually includes 22 workdays; a quarter has 66 workdays; and a year has 264 workdays.) To assess workload, divide the number of smears examined by the number of workdays in the period to determine the average number of smears examined in the district each day. You can then divide by the number of microscopists to determine the average daily number of smears per microscopist. Example In Patanga District, there are two TB microscopy units: one is in the district hospital and has 2 microscopists; the other is in a health centre and has 1 microscopist. The total number of sputum examinations performed in Patanga District in the 2nd quarter of 2004 was 3 800. 3 800 examinations = 66 workdays per quarter 58 examinations in the district per day on average

58 examinations per day = 19 examinations per day per microscopist 3 microscopists

This result is within the recommended range of 2–20 smear examinations per microscopist per day, but we do not know how much of the work is done at the district hospital and how much at the health centre. In districts like Patanga, where there is more than one TB microscopy unit, it is also helpful to assess the workload of each unit individually. When the workload of each TB microscopy unit is calculated separately, the results show how the district workload is distributed. 1.4 Assess distribution of the TB microscopy workload in the district

Study the locations of the TB microscopy units on a map of the district to see whether they are close to health facilities with more patients. In densely-populated areas with adequate transport and communications, fewer TB microscopy units are required to handle the workload, but more microscopists are needed at each (2 microscopists per microscope). In remote and sparsely populated areas, more TB microscopy units may be needed to provide access for more dispersed health facilities.

The district laboratory supervisor should also provide monthly reports on the number of persons whose sputum was examined for diagnosis and the number whose sputum was smear-positive. These numbers are needed for calculating indicators related to case detection in the district, which you will learn about in module G: Monitor and Evaluate TB Control.

Example In Patanga District, the TB microscopy unit at the hospital does 2 000 smear examinations per quarter. The TB microscopy unit in the health centre does 1 800 examinations per quarter. At the hospital: 2 000 sputum examinations = 30 sputum examinations in the hospital per day on average 66 workdays 30 sputum examinations per day = 15 sputum examinations per day per microscopist 2 microscopists

In the health centre: 1 800 sputum examinations = 27 sputum examinations per microscopist per day 66 workdays

In the TB microscopy unit in the health centre, on average, 27 smears are done by 1 microscopist per day. This exceeds the recommended limit of 20 smears per microscopist per day and shows there is a problem with workload distribution. Some of the workload needs to be transferred to the hospital TB microscopy unit, or another microscopist should be added at the overburdened TB microscopy unit. 1.5 Determine whether there is a need to increase the capacity of the TB laboratory services

Your assessment of the workload of TB microscopy units and the distribution of that workload in the district will show whether all health facilities providing TB control services have sufficient laboratory support. Indications that there is a need to increase the capacity of the TB laboratory services include: • • • Too many smears are done per day in a TB microscopy unit or per microscopist. TB microscopy units are not well located in the district, considering locations of health facilities, population distribution, or available transportation for samples and results. Increases are expected in the number of sputum samples sent for examination (for example, because additional health facilities will begin providing TB control services).

Possible ways to increase capacity include: • • • • adding or training staff in an existing TB microscopy unit so that 2 microscopists use an existing microscope, adding a microscope at an existing microscopy unit (if there will be an additional microscopist to use it), adding a new TB microscopy unit equipped with a microscope and a microscopist, improving transportation of samples to an existing TB microscopy unit,

• •

identifying and designating a good private laboratory and making it a part of quality assessment, or in facilities with a very heavy workload (e.g. large facilities), using a faster microscopy method (fluorescence staining, for which there must be a florescent microscope and trained staff).

If you believe there is a need to increase the capacity of the TB laboratory services, discuss this with the district TB laboratory supervisor. The laboratory supervisor will be interested in your assessment and should mention it when talking with higher level laboratory coordinators who will make decisions about laboratory resources.

STOP Now do Exercise B – Written Exercise and Discussion When you have reached this point in the module, you are ready to do Exercise B. Turn to page 25 and follow the instructions for Exercise B.

2. Visit TB microscopy units in the district Your main objectives when visiting a TB microscopy unit are: • • to verify that all sputum smear-positive TB cases detected by microscopy have been registered for treatment, and to verify the accuracy of sputum examination results recorded in the District TB Register.

A Tuberculosis Laboratory Register (see next page) is maintained at each TB microscopy unit. It is used to log in all sputum samples sent for examination for TB. The microscopist assigns a laboratory serial number for each patient whose sputum is received for examination. Date of receipt, patient’s name, sex, age, health facility, address, and reason for examination are also recorded. If the examination is for diagnosis, the microscopist ticks under “Diagnosis.” If it is for follow-up, the microscopist records the patient’s District TB number under “Follow-up.” When the sputum examination is completed, the microscopist records the results for each specimen (neg, +, ++, +++, or a number 1–9 if scanty). 2.1. Confirm that all smear-positive TB cases are registered in the District TB Register and that sputum examination results are entered correctly Since untreated smear-positive TB patients are likely to infect others and have a high death rate, it is very important to make sure all patients with positive sputum results are treated. If these patients have not been registered in the District TB Register, they are not receiving treatment for TB, unless perhaps they are being treated by another health-care provider, such as a private provider. Compare entries in the Tuberculosis Laboratory Register and the District TB Register to confirm that all patients who had smear-positive results in the Tuberculosis Laboratory Register are registered in the District TB Register. A significant proportion (up to 5%) of smear-positive patients is lost because they never report back to the health facility for the results of the sputum examination and treatment. Registering every smear-positive case in the District TB Register will remind you to urge health facilities to locate any missing patient. You will also be able to determine to what extent patients who do not return for results and treatment are a problem in the district. A reasonable time period, such as one month, must pass before you can expect to see all smear-positive TB cases in the Tuberculosis Laboratory Register registered in the District TB Register. It may take one month for sputum examination results to arrive at the health facility, a TB patient to start treatment, and for you to visit the health facility and register the case in the District TB Register. Therefore, when you review the Tuberculosis Laboratory Register, do not review the most recent month of entries. To begin your review, turn in the Tuberculosis Laboratory Register to the entries dated about one month ago, or the date of your previous visit to the microscopy unit. Draw a line under the last entry made that day. You will review entries from that day and earlier. Then begin reviewing sputum examination results, working backwards through the register. For example, if today is 5 October, turn in the register to find 5 September. Draw a line below the last entry dated 5 September. Then review the entries from 5 September and before, back to the line drawn at your previous visit on about 5 August. (See example on the next page.) 8

To review the Tuberculosis Laboratory Register: 1. 2. Find the column “Microscopy Results” in the Tuberculosis Laboratory Register. Look for smear-positive cases. Look down the column until you find a patient with positive results (2 or more positive smears, that is, 2 or more results recorded as +, ++, +++, or a number 1–9 for scanty). Then look at “Reason for Examination.” If the reason for examination was diagnosis, this is a smear-positive patient who should be registered in the District TB Register and receiving treatment. When you find a smear-positive TB case, look in the District TB Register to check whether the smear-positive patient is registered. Note the patient’s lab serial no. in the Tuberculosis Laboratory Register. Then look on the right side of the District TB Register, in the column “Before treatment/Lab no.” until you find the matching laboratory serial number. If the patient is found: a. b. c. Look to the left to find the patient’s name and confirm that it is the same patient. Put a tick next to the patient’s row in the Tuberculosis Laboratory Register to designate that the patient is registered in the District TB Register. Find the patient’s microscopy results recorded in the Tuberculosis Laboratory Register. Three smears should have been examined for diagnosis. Determine the highest result of the three sputum samples recorded in the Tuberculosis Laboratory Register. The highest result should be recorded in the District TB Register. Compare the result recorded in the District TB Register. If it does not match the highest result from the Tuberculosis Laboratory Register, correct the District TB Register. If you correct the District TB Register, make a note to check the patient’s TB Treatment Card when you return to the patient’s health facility. If there is an error on the TB Treatment Card, it must be corrected also. Inform the health facility staff about the error and ask them to give more attention to correct transcribing.

If the patient is not found in the District TB Register: a. Register the patient now. Copy the patient’s information from the Tuberculosis Laboratory Register, including the patient’s laboratory serial number, date of sputum smear examination, name, sex, age, address, referring health facility, and the microscopy results. (You will not be able to enter the type of patient until the patient is found.) Make a note that this patient must be found and put on treatment. Plan to visit the referring health facility to check the health facility records. When you go to that health facility at your next supervisory visit, you may find that the patient has begun treatment since your previous visit and now has a TB Treatment Card. If so, use the TB Treatment Card to complete the row in the

District TB Register by adding the type of patient, date treatment started, and treatment category. However, if you find that the patient has not started treatment, the patient must be found. Inform the health worker responsible for TB control about this case. If the patient is never found to begin treatment, record the type of patient as “Other.” 4. If you find a TB suspect in the Tuberculosis Laboratory Register who has only one sputum result that is positive for diagnosis: a. b. Write down the information on this patient. Plan to visit the referring health facility to determine whether the patient continued the diagnostic process, and the result. A patient with one positive sputum examination result should have been referred to a clinician, so that the clinician can make a clinical assessment of whether the patient has TB or do other tests. When you go to the referring facility at your next supervisory visit, find out whether the patient was referred to a clinician for assessment. If the patient was diagnosed with TB, be sure the patient is registered in the District TB Register and confirm that treatment has started. If treatment has not begun, or if the diagnostic process was not continued, ask the health worker to find the patient. 5. Continue reviewing entries in the Tuberculosis Laboratory Register to find all the smear-positive TB cases diagnosed, and confirm that they are registered in the District TB Register. Smear-positive TB cases that you have previously confirmed to be registered will have a tick by their row. Continue working backwards through the Tuberculosis Laboratory Register until you reach TB cases that you ticked at a previous visit.

STOP

Now do Exercise C – Written Exercise

When you have reached this point in the module, you are ready to do Exercise C. Turn to page 27 and follow the instructions. Do this exercise by yourself. Then discuss your answers with a facilitator.

2.2

Confirm sputum examination results from a sample of follow-up sputum examinations

From the Tuberculosis Laboratory Register, select a sample of patients that had follow-up sputum examinations since your previous visit, and confirm the laboratory results recorded in the District TB Register. To select a sample of up to 5 cases, go back 30 days from today in the Tuberculosis Laboratory Register. Look in the column “Reason for Examination,” and working backwards through the register, select up to 5 TB patients who had follow-up sputum examinations. See the example on the next page. a. When you find a TB patient in the Tuberculosis Laboratory Register whose reason for examination was follow-up, note the patient’s District TB number (recorded in that column). Also note the highest result of the two sputum samples. Look at the left side of the District TB Register until you find the patient’s District TB number. Confirm that the patient’s name is the same. Check that the highest result from the Tuberculosis Laboratory Register is accurately recorded in the District TB Register. If not, correct the District TB Register. Repeat these steps until you have confirmed the sputum examination results from several follow-up sputum examinations.

b. c. d.

If you correct the District TB Register, make a note to check the patient’s TB Treatment Card when you return to the patient’s health facility. If there is an error on the TB Treatment Card, it must be corrected also.

2.3

Review the Tuberculosis Laboratory Register to identify problems

Although your main purpose for looking at the Tuberculosis Laboratory Register is to check the District TB Register, you may notice entries that cause you to suspect a problem with performance at the TB microscopy unit or health facilities. Below are some items that you may notice in the Tuberculosis Laboratory Register and the implications.

You may suspect a problem if: The Tuberculosis Laboratory Register is not filled out completely and correctly. Some TB suspects did not have 3 samples examined for diagnosis.

Implications: The microscopist may need training or may need reinforcement from the laboratory supervisor. The microscopist may choose not to process the third sputum sample because the previous two were positive. Health workers may not know the correct number of sputum samples to collect, or the patients do not return with the second sample. You can address this with staff at the health facilities. This is uncommon. It is possible that the microscopist is preparing the required number of smears from fewer samples. There may be a problem with the performance of the microscopist. The microscopist may not look closely enough, or there may be a new microscopist who needs some guidance. The microscopist may repeat the first result without reading the other samples. The laboratory supervisor should review the work. Check that slides are kept and periodically rechecked for quality by the supervisory laboratory, and that feedback is provided to the microscopist. If all samples have some bacilli, the immersion oil may have become contaminated with bacilli, or slides could be scratched, or the lens could be contaminated.

Some TB patients did not have 2 samples examined for follow-up.

Every TB suspect has provided 3 samples for diagnosis, and every TB patient has provided 2 samples for follow-up. The proportion of positive results of each type (+++, ++, +, scanty) is not as expected, e.g. there are no “+” or “scanty” results. The proportions of positive results of each type change (e.g. no scanty, too many scanty). For a particular case, the results are not reasonable, (for example, one result is +++ and the two others are negative). The result of all smears for a patient is the same. (The expected result is higher positivity for the second, overnight sample.)

The laboratory is rejecting samples because of contamination by containers that have leaked.

There may be a need to train health facility workers how to close the containers tightly, or the programme may need to use different containers.

You may suspect a problem if: The total workload (number of sputum smears examined) in a day for diagnosis and follow-up seems too large.

Implications: If more than 20 smears are examined per day per microscopist (or more than 100 per week), visual fatigue will lead to a deterioration of reading quality. Capacity of the TB laboratory services may need to be increased. If a microscopist reads fewer than 10–15 smears per week, proficiency in reading smears cannot be maintained. Discuss either of these problems with the laboratory supervisor.

The number of sputum smears examined in an average week by one microscopist seems too small.

As the District TB Coordinator, you are NOT the laboratory supervisor and have no direct authority there. If you suspect any problems with performance at a TB microscopy unit, you should inform the district laboratory supervisor so that the situation can be investigated. 2.4 Use laboratory data to assess how health facilities are identifying TB suspects

If health facilities do not have Registers of TB Suspects, use the Tuberculosis Laboratory Register to do a quick assessment of how staff are identifying TB suspects at health facilities. Count entries in the Tuberculosis Laboratory Register to determine for one month: • • What was the number of TB suspects who had sputum examined for diagnosis in a month? How many of these were smear-positive?

Then calculate to determine: • What proportion of TB suspects tested were smear-positive?

The proportion of TB suspects tested who are smear-positive is usually 2–10%. If more than 15% are smear-positive, persons with more advanced disease are being selected for sputum examination, i.e. severe cases with long delay in diagnosis, instead of all people with cough for 2 weeks or more. Discuss this problem with the officer in charge at the health facility to decide the probable cause and a solution. An increase in case detection efforts should be reflected in more sputum smear examinations per month and a lower positivity rate. 2.5 Check whether microscopists keep slides for quality assurance by the provincial laboratory supervisor Microscopists should keep slides so that they can be reviewed by a laboratory supervisor at the provincial level for quality assurance. The provincial supervisor should periodically check for quality of the slide preparation and the accuracy of reading on both positive and negative slides, and should then send feedback to the technician. 15

Talk with the microscopist to find out whether slides are kept for review by the provincial laboratory supervisor. Ask: • • • • • • Do you keep the slides of all smear-positive TB cases? Do you keep negative slides? Where are the slides stored? How long do you keep slides? Have you been asked to send slides to the provincial TB laboratory, or has someone come here to collect or check your slides? If you send slides to the provincial TB laboratory, do you send all slides or do you send a sample? If a sample, how do you choose the sample? Did you receive a response? What was it? ( ___% discrepancy on negatives and ___% discrepancy on positives.)

2.6 Check equipment and supplies at the TB microscopy unit During your visit, observe and ask the microscopist questions about the microscope and supplies. Assess whether a microscope is in good working condition by asking the microscopist whether it works well mechanically so that it can focus. Ask if he or she can see well through it. To assess whether reagents and other supplies needed in the TB microscopy unit are available in needed quantities, ask the microscopist. Needed supplies include: • • • • • reagents: carbol fuchsin, methylene blue, alcohol (methanol), sulfuric acid immersion oil running water other materials: slides, boxes to store slides, sputum containers (if patients come to the laboratory to collect sputum) electricity or sunlight (depends on type of microscope).

Report to the district laboratory supervisor any laboratory equipment or supply needs noted during your visit. 2.7 Check whether the TB microscopy unit has trained staff

Ask the microscopist about his or her training. Microscopists working in TB microscopy units at health facilities or the district hospital should be trained in the following procedures: • • • • • collection, storage, and transport of sputum samples for microscopy smear preparation slide reading reporting of results and recording of data in the Tuberculosis Laboratory Register storage of positive slides and negative slides for quality assurance 16

•

Safety measures for handling sputum samples and performing microscopy (including disinfection of table and hands; ventilation; discarding used materials).

Ask the microscopist how he or she was trained to prepare and read TB slides. Laboratory technicians who have a background in basic laboratory skills require 1 week (5 full days) of practical training to learn to prepare and read TB slides. An individual who has not previously had formal laboratory training can be trained to do sputum microscopy but will require longer training, at least 2 weeks.

Keep notes of items to follow up after visits to TB microscopy units

Keep a list of items to check at various health facilities, based on your findings at the TB microscopy units. This would include: • any smear-positive TB patients who were just found in the Tuberculosis Laboratory Register and entered in the District TB Register, but who may not have started treatment (You will need to confirm that they start treatment. Then you will use their TB Treatment Cards to complete the entries in the District TB Register.) any TB suspects who had one positive sputum result (to confirm that they continued diagnostic process) and any patients who had incorrect sputum examination results (for diagnosis or follow-up) recorded in the District TB Register when compared with the Tuberculosis Laboratory Register, so that you can correct their TB Treatment Card.

• •

If you identified any problems or concerns on your visit to TB microscopy units, such as a faulty or broken microscope, or a microscopist who was not sufficiently trained, plan to communicate your important observations to the district TB laboratory supervisor. When you discuss your observations, collaborate with the laboratory supervisor as needed to help solve the problems.

Summary of important points • A TB microscopy unit is a site that performs sputum smear microscopy for diagnosis of TB suspects and follow-up of TB patients in treatment. Sputum samples should be processed and results reported within 24 hours of receipt at the laboratory. To assess whether there are sufficient TB laboratory services in the district, consider: − whether every health facility that provides TB control services has reasonable access to a TB microscopy unit, − the overall microscopy workload in the district, and − the distribution of the microscopy workload among TB microscopy units. At each TB microscopy unit, compare entries in the Tuberculosis Laboratory Register and the District TB Register to verify completeness and accuracy. For each TB suspect with positive sputum examination results in the Tuberculosis Laboratory Register, confirm that the patient is registered in the District TB Register. −

•

If the patient is found in the District TB Register, tick next to the patient’s row in the Tuberculosis Laboratory Register. Also confirm that the highest result of the three sputum samples is recorded correctly in the District TB Register. If the patient is not found in the District TB Register, register the patient immediately. When you visit the referring health facility later, determine whether the patient has begun treatment. If not, inform the health worker responsible for TB control that this patient must be found and put on treatment. If the patient cannot be found and does not begin treatment, register the type of patient as “Other.” If a patient has only one sputum result that is positive (for diagnosis), write down information on the patient so that you can check later at the referring health facility whether the patient was referred to a clinician for diagnosis.

−

• •

Review the Tuberculosis Laboratory Register for entries that cause you to suspect some problem with performance at the TB microscopy unit or by staff at health facilities. Confirm the following items and inform the district laboratory supervisor of any needs: − − −

Microscopists keep both negative and positive sputum slides for quality review by the provincial laboratory supervisor. The microscope is in good working condition, and reagents and other supplies are sufficient. TB microscopy unit staff are trained.

•

A significant proportion (up to 5%) of smear-positive patients are lost because they never report back to the health facility for the results of the sputum examination and begin treatment. Registering these patients in the District TB Register helps to ensure that the health facility will be urged to locate them. It also shows to what extent patients who do not return for results and treatment are a problem in the district. Keep notes of items to check at your next supervisory visit to various health facilities, based on your findings at the TB microscopy units. 19

•

Self-assessment questions Answer the self-assessment questions below to check what you have learned. Then compare your answers with those on page 22. 1. A TB microscopy unit should prepare and read sputum slides and record and return the results to the referring health facility within ______ hours of receipt. If a microscopist reads too many sputum smears per day (more than _____ per day), quality is likely to suffer because of ________________________________________. If a microscopist reads too few sputum smears per week (fewer than ___________ per week), quality is likely to suffer because of ___________________________________. 3. There were 1 625 sputum examinations performed in a district in a month at two microscopy units. The City Hospital TB microscopy unit has two microscopes and 3 microscopists. They performed 1 200 sputum examinations last month. The Rain Forest Health Centre has one microscope and 1 microscopist. He performed 425 sputum examinations last month. a) How many sputum examinations were performed per microscopist per day at City Hospital TB microscopy unit?

b) How many sputum examinations were performed per day by the microscopist at the Rain Forest Health Centre?

c) Is there a problem with the size of the workload or the distribution of the workload between the two TB microscopy units?

A District TB Coordinator found a TB suspect who has smear-positive results in the Tuberculosis Laboratory Register but 6 weeks later was not in the District TB Register. a) The District TB Coordinator should: (tick all answers that are correct) ____ Just write down the TB suspect’s name and address on a piece of paper to check on later. ____ Register the TB case in the District TB Register.

Answers to self-assessment questions If you had difficulty answering any question, turn back and study the section indicated (in parentheses). If you do not understand something, discuss it with a facilitator. 1. A TB microscopy unit should prepare and read sputum slides and record and return the results to the referring health facility within 24 hours of receipt. (See section 1.1) If a microscopist reads too many sputum smears per day (more than 20 per day), quality is likely to suffer because of visual fatigue . (See section 1.3) If a microscopist reads too few sputum smears per week (fewer than 10–15 per week), quality is likely to suffer because of lack of practice . (See section 1.3) 3. a) 1 200 examinations in a month = 55 examinations per day 22 workdays in a month 55 examinations per day = 18 per microscopist per day 3 microscopists b) 425 examinations = 19 examinations per day 22 workdays c) There is no problem with the workload or the distribution between the microscopy units since at both units the microscopists read between 2 and 20 slides per day. (See section 1.4) 4. a) 9 Register the TB case in the District TB Register. b) 9 Record in the District TB Register that the type of patient is “Other.” (See section 2.1.1) 5. 6. The entry is not correct. The highest result should be recorded in the District TB Register. It should be changed to +++. (See section 2.1.1) The District TB Coordinator should report these needs to the district laboratory supervisor. (See section 2.5)

The End Congratulations on finishing this module!

Exercises for Module F: Laboratory Support for TB

Exercise A Written Exercise – Assessing access to TB microscopy units In this exercise you will assess whether the health facilities in Faba District have access to a TB microscopy unit. Find the map of Faba District in your module B: Faba District. Examine the map. Then write answers to the questions below. 1. Where is sputum microscopy performed in Faba District?

What factors should be considered when deciding whether a facility has access to a TB microscopy unit?

Do all health facilities that currently provide TB control services in Faba District have access to a TB microscopy unit?

If Emeral Health Post began offering TB control services, would it have access to a TB microscopy unit? Why or why not?

When you have finished this exercise, review your answers with a facilitator.

When you have finished this exercise, GO BACK to page 4 and read until the next stop sign (page 7).

Exercise B Written Exercise – Assessing the need to increase the capacity of the TB laboratory services In this exercise you will calculate the average number of sputum smear examinations performed by each TB microscopy unit per day in Faba District, in order to assess whether there is a need to increase the capacity of the TB laboratory services. If so, you will suggest possible ways to improve the situation. 1. Read the following information about the TB laboratory services in Faba District: There is currently only one TB microscopy unit in the district, and that is at the Agraville Hospital laboratory. There is one microscope, and there are 2 trained microscopists who perform multiple hospital laboratory functions. The more senior of these was recently appointed as district laboratory supervisor. The district laboratory supervisor reviews slide for quality assurance, provides back-up, and performs other laboratory functions, so he will no longer read sputum smears. The other microscopist principally does sputum smears. It is May 2004. The District TB Coordinator is meeting with the district TB laboratory supervisor, who has brought the laboratory records. These records show that the TB microscopy unit at Agraville Hospital performed 1 960 sputum smear examinations during the first quarter of 2004. 2. Complete the steps below to calculate the average number of sputum smear examinations performed per microscopist per day. a) How many workdays are in a quarter? b) Calculate the number of smear examinations performed per day by the microscopist: 1 960 smear examinations performed = 66 workdays examinations per day per microscopist

Exercise continued on next page

Write answers to the following questions. a) What is the maximum recommended number of sputum examinations per microscopist per day? b) What is the minimum recommended number per day? c) Based on your calculations for the first quarter of 2004, is the TB microscopy workload too high at the Agraville Hospital laboratory?

d) Think about the plans you have read for Faba District. Review the highlights of plans for 2004 on page 5 of module B: Faba District. Do you think the microscopy workload will increase or decrease later in 2004 and 2005?

e) What would you suggest as possible ways to improve the capacity of the TB laboratory support in Faba District?

When you have finished this exercise, review your answers with a facilitator.

When the group has finished this discussion, GO BACK to page 7 and read until the next stop sign (page 11).

Exercise C Written Exercise – Confirming registration of all smear-positive cases in the District TB Register

In this exercise you will check that all smear-positive cases recorded in the Tuberculosis Laboratory Register at the microscopy unit at Agraville Hospital are registered in the District TB Register. You will also confirm that the sputum examination results were correctly recorded. You will list any patients to check on during your next supervisory visits to health facilities. You will use module L: Tuberculosis Laboratory Register in this exercise. That module contains pages from the Tuberculosis Laboratory Register from 12 April through 8 July 2004, the date of the visit to Agraville Hospital described below. The relevant pages of the District TB Register for this exercise are included on pages 30–34 of this module. 1. Read the following information about today’s supervisory visit to Agraville Hospital. Dr Oke Karimi, the District TB Coordinator, is visiting Agraville Hospital on 8 July. This morning he visited the health worker responsible for TB case detection and treatment in the outpatient unit. There, he reviewed all the current TB Treatment Cards and added the new cases to the District TB Register (District TB numbers F-129 to F138 with date of registration 8/7). See the cases that he registered today in the District TB Register on page 33 of this module. Dr Karimi has now gone down the hall to visit the microscopy unit at the Agraville Hospital laboratory. In the microscopy unit, he should review the Tuberculosis Laboratory Register and confirm that all smear-positive cases detected by the microscopy unit have been registered in the District TB Register. Because a reasonable time must elapse after sputum examination to allow time for the TB patients to start treatment and for them to be registered in the District TB Register, Dr Karimi should not review the most recent month of entries in the Tuberculosis Laboratory Register. Since his previous visit to the microscopy unit was on 3 June, Dr Karimi should review entries in the Tuberculosis Laboratory Register made on 3 June and previously, that is, entries from about 3 June working backwards to 6 May (the date of the May visit to Agraville Hospital). 2. Pretend that you are Dr Karimi. Confirm that all smear-positive cases that were detected by sputum examination before your previous visit have been registered in the District TB Register. Follow the directions on the next page. (You may review the more detailed instructions on how to locate all smear-positive cases and confirm that they are registered on pages 10–11 of this module if needed.) Exercise continued on next page

Open module L: Tuberculosis Laboratory Register from Agraville Hospital microscopy unit to the entries made today, 8 July. Do not review the most recent month of entries. Turn backwards in the register to 3 June. Draw a line under the last entry made on 3 June. Begin reviewing entries above that line, working backwards through the Tuberculosis Laboratory Register. Find each smear-positive case by looking in the column “Microscopy results” for smear-positive cases. If the reason for examination is diagnosis, this is a smear-positive patient who should be registered in the District TB Register and receiving treatment. When you find a smear-positive case: • • • turn to the District TB Register (provided on pages 30–34) and find the case, using laboratory serial number and patient’s name, to confirm that the case has been registered there, place a tick next to the case in the Tuberculosis Laboratory Register to indicate that the case has been registered, and confirm that the highest of the laboratory results was correctly recorded in the District TB Register. (If there was a mistake, correct it on the District TB Register.)

If you find a smear-positive case that has not yet been registered: • • • add it to the District TB Register, place a tick next to the case in the Tuberculosis Laboratory Register to indicate that the case has been registered, and make a note to determine when you visit the referring health facility whether this case has begun treatment and, if not, to ask the health worker to find the patient.

If you find a TB suspect who has only one sputum result that is positive for diagnosis: • • write down the information on the patient, and make a note to determine when you visit the referring facility whether this case has continued the diagnostic process, and the result.

Continue reviewing entries in the Tuberculosis Laboratory Register to find all the smear-positive TB cases and confirm that they are registered in the District TB Register. Continue working backwards until you reach TB cases that Dr Karimi ticked (to show that he confirmed registration) at a previous visit (6 May). (Stop at number 836.)

Note in the space below any cases to follow-up on, such as cases to check whether they have begun treatment or have continued the diagnostic process:

When will you check whether smear-positive TB cases detected by the microscopy unit on 5 and 6 July are registered in the District TB Register?

When you have finished this exercise, review your answers When you have finished this exercise, review your answers with facilitator. with aa facilitator.

Then GO BACK to page 11. Read to the end of the module (page 22).

Exercise continued on next page

Note: Preceding pages from the District TB Register are not included here. Registrations of all cases on those pages were confirmed by Dr Karimi at previous visits to the Agraville Hospital microscopy unit.

Exercise continued on next page

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Exercise continued on next page

ª 33

Annex Request for Sputum Examination Tuberculosis Laboratory Register

TB LABORATORY FORM REQUEST FOR SPUTUM EXAMINATION Name of health facility ____________________________ Name of patient ________________________________ Date _________________ Age ______ Sex: M F

Complete address __________________________________________________________ _______________________________ Reason for examination: Diagnosis OR Follow-up Disease site: TB Suspect No. ______________ Patient’s District TB No.* ______________ Extrapulmonary (specify)______________ District _______________

Pulmonary

Number of sputum samples sent with this form _____ Date of collection of first sample ___________ Signature of specimen collector ________ * Be sure to enter the patient’s District TB No. for follow-up of patients on TB treatment.

RESULTS (to be completed by Laboratory) Lab. Serial No. ____________________________ (a) Visual appearance of sputum: Mucopurulent (b) Microscopy: DATE SPECIMEN 1 2 3 RESULTS +++

Blood-stained

Saliva

POSITIVE (GRADING) ++ + scanty (1–9)

Date _______

Examined by (Signature) __________________________________

The completed form (with results) should be sent to the health facility and to the District Tuberculosis Unit.

TUBERCULOSIS LABORATORY REGISTER Sex M/F Diagnosis Follow-up 1 2 3 Age Complete address (for new patients) Name of referring health facility Microscopy results Reason for a examination Remarks

Lab serial no.

Date

Name (in full)

If sputum is for diagnosis, write a tick under Diagnosis. If sputum is for follow-up, write the patient’s District TB number under Follow-up.

WHO/HTM/TB/2005.347e

Management of Tuberculosis Training for District TB Coordinators

C E E: MANAGE DRUGS AND SUPPLIES FOR TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Manage Drugs and Supplies for TB Control Contents Page Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................2 1. Quarterly, order anti-TB drugs for the district............................................................3 1.1 Estimate the quantity of anti-TB drugs needed in one quarter for expected cases ...................................................................................................................3 1.1.1 Contents of a pre-packaged kit of anti-TB drugs...................................3 1.1.2 Estimate the expected number of TB cases who will need anti-TB drugs in the next quarter ...........................................................6 1.1.3 What about patients who are not in the average weight band?..............7 1.1.4 Drugs for treatment of children..............................................................9 1.2 1.3 1.4 2. Determine the number of anti-TB drug kits to order for the quarter ...............10 Estimate the additional anti-TB drugs required for special cases....................12 Place an order for anti-TB drugs for the district ..............................................13

Quarterly, order TB-related supplies for the district ................................................13 2.1 Determine quantities of needles, syringes, and sterile water for injection to order .............................................................................................................13 2.2 Determine the quantity of sputum containers to order.....................................14 2.3 Place an order for TB-related supplies for the district.....................................15

Quarterly, request distribution of anti-TB drugs and TB-related supplies to each health facility ....................................................................................................16 3.1 Determine the number of kits of anti-TB drugs to distribute to each health facility ...................................................................................................16 3.2 Request distribution of anti-TB drugs to health facilities................................17 3.3 Request distribution of TB-related supplies to health facilities.......................18

Each year, order supply of forms and registers for the district.................................18 4.1 4.2 Estimate the number of each form or register that will be needed next year...18 Determine the total number of each form or register to order for the year......19

Schedule for ordering and distribution .....................................................................20

6. 7. 8. 9.

Ensure supply of additional drugs for TB/HIV patients ...........................................22 Ensure good storage procedures at the district storeroom. .......................................22 When any problem occurs with drug supply, take action quickly............................23 Report any problem with drug quality to the provincial TB coordinator .................23

Summary of important points ............................................................................................24 Self-assessment questions..................................................................................................26 Answers to self-assessment questions ...............................................................................28 Exercises Exercise A.................................................................................................................32 Exercise B .................................................................................................................35 Annexes A: How to read the drug code for TB treatment regimens .......................................38 Standard number of doses for phases of different duration..................................39 B: Ordering and distribution worksheets for districts that use pre-packaged kits of anti-TB drugs ...................................................................................................40 C: Ordering separate tablets of anti-TB drug – Alternative version of sections 1.1 and 1.2 for districts that order separate tablets of anti-TB drugs instead of kits 1.1 Estimate the quantity of anti-TB drugs needed in one quarter for expected cases ..........................................................................................42 1.1.1 1.1.2 1.1.3 1.1.4 1.1.5 Estimate the expected number of cases in each treatment category next quarter ....................................................................42 Specify the number of tablets of oral anti-TB drugs and vials of streptomycin needed to treat one case......................................43 Multiply to determine the quantity of tablets or vials needed to treat all expected cases .............................................................44 What about patients who are not in the average weight band? ....45 Drugs for treatment of children ....................................................46

1.2 Determine the quantity of anti-TB drugs to order for the quarter ............47 Alternative Exercise A.....................................................................................50

D: Distributing separate tablets of anti-TB drugs – Alternative version of sections 3.1–3.3 for districts that distribute separate tablets of anti-TB drugs to health facilities instead of kits 3.1 Determine quantities of anti-TB drugs to distribute to each health facility ............................................................................................54 3.2 Request distribution of anti-TB drugs to health facilities.........................56 3.3 Request distribution of TB-related supplies to health facilities................56 Alternative Exercise B .....................................................................................57 E: Ordering and distribution worksheets for districts that use separate tablets of anti-TB drugs..................................................................................................59 Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter – Daily treatment in the initial phase and intermittent treatment in the continuation phase...........................59 Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter – Daily treatment in the initial and continuation phases ...................................................................................60 Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter – Daily treatment in the initial phase and intermittent treatment in the continuation phase ...........................................................................................61 Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter – Daily treatment in the initial and continuation phases...............................................62

Manage Drugs and Supplies for TB Control Introduction One of your most important tasks as District TB Coordinator is to ensure that all health facilities in the district have a regular supply of the drugs and other materials required for TB diagnosis and treatment. Diagnosis of TB depends on a having a supply of sputum containers at every health facility. The treatment of TB depends on drugs and other supplies such as needles and syringes. Anti-TB drugs must reach the patient immediately after diagnosis, and sufficient anti-TB drugs must be available to complete the entire course of treatment without interruption. Problems with drug supply are dangerous because they can lead to the spread of TB, development of drug resistance, and poor treatment outcomes of TB patients. Problems with drug supply are also harmful to the morale of patients and health staff. The national TB control programme will determine the standard drug regimens, the presentations and packaging of the anti-TB drugs to be provided for your district, and how the supplies will be managed. Important decisions made by the national TB programme include: x Use of fixed-dose combination tablets (FDCs) versus separate tablets of each drug (Note: FDCs combine 2, 3, or 4 drugs in one tablet.) x Blister packs versus loose tablets x Recommended drug regimen for each category of patient, for example: use of the same or a different drug regimen for Category I and Category III patients, use of rifampicin versus ethambutol in the continuation phase, and use of ethambutol versus streptomycin in the initial phase of Category I treatment x Daily administration of drugs versus intermittent administration x The number of weight bands used to calculate drug dosages in the standard regimens x Whether drugs will be pre-packaged in patient kits containing a complete treatment regimen x Whether drug needs will be calculated and stock will be monitored in complete regimens (pre-packaged kits) versus numbers of bottles and tablets x Whether children with TB will be treated with adult kits, or with loose tablets or with paediatric presentations of anti-TB drugs x The amount of reserve stock that the programme has decided to maintain These decisions will affect how you order and distribute anti-TB drugs. Depending on the specific presentations and packaging of anti-TB drugs provided to your district, you may need to adjust the guidelines and worksheets in this module for ordering and distributing them.

Objectives of this module Participants will learn: x How to calculate the quantity of anti-TB drugs to order for the district at the beginning of each quarter x How to calculate the quantity of sputum containers to order for the district at the beginning of each quarter x How to calculate quantities of anti-TB drugs to distribute to each health facility each quarter x How to calculate quantities of forms and registers needed for next year x A timeline for ordering anti-TB drugs and supplies for the district and for distributing them to health facilities Refer to section:

1 2.2 3 4 5

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

Exercises for Module E: Manage Drugs and Supplies for TB Control

Exercise A Written Exercise – Calculating quantities of anti-TB drugs to order for the district In this exercise you will use the Ordering Worksheet to calculate quantities of anti-TB drugs to order for the district for the next quarter. You will base your calculations on information about: x the number of expected cases in Faba District (you will tally cases registered in the previous quarter, that is, the 2nd quarter of 2004 in Faba’s District TB Register), and x current stocks at the district storeroom. 1. Read the following information about Faba District. TB treatment regimens and packaging in Faba District: In Faba District, anti-TB drugs are provided in pre-packaged kits. The district storeroom receives two different types of kits. The same regimen is provided for Category I and Category III patients, and a different regimen is provided for Category II patients. Streptomycin vials, sterile syringes and needles and sterile water for injection are included in the Category II kit. Treatment in the continuation phase is intermittent (3 times per week). Children who have TB are treated with adult kits adapted for a child’s body weight. Category I and III: Category II: 2(HRZE) / 4(HR)3 2(HRZE)S / 1(HRZE) / 5(HR)3E3

Stock at the district storeroom: The Faba District TB Coordinator checked the inventory report from the district storeroom dated 30 June 2004 to determine the quantities of anti-TB drugs in stock at the end of the quarter: Category 1 and III: 50 kits Category II: 6 kits 2. Tally the TB cases registered in the district during the previous quarter. The Faba District TB Coordinator made the table below to tally the cases registered in the District TB Register from each health facility during the 2nd quarter of 2004. Use this table to tally the cases for him. x Get out your copy of Faba’s District TB Register (module K). Turn in the register book to the 2nd quarter of 2004.

x Review the register, case by case. Tally cases aged less than 15 years along with adult cases. x Look at the “Health facility” column and then look across to the “Treatment category” column to see the category of treatment given. x On the tally sheet, find the health facility name and place a tick in the category of treatment. x When all cases in the entire quarter are tallied, total the number of cases in each category. Ask your facilitator for help if you have difficulty with this task. Faba District TB cases in 2nd quarter 2004 Health Facility A. Agraville Hospital B. Bella Health Centre D. Denali Health Post G. Gadara Health Post H. High Road Health Post Category I Category II Category III

TOTAL

The District TB Coordinator expects approximately the same number of cases next quarter.

Exercise continued on next page

Complete the Ordering Worksheet below to calculate the quantities of anti-TB drugs that the Faba District TB Coordinator should order for next quarter. Ordering Worksheet: Pre-packaged kits of anti-TB drugs to order to treat adult patients in the district during one quarter Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : patients patients

Instructions: Complete one worksheet for the district.

x x x

Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Number to order after subtracting current stocks B–C=D

Kit (or drug) and category of patient who a needs it Category I and III kits Category II kits

When you you have When have finished finished completing completing the the worksheet, worksheet, review review your answers answers with with a a facilitator. facilitator. your

Then GO BACK to page 12. Read to the next stop sign (page 18).

Exercise B Written Exercise – Calculating quantities of anti-TB drugs to distribute to each health facility for the quarter

In this exercise you will use the Distribution Worksheet to calculate quantities of anti-TB drugs to distribute to Agraville Hospital for next quarter. You will base your calculations on information given about: x the number of cases registered in the previous quarter at this health facility (2nd quarter of 2004) and x quantities of anti-TB drugs in stock at the most recent supervisory visit to that facility (or estimate of drugs in stock on the last day of the previous quarter). 1. Read the following information about Agraville Hospital. On the most recent visit to Agraville Hospital, the District TB Coordinator found the following in stock: Category 1 and III: 21 boxes Category II: 5 boxes (including streptomycin and injection supplies)

Complete the Distribution Worksheet on the next page to calculate the quantities of anti-TB drugs the Faba District TB Coordinator should distribute to Agraville Hospital for next quarter. Check your tally of cases registered last quarter (done in Exercise A, page 33) to find the number in each category from Agraville Hospital. Use this number as the expected cases next quarter.

Exercise continued on next page

Distribution Worksheet: Kits of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter Agraville Hospital (name of health facility)

Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 :

patients patients

Instructions: Complete a separate worksheet for each health facility.

x x x

Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Number to distribute after subtracting current stocks B-C=D

Kit (or drug) and category of patient who needs it Category I and III kits Category II kits

you have have finished finished completing completing the the worksheet, worksheet, review review When you your answers with a facilitator.

Then GO BACK to page 18. Read and work to the end of the module (page 29).

Annexes A: How to read the drug code for TB treatment regimens ...............................................38 Standard number of doses for phases of different duration .........................................39 B: Ordering and distribution worksheets for districts that use pre-packaged kits of anti-TB drugs...........................................................................................................40 C: Ordering separate tablets of anti-TB drugs..................................................................42 Alternative version of sections 1.1 and 1.2 for districts that order separate tablets of anti-TB drugs instead of kits ........................................................................42 Alternative Exercise A.................................................................................................50 D: Distributing separate tablets of anti-TB drugs .............................................................54 Alternative version of sections 3.1–3.3 for districts that distribute separate tablets of anti-TB drugs to health facilities instead of kits ..........................................54 Alternative Exercise B .................................................................................................57 E: Ordering and distribution worksheets for districts that use separate tablets of anti-TB drugs...........................................................................................................59 Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter – Daily treatment in the initial phase and intermittent treatment in the continuation phase........................................................59 Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter – Daily treatment in the initial and continuation phases......................................................................................................60 Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter – Daily treatment in the initial phase and intermittent treatment in the continuation phase.......................61 Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter – Daily treatment in the initial and continuation phases...............................................................................62

Annex A: How to read the drug code for TB treatment regimens

TB treatment regimens are described using a standard code where each anti-TB drug has an abbreviation. Those abbreviations are: Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) Example one: A common regimen is written: The number before the letters is the duration of the phase in months. This initial phase is 2 months. The code shows the 2 phases of the regimen, separated by a slash. The letters correspond to the drugs to take during the phase. This continuation phase is of 4 months’ duration.

2(HRZE)/4(HR)3

A subscript number after a letter is the number of doses of that drug per week. Frequency of treatment with the combination HR tablet should be 3 times per week.

When 2 or more drugs (letters) appear in parentheses, this indicates a combination tablet of those drugs.

If there is no subscript number after a letter, frequency of treatment with that drug is daily. These initial-phase drugs should be taken daily.

The above regimen uses 2 fixed-dose combination tablets (also called FDCs). In the initial phase of 2 months, each day the TB patient would take a certain number (depending on the patient’s weight) of the combination tablet containing all 4 drugs, isoniazid, rifampicin, pyrazinamide, and ethambutol. In the continuation phase, the TB patient would take a certain number of tablets (depending on the patient’s weight) of an FDC containing isoniazid and rifampicin (HR) 3 times per week for 4 months. Example two: 2(HRZE)S /1(HRZE) /5(HR)3E3 The initial phase is 3 months but has two parts. For 2 months, drug treatment includes an FDC with isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) administered daily and also a daily injection of streptomycin (S). In the third month, drug treatment is with the combination tablet (HRZE); the streptomycin is not given. The continuation phase is 5 months. Drug treatment is with the FDC tablet (HR) given 3 times per week (subscript number 3 after the letters) and ethambutol (E), also given 3 times per week.

Annex A, continued

Standard number of doses for phases of different duration In the standard code for TB treatment regimens, the duration of each phase is stated in months. How many doses is that? The number of doses is standardized as follows: x One month is considered to be 4 weeks. x For a daily regimen, a patient needs 28 doses per month (4 weeks x 7 days). x For a 3 times per week regimen, a patient needs 12 doses per month (4 weeks x 3 doses per week). Multiply either 28 or 12 by the number of months in the phase to determine the total doses required. For a daily regimen (1 month = 28 doses): 2 months = 56 doses 3 months = 84 doses 4 months = 112 doses 5 months = 140 doses 6 months = 168 doses 4 months = 48 doses 5 months = 60 doses For a 3 times per week regimen (1 month = 12 doses):

A patient may require more than the stated number of months to take all the doses, as will happen, for example, when a patient on a daily regimen skips Sundays. National TB control programmes may expect “daily” drug administration only 6 days per week for directly observed regimens, for instance, because health facilities do not work on Sundays. Taking all 56 doses of a 2-month initial phase of treatment may then require 9–10 weeks, and this is acceptable. The phase is completed when the patient has taken all the doses for the phase.

Annex B: Ordering and distribution worksheets for districts that use pre-packaged kits of anti-TB drugs

Instructions: Complete one worksheet for the district.

x x x

Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Number to order after subtracting current stocks B–C=D

Kit (or drug) and category of patient who a needs it Category I and III kits Category II kits

Annex B, continued

Distribution Worksheet: Kits of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter (name of health facility)

Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 :

patients patients

Instructions: Complete a separate worksheet for each health facility.

x x x

Fill in the number of kits needed for the expected patients in each category in column A. Then complete the calculations in column B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Kits needed to treat expected patients B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Number to distribute after subtracting current stocks B-C=D

Kit (or drug) and category of patient who needs it Category I and III kits Category II kits

Annex C: Ordering separate tablets of anti-TB drugs This annex presents alternative text and worksheets for sections 1.1 and 1.2. It is provided for District TB Coordinators who must order quantities of separate tablets of oral anti-TB drugs and vials of streptomycin, instead of ordering pre-packaged kits. It assumes that the country will use fixed-dose combination tablets (FDCs), which are recommended by WHO. It also includes Alternative Exercise A, which provides practice using the Ordering Worksheet for separate tablets. If FDCs are not available, District TB Coordinators can use the same procedures to calculate quantities of each of the different tablets required, but will need to adapt the worksheet to include calculations for each of the different drugs and strengths of tablets.1 1.1 Estimate the quantity of anti-TB drugs needed in one quarter for expected cases The formula for calculating the number of tablets of oral anti-TB drugs and vials of streptomycin needed for expected cases in one quarter is as follows: expected number of new cases in each treatment category next quarter X number of tablets or vials needed to treat one case = number of tablets or vials needed to treat expected cases in each category next quarter

This calculation is repeated for each different tablet and vial used in the district, until quantities of all drugs for all categories have been determined. How to fill in each number in this formula is described in the next three steps. 1.1.1 Estimate the expected number of cases in each treatment category next quarter

To estimate the expected number of TB cases who will need anti-TB drugs in the next quarter, assume that this number will be approximately the same as in the previous quarter. Determine the number of cases in each treatment category by tallying the cases registered in the District TB Register during the previous quarter. Prepare a tally sheet by listing the names of the health facilities in your district on a table such as the one shown below. Find the pages in the District TB Register for the quarter that just ended. Review the register, case by case.2 Look at the “Health Facility” column and then look across to the “Treatment category” column to see the category of treatment given. On

In this situation, a District TB Coordinator will need to calculate separately the quantity of each type of tablet needed for each category of treatment. Category I and III may require 6 different types of tablets, and Category II may require 6 different types of tablets plus streptomycin. Refer to WHO-recommended formulations of essential anti-TB drugs in Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.313). 2 Also look at the age of the patient. If children who have TB (aged less than 15 years) will be treated with the standard FDCs provided for adult cases, include children in this tally of cases. If children will be treated with other presentations of anti-TB drugs and you will need to order these drugs, tally children separately.

Annex C, continued

your tally sheet, find the health facility name and place a tick in the category of treatment. When all cases in the entire quarter are tallied, total the number of cases in each category. Example Patanga District TB cases in 1st quarter 2004 (adults) Health Facility Haley Health Centre Dona Health Centre Maxa Health Post Patanga District Hospital Diogi Health Centre Ami Health Centre Pierta Health Centre Moses Health Centre Enya Health Centre //// /// // //// //// //// /// //// // /// // / / // /// Category I / / / // / Category II Category III

TOTAL

If there are plans to expand TB control services to additional facilities, or if one quarter of the year usually has a higher number of cases, increase the number expected in that quarter accordingly. Keep this tally sheet. You will refer to it for the number of TB patients in each category at each health facility when requesting distribution of drugs to each facility (see section 3). 1.1.2 Specify the number of tablets of oral anti-TB drugs and vials of streptomycin needed to treat one case

If separate tablets are provided to your district, the number of tablets or vials needed per case will depend on the regimen and presentation of the drugs provided. Figures 4 and 5 on the next page show the approximate amount of each drug needed to treat one patient who weighs between 40 and 54 kg, following standard regimens and using FDCs. Assumptions in Figures 4 and 5 are that: all patients in Categories I and III receive the same four-drug treatment regimen, with ethambutol in the initial phase and HR in the continuation phase; x streptomycin is used for Category II patients for 2 months (56 doses). x

Notice that Figure 4 is for regimens with intermittent treatment in the continuation phase, that is, administration of drugs three times per week. Figure 5 is for regimens with daily treatment in the continuation phase.

Annex C, continued

Refer to Annex A if you would like a review of how to read the drug code and the standard number of doses required for different treatment regimens.

Figure 4: Estimated drug requirements to treat one adult patient in the 40–54 kg weight band Daily treatment in the initial phase (28 doses per month) and intermittent treatment in the continuation phase (12 doses per month) Drug Combination (HRZE) in mg: H 75, R 150, Z 400, E 275 Combination (HR): H 150 mg, R 150 mg Ethambutol 400 mg Streptomycin 1 g vial Category I / III 2(HRZE) / 4(HR)3 3 tablets x 28 doses x 2 months = 168 tablets 3 tablets x 12 doses x 4 months = 144 tablets Category II 2(HRZE)S / 1(HRZE) / 5(HR)3E3 3 tablets x 28 doses x 3 months = 252 tablets 3 tablets x 12 doses x 5 months = 180 tablets 4 tablets x 12 doses x 5 months = 240 tablets 0.75 g x 28 doses x 2 months = 56 vials

Figure 5: Estimated drug requirements to treat one adult patient in the 40–54 kg weight band Daily treatment of drugs in the initial and continuation phases (28 doses per month) Drug Combination (HRZE) in mg: H 75, R 150, Z 400, E 275 Combination (HR): H 75 mg, R 150 mg Ethambutol 400 mg Streptomycin 1 g vial Category I / III 2(HRZE) / 4(HR) 3 tablets x 28 doses x 2 months = 168 tablets 3 tablets x 28 doses x 4 months = 336 tablets Category II 2(HRZE)S / 1(HRZE) / 5(HR)E 3 tablets x 28 doses x 3 months = 252 tablets 3 tablets x 28 doses x 5 months = 420 tablets 2 tablets x 28 doses x 5 months = 280 tablets 0.75 g x 28 doses x 2 months = 56 vials

Refer to Figures 4 and 5 (or similar tables for the drug regimens and presentations used in your country) to determine the number of tablets and vials needed to treat one case. 1.1.3 Multiply to determine the quantity of tablets or vials needed to treat all expected cases

Multiply the expected number of cases in the category by the number of tablets needed to treat one case, for example, 168 (HRZE) tablets are needed to treat one Category I case. Repeat the calculation for each different tablet and for streptomycin vials. The sum of all these calculations is the quantity of tablets and vials needed in the district for all expected cases in the category.

Annex C, continued

Example The District TB Coordinator in Patanga District counted 39 Category I patients, 9 Category II patients, and 4 Category III patients registered in the district in the previous quarter. The District TB Coordinator calculated the number of (HRZE) tablets needed next quarter as shown below. All three categories use (HRZE) tablets. 43 expected cases in Category I plus Category III (39 Category I cases + 4 Category III cases) x 168 (HRZE) tablets needed per case (see Figure 4) 7 224 (HRZE) tablets needed for Category I and Category III 9 expected cases in Category II x 252 (HRZE) tablets needed per case (see Figure 4) 2 268 (HRZE) tablets needed for Category II 7 224 (HRZE) tablets for Category I and Category III + 2 268 (HRZE) tablets for Category II 9 492 (HRZE) tablets for all categories

The District TB Coordinator did similar calculations to determine the quantity needed of (HR) tablets for Category I, II, and III, and the number of ethambutol tablets and streptomycin vials needed for Category II. 1.1.4 What about patients who are not in the average weight band?

For the fixed-dose combination tablets (HRZE), (HRZ), and (HR), the standard daily dose given to adult patients in the average weight band is contained in three tablets for any category. (Ethambutol tablets are added as a separate drug in the continuation phase of Category II treatment because the combination (HRE) is not yet available.) The numbers of tablets of these FDCs per dose for the adult weight bands are shown below. Weight band (adults) <25 kg 25–39 kg 40–54 kg (average) 55–70 kg >70 kg Dose of (HRZE), (HRZ), or (HR)1 1 tablet a day 2 tablets a day 3 tablets a day 4 tablets a day 5 tablets a day

Gathering tablets to make a kit for a particular patient at the health facility requires calculating the number of each different type of tablet to provide the patient with the appropriate dose for his or her body weight. Standard blister presentations, such as blister packs of 28 tablets, facilitate making an individualized patient’s kit. The health worker collects the number of blister packs that will provide the correct number of tablets for the patient’s kit.

Note that different strengths of some drugs are needed for daily and intermittent administration, so the formulation of the tablets for daily and intermittent regimens varies.

Annex C, continued

Example In health facilities in the Patanga District, a health worker assembles the tablets for a patient’s entire treatment regimen and places them in a box (kit) at the time the patient begins treatment. The Category I and III regimen is 2(HRZE)/4(HR)3. The facility is supplied with tablets in blister packs of 28 tablets of (HRZE) for daily administration and 12 tablets of (HR) for intermittent administration. So, the number of tablets needed per dose corresponds to the number of blister packs needed per month. To make a Category I or III kit for a patient of average weight (40–54 kg), the health worker selects 6 blister packs of the initial-phase drugs (3 tablets per day x 2 months) and 12 blister packs of the continuation-phase drugs (3 tablets per day x 4 months) to put into the kit. Weight bands (adults) Tablets needed per dose = blister packs needed per month Blister packs of (HRZE) needed for initial phase (2 months) Blister packs of (HR) needed for continuation phase (4 months)

<25 kg 25–39 kg 40–54 kg (average) 55–70 kg >70 kg

1 2 3 4 5

2 4 6 8 10

4 8 12 16 20

For patients weighing less, the health worker selects fewer blister packs. For patients weighing more, the health worker selects more. You can order tablets as if all adult patients are average weight; roughly equal numbers of patients will need more tablets in their kits as will need fewer. 1.1.5 Drugs for treatment of children

Most children with TB (cases aged less than 15 years) have extrapulmonary or pulmonary smear-negative TB. The treatment regimens for children and the drug dosage per kilogram are the same as for adults. Standard FDCs provided for Category I and III cases can be used by adjusting the number of tablets given per dose. Example Blister packs of (HRZE) needed for initial phase (2 months) Blister packs of (HR) needed for continuation phase (4 months)

Weight bands (children)

Tablets needed per dose = blister packs needed per month

5–10 kg 11–21 kg 21–30 kg

1/2 1 2

1 2 4

2 4 8

Annex C, continued

Other alternatives for treatment of children are to use paediatric FDCs: (HRZ) (H 30 mg + R 60 mg + Z 150 mg); (HR) (H 30 mg + R 60 mg); adult FDCs that are scored to facilitate breaking the tablets, or loose tablets of the separate drugs1. This allows the use of narrower weight bands. If children will be treated with presentations of anti-TB drugs such as these, and you will need to order these drugs, tally children separately from adult cases. Calculate the number of each tablet needed to treat one child. Then use the formula below: expected number of TB cases in children next quarter x number of tablets or vials needed to treat one case = number of tablets or vials needed to treat expected TB cases in children next quarter

Example The District TB Coordinator in Patanga District counted 3 TB cases in children (Category I and III) registered in the district in the previous quarter. The District TB Coordinator calculated the number of (HRZ) paediatric tablets needed next quarter as shown below (2 paediatric (HRZ) tablets are needed per dose for an average weight child, 11–14 kg.) 3 expected cases in children (Category I plus Category III) x 112 (HRZ) tablets needed per case (2 tablets per dose x 28 doses x 2 months) 336 (HRZ) tablets needed for children (Category I and Category III)

The District TB Coordinator did similar calculations to determine the number of (HR) tablets needed for continuation phase treatment for children next quarter. 1.2 Determine the quantity of anti-TB drugs to order for the quarter Once you have calculated the quantity of each tablet and the vials of streptomycin needed to treat the expected number of cases for the quarter, you must increase the quantity to allow for reserve stock and then subtract the stock remaining at the end of the previous quarter. number of tablets or vials needed to treat expected cases in one quarter x 2 (for reserve) – number in stock at end of previous quarter = number to order

A reserve stock of drugs is to allow for more cases than expected; for delays in procurement, delivery or distribution of drugs; theft; loss or damage due to accidents; or any combination of these factors. When fully stocked, the district storeroom should have one additional quarter’s stock of anti-TB drugs at the district level as a reserve. To avoid building up too much stock in the district storeroom, however, you must consider the stock that is already there. The formula above reduces the total quantity you have estimated by the number already in stock. Find out the number in stock by visiting the district 1

Liquid presentations have shorter shelf-life and are more expensive and difficult to transport.

Annex C, continued

storeroom at the end of each quarter and recording quantities of anti-TB drugs present, or by checking an inventory report. Below is an Ordering Worksheet that organizes the calculations described in sections 1.1 and 1.2 in a table. As an example, it shows the calculations for Patanga District continuing from the tally of adult cases on page 43. Patanga District is provided FDC tablets of (HRZE) and (HR), separate tablets of E, and vials of streptomycin. Treatment in the continuation phase is intermittent. Example Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter Daily treatment in the initial phase (28 doses per month) and intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 43 patients 9 patients

Instructions: Complete one worksheet for the district.

x x x

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients ( 43 x 168 tablets) + ( 9 x 252 tablets) = 9 492 tablets ( 43 x 144 tablets) + ( 9 x 180 tablets) = 7 812 tablets 9 x 240 tablets = 2 160 tablets = 9 x 56 vials 504 vials B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to order after subtracting current stocks B-C =D

Drug and category of a patient who needs it Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

18 984 tablets

11 500 tablets

7 484 tablets

15 624 tablets

7 000 tablets

8 624 tablets

4 320 tablets 1 008 vials

1 250 tablets 450 vials

3 070 tablets 558 vials

This means: (43 patients in Cat I plus III x 168 tablets per patient) + (9 patients in Cat II x 252 tablets per patient) = 9 492 (HRZE) tablets

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. Supplies for giving streptomycin injections may also be added to the order.

Annex C, continued

An Ordering Worksheet can be used for calculations in your district. Blank worksheets for ordering separate tablets of anti-TB drugs are in Annex E. Notice that the two ordering worksheets differ: the first worksheet is for daily treatment in the initial phase and intermittent treatment in the continuation phase; the second worksheet is for daily treatment in both the initial and continuation phases. The worksheets should be modified if different formulations of tablets are used in your district.

STOP Now do Alternative Exercise A – Written Exercise When you reach this point, you are ready to do Alternative Exercise A. Turn to the next page and follow the instructions. Do the exercise by yourself and then discuss your answers with a facilitator.

Alternative Exercise A Written Exercise – Calculating quantities of separate tablets of anti-TB drugs to order for the district In this exercise you will use the Ordering Worksheet to calculate quantities of anti-TB drugs to order for the district for the next quarter. You will base your calculations on information about: x the expected number of cases in Faba District (you will tally cases registered in the previous quarter in Faba’s District TB Register), and x current stocks at the district storeroom. 1. Read the following information about Faba District. TB treatment regimens and packaging in Faba District: In Faba District, anti-TB drugs are provided to health facilities in separate boxes of (HRZE), (HR), and ethambutol, and boxes of vials of streptomycin. The tablets are packaged in blisters of 28 or 12 each. Patient kits are assembled by staff at health facilities for each patient at the time the patient begins treatment. In Faba District, the same regimen is used for Category I and Category III patients; a different regimen is used for Category II patients. Treatment in the continuation phase is intermittent. Children who have TB are treated with the same FDCs as adults. Category I and III: Category II: 2(HRZE) / 4(HR)3 2(HRZE)S / 1(HRZE) / 5(HR)3E3

Stock at the district storeroom: The Faba District TB Coordinator checked the inventory report from the district storeroom dated 30 June 2004 to determine the approximate quantities of anti-TB drugs in stock at the end of the second quarter: 9 900 (HRZE) tablets 8 300 (HR) tablets 1 100 ethambutol tablets 320 vials of streptomycin

Annex C, continued

Tally the TB cases registered in the district during the previous quarter. The Faba District TB Coordinator made the table below to tally the cases registered in the District TB Register from each health facility during the 2nd quarter 2004. Use this table to tally the cases for him. x Take out your copy of Faba’s District TB Register (module K). Turn in the register book to the 2nd quarter of 2004. x Review the register, case by case. Tally cases aged less than 15 years along with adult cases. x Look at the “Health facility” column and then look across to the “Treatment category” column to see the category of treatment given. x On the tally sheet, find the health facility name and place a tick in the category of treatment. x When all cases in the entire quarter are tallied, total the number of cases in each category. Ask your facilitator for help if you have difficulty with this task. Faba District TB cases in 2nd quarter 2004

Health Facility A. Agraville Hospital B. Bella Health Centre D. Denali Health Post G. Gadara Health Post H. High Road Health Post

Category I

Category II

Category III

TOTAL

The District TB Coordinator expects approximately the same number of cases next quarter.

Exercise continued on next page

Annex C, continued

Complete the Ordering Worksheet below to calculate the quantities of anti-TB drugs that the Faba District TB Coordinator should order for next quarter. Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter Daily treatment in the initial phase (28 doses per month) and intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : patients patients

Instructions: Complete one worksheet for the district.

x x x

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients ( ___ x 168 tablets) + ( ___ x 252 tablets) = _______ tablets B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to order after subtracting current stocks B-C=D

Drug and category of a patient who needs it Combination (HRZE) (Cat I + III) + (Cat II) Combination (HR) (H150 R150 mg) (Cat I + III) + (Cat II)

tablets

( ___ x 144 tablets) + ( ___ x 180 tablets) = ________ tablets ____ x 240 tablets = _______ tablets ____ x 56 vials = _______ vials

tablets

Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

tablets

vials

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. Supplies for giving streptomycin injections may also be added to the order.

Annex C, continued

When you you have have finished finished completing completing the the worksheet, worksheet, review review When your answers answers with with a a facilitator. facilitator. your

Then GO BACK to page 12, section 1.3, and read. When you reach the box on page 16, you will turn to Annex D.

Annex D: Distributing separate tablets of anti-TB drugs This annex presents alternative text and worksheets for sections 3.1–3.3 in this module. It is provided for District TB Coordinators who distribute quantities of separate tablets of oral anti-TB drugs to health facilities, instead of pre-packaged kits. It assumes that the country will use fixed-dose combination tablets (FDCs). It also includes Alternative Exercise B, which provides practice using the Distribution Worksheet for separate tablets. If FDCs are not available, District TB Coordinators can use the same procedures to calculate quantities of each of the different tablets required at each health facility, but will need to adapt the worksheet to include calculations for each of the different drugs and strengths of tablets. 3.1 Determine quantities of anti-TB drugs to distribute to each health facility The Distribution Worksheet on page 55 shows how to calculate quantities to distribute to each health facility. Notice that it is very similar to the Ordering Worksheet. Refer to the example as you read the steps below. x

Select the correct version of the worksheet – daily or intermittent treatment during the continuation phase. (In Patanga District, treatment in the continuation phase is intermittent, so that is the worksheet chosen.) Write the name of the health facility and the expected number of patients next quarter in each treatment category at the top of the worksheet and in column A. This is the same as the number of patients treated last quarter at the health facility, unless you have reason to adjust it. Refer to the tally of the number of cases at each health facility (section 1.1.1). Specify the number of tablets or vials of each anti-TB drug needed to treat one patient. (The worksheet provides standard numbers in column A; modify these if necessary using tables for the drug regimens and presentations used in your country.) Column A: Multiply to determine quantities of tablets or vials needed to treat all expected patients in three categories.

x x

Column B: Multiply by 2 to determine the quantity required at the health facility to maintain one additional quarter’s reserve stock. x Column C: Estimate quantities of anti-TB drugs (tablets or vials) in stock at the health facility at the end of the previous quarter. Check notes of quantities in stock at the health facility at the time of your most recent supervisory visit. (See the checklist in module C: Conduct Supervisory Visits for TB Control.) If it has been awhile since the visit, estimate the stock remaining. x

Column D: Subtract the amount currently in stock in the health facility from the quantity of each drug required. The result is the quantity to distribute to the health facility. Note: Always have in stock at each health facility the anti-TB drugs for treatment of at least one TB patient in each category.

Example

Annex D, continued

The Patanga District TB Coordinator used the worksheet below to calculate how many tablets and vials to send to Diogi Health Centre. He referred back to the tally of cases at each health facility last quarter (see tally on page 43). Diogi Health Centre had 8 Category I patients, 3 Category II patients, and 1 Category III patient. (None were children so he will not send any paediatric anti-TB drugs for next quarter.) He looked at the checklist completed during a recent supervisory visit to find out the numbers of (HRZE) tablets, (HR) tablets, and streptomycin vials that were in stock at that time at Diogi Health Centre and recorded these amounts in column C.

Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter Diogi Health Centre (name of health facility)

Daily treatment in the initial phase (28 doses per month and Intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : 9 patients 3 patients

Instructions: Complete a separate worksheet for each health facility.

x x x

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to distribute after subtracting current stocks B–C=D

Drug and category of patient who needs it

Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

( _9__ x 168 tablets) + ( _3_ x 252 tablets) = __2 268_ tablets

4 536 tablets

1 512 tablets

3 024 tablets

( _9__ x 144 tablets) + ( _3_ x 180 tablets) = _1 836_ tablets _3_ x 240 tablets = __720_ tablets _3_ x 56 vials = __168_ vials

3 672 tablets

1 200 tablets

2 472 tablets

1 440 tablets 336 vials

300 tablets 120 vials

1 140 tablets 216 vials

Annex D, continued

The Distribution Worksheet can be used for calculations in your district. Blank worksheets for planning distribution of separate tablets to health facilities are in Annex E. Notice that the two distribution worksheets differ: the first worksheet is for daily treatment in the initial phase and intermittent treatment in the continuation phase; the second worksheet is for daily treatment in both the initial and continuation phases. The worksheets should be modified if different formulations of tablets are used in your district. 3.2 Request distribution of anti-TB drugs to health facilities During the first week of the quarter, inform the district storeroom (or Essential Drugs Programme) of the quantities of anti-TB drugs to be distributed to each health facility. If health facilities need additional anti-TB drugs, such as isoniazid for preventive therapy, add these to the distribution requests. If a particular health facility has requested additional drugs for special cases, such as for treatment of a patient with MDR-TB, include these drugs also. Ensure that the needed drugs are then sent to or collected by each health facility in a timely manner. 3.3 Request distribution of TB-related supplies to health facilities Estimate quantities of sputum containers, vials of sterile water, and sterile needles and syringes needed by each health facility for the quarter. Remember to subtract the quantity in stock from the number needed, to avoid stocking too much of any supply. To calculate the number of sputum containers to distribute to each health facility, use the same process as in section 2.2, but base the calculation on the number of cases expected at the particular health facility. Or, use the simplified method described in the footnote on page 15: Number of smear-positive cases expected in the quarter at the health facility x 50 – number of sputum containers in stock

number of sputum containers to distribute to the health facility

STOP Now do Alternative Exercise B – Written Exercise When you reach this point, you are ready to do Alternative Exercise B. Turn to the next page and follow the instructions. Do the exercise by yourself and then discuss your answers with a facilitator.

Annex D, continued

Alternative Exercise B Written Exercise – Calculating quantities of anti-TB drugs to distribute to each health facility for the quarter

Read the following information about Agraville Hospital. On a recent visit to Agraville Hospital, the District TB Coordinator checked the stocks of the anti-TB drugs. He estimates that the stock remaining at the end of the quarter includes: 4 800 (HRZE) tablets 3 900 (HR) tablets 1 200 ethambutol tablets 275 vials of streptomycin

Complete the Distribution Worksheet on the next page to calculate the quantities of anti-TB drugs the Faba District TB Coordinator should distribute to Agraville Hospital for next quarter. Check your tally of cases last quarter (done in Alternative Exercise A, page 50) to find the number of cases registered in each category from Agraville Hospital. Use this number as the expected number of cases for next quarter.

Exercise continued on next page

Annex D, continued

Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter Agraville Hospital (name of health facility)

Instructions: Complete a separate worksheet for each health facility.

x x x

Drug and category of patient who needs it

Tablets and vials needed to treat expected patients ( ____ x 168 tablets) + ( ____ x 252 tablets) = ______ tablets

Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

tablets

( __ x 144 tablets) + ( _ x 180 tablets) = tablets _ x 240 tablets = __ tablets _ = x 56 vials __ vials

tablets

tablets vials

Whenyou youhave havefinished finishedcompleting completingthe theworksheet, worksheet,review review When your answers with a facilitator. your answers with a facilitator.

Then GO BACK to page 18, section 4. Read and work to the end of the module (page 29).

Annex E: Ordering and distribution worksheets for districts that use separate tablets of anti-TB drugs

Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter Daily treatment in the initial phase (28 doses per month) and intermittent treatment in the continuation phase (12 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : patients patients

Instructions: Complete one worksheet for the district.

x x x

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients ( ____ x 168 tablets) + ( ____ x 252 tablets) = ________ tablets B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to order after subtracting current stocks B-C=D

Drug and category of patient who needs a it Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

tablets

( ___ x 144 tablets) + ( ___ x 180 tablets) = ________ tablets ____ x 240 tablets = ______ tablets _____ x 56 vials = _______ vials

tablets

vials

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. Supplies for giving streptomycin injections may also be added to the order.

Annex E, continued

Ordering Worksheet: Separate tablets of anti-TB drugs to treat adult patients in the district during one quarter Daily treatment in the initial and continuation phases (28 doses per month) Category I + Category III: 2(HRZE) / 4(HR): Category II: 2(HRZE)S / 1(HRZE) /5(HR)E : patients ____ patients

Instructions: Complete one worksheet for the district.

x x x

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Determine the current stock at the district from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients ( ____ x 168 tablets) + ( ____ x 252 tablets) = ________ tablets B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to order after subtracting current stocks B-C=D

Drug and category of patient who needs a it Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

tablets

( ____ x 336 tablets) + ( _____ x 420 tablets) = ________ tablets ____ x 280 tablets = ______ tablets ___ x 56 vials = ______ vials

tablets

vials

Depending on the policies and procedures of the national TB control programme, you may need to add one or more of the following to the district order: other presentations of anti-TB drugs for treatment of children; additional tablets of anti-TB drugs for special cases such as loose tablets of individual anti-TB drugs, drugs for Category IV cases, isoniazid for preventive therapy for children and for PLWHA; and co-trimoxazole and ART drugs for TB/HIV patients. Supplies for giving streptomycin injections may also be added to the order.

Annex E, continued

Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter _________________ (name of health facility)

Instructions: Complete a separate worksheet for each health facility.

Fill in the expected number of patients in each category in column A and multiply by the number of tablets or vials needed per patient as shown in the formula. The tablets or vials needed per patient are provided in column A. Then complete the calculations in columns A and B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients ( ____ x 168 tablets) + ( ____ x 252 tablets) tablets = _____ B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to distribute after subtracting current stocks B-C=D

x x

Drug and category of patient who needs it

Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

tablets

(_ +( _ =

x 144 tablets) x 180 tablets) ___ tablets

tablets

_ x 240 tablets = ____ tablets ______ x 56 vials = ___ vials

tablets vials

Annex E, continued

Distribution Worksheet: Separate tablets of anti-TB drugs to distribute to a health facility to treat adult patients during one quarter _________________ (name of health facility)

Daily treatment in the initial and continuation phases (28 doses per month) Category I + Category III: 2(HRZE) / 4(HR)3 : Category II: 2(HRZE)S / 1(HRZE) /5(HR)3E3 : patients patients

Instructions: Complete a separate worksheet for each health facility.

x x x

Fill in the expected number of patients in each category in column A and multiply by the number or tablets or vials needed per patient as shown in the formula. Then complete the calculations in columns A and B. Estimate the stock remaining at the health facility from records and fill in column C. Complete the calculations in column D. A Tablets and vials needed to treat expected patients ( +( = x 168 tablets) x 252 tablets) ___ tablets B Multiply by 2 for reserve stock Ax2=B C Estimated stock on last day of previous quarter D Amounts to distribute after subtracting current stocks B-C=D

Drug and category of patient who needs it

Combination (HRZE) (Cat I + III) + (Cat II) Combination (H150 R150 mg) (Cat I + III) + (Cat II) Ethambutol (Cat II) Streptomycin (1 g vial) (Cat II)

tablets

( +( =

x 336 tablets) x 420 tablets) ______ tablets x 280 tablets _ tablets x 56 vials _ vials

tablets

= =

tablets vials

WHO/HTM/TB/2005.347d

Management of Tuberculosis Training for District TB Coordinators

PROVIDE TRAINING FOR TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Provide Training for TB Control Contents Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................1 1. 2. 3. What is good training? ................................................................................................2 When is training needed?............................................................................................3 Ensure initial training of health facility staff in TB case detection and treatment .....4 3.1 Ensure that health facility staff know what tasks they are responsible for........4 3.2 Arrange for health facility staff to be trained in key TB case detection and treatment tasks.............................................................................................5 3.3 Ensure that microscopists receive training needed ............................................6 3.4 Train additional health facility staff to identify TB suspects.............................6 4. 5. Follow up after initial training ....................................................................................8 Conduct on-the-job training or organize training sessions as needed.........................9 5.1 Conduct on-the-job training...............................................................................9 5.2 Organize a brief training session for a group...................................................12 Summary of important points ............................................................................................15 Self-assessment questions..................................................................................................16 Answers to self-assessment questions ...............................................................................18 Exercises ............................................................................................................................21 Exercise A.................................................................................................................22 Exercise B .................................................................................................................24 Annex A: Learning objectives of the course Management of Tuberculosis: Training for Health Facility Staff .........................................................................26 B: Register of TB Suspects (for reference in Exercise A).........................................28

Provide Training for TB Control Introduction As District TB Coordinator, it is your responsibility to ensure that health facility staff who provide TB control services are properly trained. While it may not always be your job to actually train staff, it is important that you be able to recognize good training and arrange appropriate training experiences for staff. Training can be provided in many formats, such as on-the-job training, briefings, workshops, or multi-day training courses. The format is not as important as whether the training includes certain basic elements, such as active practice of tasks to be done on the job. This module will help you to recognize and provide good training for health workers responsible for TB case detection and treatment, whether they are new or experienced at their jobs. The need for training in the district TB control programme never goes away. After initial training of health facility staff responsible for TB control services, there is a continuing need for training to maintain their skills and knowledge. For example, training may be needed if: • • • there are changes in procedures, staff have forgotten infrequently used skills or knowledge, or staff have become careless with frequently performed tasks.

In addition, initial training will need to be repeated periodically for new staff who are assigned responsibilities for TB case detection and treatment.

Objectives of this module Participants will learn how to: • • • Recognize good training Provide training for health facility staff to prepare them to identify TB suspects Resolve problems due to lack of skills or knowledge through training Refer to section: 1 3.4 5

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

1. What is good training? Good training is performance-based

Performance-based training teaches tasks that must be performed as part of a job. This type of training teaches participants skills and knowledge needed to perform specific tasks, as well as information needed to understand what they are doing and why. Good training does not waste time teaching skills that are not needed, or information that is irrelevant to the job. For example, performance-based training about directly observed treatment for TB outpatients would include information on detecting and treating cases in an outpatient setting; it would not include detailed instruction on inpatient care. Good training incorporates information, examples, and practice

Learning new tasks, and teaching others, are familiar parts of life. Think about a time when you learned a new skill, such as swimming, or cooking rice. If you had a good teacher, that person probably: • • • first told you how (information), then showed you how (example), and then helped you to practise until you could do it yourself.

These simple elements of good teaching can be used in training health workers to perform tasks involved in TB case detection and treatment. It is not necessary to use standard methods of hearing a lecture or reading a textbook. It is necessary to practise doing the tasks. • Information: Inform health workers about the tasks and describe them. You can provide information by having health workers read a description of the tasks, or by explaining in your own words. Give other relevant information about when and why to perform the tasks, supplies needed, etc. Examples: Demonstrate how to perform the tasks. For example, show how to handle anti-TB drugs, how to write on the TB Treatment Card, etc. A demonstration is often combined with giving information. A demonstration, on the job or in a training situation, is an effective teaching method. Practice: Ask the health worker to perform the tasks, or part of the tasks, as you watch. Give guidance while the health worker tries. Doing a task helps a person learn and remember it much more effectively than just reading about it, hearing a description or watching an instructor. Feedback should always follow practice. When the health worker performs a task well, the instructor should give praise. If the health worker makes a mistake or is unsure, specific help should be given.

•

Good training provides relevant practice

Practice should be as similar as possible to the actual task performed on the job. For example: • If a task involves making a decision, the learner will need to practise making that decision. An exercise could describe a situation in which a decision must be made, and ask the health worker to decide, for example, what treatment regimen to select if a smear-positive TB patient has been previously treated for TB. If a task involves communicating information, the learner will need to practise communicating. Communication can be practised in a role play. For example, a health worker could role play encouraging a reluctant patient to continue treatment. If a task involves doing something, such as handling drugs or writing on the TB Treatment Card, the learner will need to practise that procedure. A suitable exercise might describe treatment observed or days missed, and ask the health worker to record the treatment given on the TB Treatment Card.

•

It is best when the practice situation is as similar to the real work situation as possible. On-thejob training can be especially helpful since participants can practise in the real work setting while being closely supervised. The instructor can watch the health worker do tasks, correct any mistakes on the spot, and give additional instruction needed. Of course, trainees should not practice with real patients until they have demonstrated that they are capable. The instructor should supervise closely as the trainees begin working with real patients. Sections 3 and 4 of this module describe recommended training for health workers responsible for TB case detection and treatment.

When is training needed?

Training is needed when health facility staff do not know how to do tasks for which they are responsible, for example, when: • • • • TB control services are added to a health facility, TB control services are changed to be in accord with the national guidelines for treatment regimens and other procedures, new health facility staff are given responsibility for TB case detection and treatment, or current health facility staff, who have not previously been responsible for TB case detection and treatment, are given this responsibility.

In the above situations, staff are likely to need a thorough initial training, as described in section 3 of this module. Initial training is especially needed if health facility staff are accustomed to treating TB cases in a different way than specified in the national guidelines; these staff will need to “un-learn” old procedures as well as learn new ones. Training is also needed when there is a specific performance problem due to a lack of skill or knowledge. In module C: Conduct Supervisory Visits for TB Control, you learned how to identify performance problems and determine if they are caused by a lack of skill or knowledge. Section 4 of this module will describe how to provide training to address these

problems. This training may be brief and simple, such as on-the-job training, or a workshop to provide refresher training or re-training in certain tasks. When expanding TB control services to non-public health facilities, private practitioners may need training. Be careful to consider constraints on their time and schedules when recommending or choosing a training method.

Ensure initial training of health facility staff in TB case detection and treatment

3.1 Ensure that health facility staff know what tasks they are responsible for Before initial training, the officer in charge of the health facility should inform staff of their new responsibilities for TB case detection and treatment. The initial training should teach how to perform those tasks. Key tasks that should be performed by selected health facility staff are as follows: • • • • • • • • Detect cases of TB (includes identifying and informing TB suspects; and collecting, storing, and sending sputum samples for examination). Treat TB patients (includes selecting appropriate TB treatment regimens, providing directly observed treatment, completing TB Treatment Cards, and ensuring follow-up sputum examinations are done and treatment is continued appropriately). Inform patients about TB. Inform patients about HIV and TB/HIV in areas where HIV is common. Identify and supervise community TB treatment supporters. Manage drugs and supplies for TB. Ensure continuation of TB treatment (includes making home visits to patients who miss treatment). Monitor TB case detection and treatment at the health facility level.

Health facility staff who see many patients, for example those who greet, register, or initially assess patients, should be given the responsibility of asking all adults about cough in order to identify TB suspects. (This task is described in more detail in section 3.4.) If the health facility has its own TB microscopy unit rather than sending sputum samples away for examination, then a trained microscopist is needed to do the following tasks: • • • • • • • Receive and record samples. Prepare slides of sputum smears. Read slides. Report results and record data in the Tuberculosis Laboratory Register. Store positive slides and negative slides for quality assurance. Maintain the microscope and microscopy supplies safely. Follow safety measures for handling sputum samples and performing TB microscopy (including disinfection of table and hands, ventilation).

Encourage the officer in charge of the health facility to meet with health workers and clearly describe: • • • • their tasks related to TB control services, the training that they will receive in order to be prepared for their tasks, how new tasks will affect their current responsibilities, when they will begin performing their new tasks.

3.2 Arrange for health facility staff to be trained in key TB case detection and treatment tasks Health facility staff responsible for TB control services must be trained in all the tasks to detect and treat TB cases. These individuals must be trained, supplied, and ready to do their jobs before others at the health facility begin identifying TB suspects. The course Management of Tuberculosis: Training for Health Facility Staff is the recommended way to train health facility staff responsible for case detection and treatment. As District TB Coordinator, it is your responsibility to be aware of when and where this course is being conducted in your area. If courses are not available at locations and times suitable for staff in your district, discuss the need for these training courses with a higher level (e.g. the provincial TB coordinator). Coordinate with the officer in charge of the health facility so that staff can attend the training course. This is a 5-day training course, but it may be offered as a series of separate shorter sessions. Avoid sending too many people away for training at the same time. Obtain invitations to the course for health facility staff well in advance. The course Management of Tuberculosis: Training for Health Facility Staff teaches the specific skills and knowledge that health workers need to detect cases of pulmonary TB, manage drug therapy for TB patients, inform patients about TB, and monitor the success of TB case detection and treatment at health facility level. The course does not teach basic medical techniques familiar to health workers, such as how to give injections or sterilize needles and syringes. The course does not teach medical procedures used by clinicians to diagnose TB, manage severe side-effects, treat TB patients who have defaulted, or treat patients with chronic or multidrug-resistant TB. For information on these procedures, physicians and other clinicians should refer to WHO treatment guidelines and appropriate references.1 Like the course for District TB Coordinators that you are attending now, the course for health facility staff uses a variety of methods and instruction, including reading, written exercises, 1

Examples of references include: Crofton J, Horne N, Miller F. Clinical tuberculosis, 2nd ed. London, Macmillan Education Limited, 1999. Frieden T, ed. Toman’s tuberculosis. Case detection, treatment, and monitoring: questions and answers, 2nd ed. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.334). Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.313).

discussions, role plays, demonstrations, and observations in a real health facility. Practice, whether in written exercises or role plays, is a critical element of instruction. Typically, small groups of participants are led and assisted by “facilitators” as they work through the course modules. As in this course, the facilitators are not lecturers. Their role is to answer questions, provide individual feedback on exercises, lead discussions, structure role plays, etc. For the most part, participants work at their own pace through the modules, although in some activities, such as role plays and discussions, the small group works together. The training course for health facility staff includes the following modules: A: Introduction B: Detect Cases of TB C: Treat TB Patients D: Inform Patients about TB E: Identify and Supervise Community TB Treatment Supporters F: Manage Drugs and Supplies for TB G: Ensure Continuation of TB Treatment H: Monitor TB Case Detection and Treatment

The course for health facility staff also includes a field exercise to observe TB case management at a health facility and a reference booklet containing important forms, worksheets, and summaries of procedures taught in the course: I: Field Exercise – Observe TB Management J: Management of Tuberculosis – Reference Booklet

The learning objectives of each module of the course Management of Tuberculosis: Training for Health Facility Staff are listed in Annex A of this module. 3.3 Ensure that microscopists receive training needed

If the health facility will have its own TB microscopy unit, collaborate with the district laboratory supervisor to ensure that microscopists receive the necessary training. A laboratory technician who already has basic laboratory skills will need one week (5 full days) of practical training to learn to prepare and read slides of sputum smears. If the technician lacks previous laboratory training and experience, at least 2 weeks of training is needed. A good reference for microscopists is Laboratory services in tuberculosis control. Part II: Microscopy. Geneva, World Health Organization, 1998 (WHO/TB/98.258). 3.4 Train additional health facility staff to identify TB suspects When staff responsible for TB case detection and treatment have been trained, and the facility has been supplied with anti-TB drugs and other supplies, it is time to train other health facility staff (such as those who greet and register patients) to identify TB suspects. Any adult who has coughed for 2 weeks or more is a “TB suspect” for pulmonary TB and should have a sputum examination.

The task of identifying TB suspects involves asking all adults (aged 15 years or older1) who come to the health facility: • • Do you have a cough?2 How long have you been coughing?

Health facility staff must learn to ask these questions of all adults who come to the facility (not just patients, but also family members and others accompanying patients). About 50% of TB suspects may be missed if the above questions are asked only of people who come to the health facility because of cough. Health facility staff must also learn exactly what to do when they find an adult who has been coughing for 2 weeks or longer. For example, they must learn how to ensure that the TB suspect sees the appropriate staff. In order to be motivated to ask the questions about cough, health workers must also understand the importance of asking the questions and the rationale for asking them: • • • Asking the questions helps find TB cases early and facilitates cure. Early diagnosis and treatment of TB reduces transmission to others, including health facility staff. It is easy to ask the questions; it takes little time but is very important.

Training to identify TB suspects can and should be conducted on the job. On-the-job training is conducted in the health facility using real examples and carefully supervised practice with real patients. You may conduct the training or prepare the health facility supervisor or nurse to conduct the training. An example of on-the-job training to identify TB suspects is provided on the next page. Additional examples of on-the-job training are provided in section 5.

Some countries use 12 years. This will depend on the country-specific decision on the age range of children and adults. 2 Some countries may ask about productive cough.

Example On-the-job training to identify TB suspects To provide: Possible training methods include: Describe to health workers their new task (to identify TB suspects by asking all adults the two questions about cough). Explain what to do when they find an adult who has been coughing for 2 weeks or more. Have the officer in charge of the health facility explain the importance and the rationale for asking about cough. Post reminders to ask the questions about cough to all adults. Examples Demonstrate asking the questions to a health worker or a real patient. Have health workers role play asking the questions to you or to one another. Ask them what they will do when they hear certain answers. Practice Watch and listen while health workers ask the questions to adults who enter the health facility. Confirm that they ask all adults the questions and that they notify the appropriate nurse of all TB suspects.

Information

Follow up after initial training

After initial training of health facility staff, it is important to ensure that staff have actually learned, and continue to maintain, the necessary skills and knowledge to do their jobs. During supervisory visits to health facilities, observe and ask questions of health facility staff to assess whether their performance of TB case detection and treatment tasks is consistent with guidelines and training. (This process was described in module C: Conduct Supervisory Visits for TB Control.) Your purpose is to check: • • whether training was effective (that is, whether health workers learned the skills and knowledge needed to do their tasks), and whether skills and knowledge learned in training are being used correctly on the job.

If staff did not learn the necessary skills and knowledge in training, it will be important to report this to the training coordinator. During supervisory visits following training, ask staff if they have any questions related to the training or application of their new skills on the job. Be sure to reinforce good performance of new skills. If there are problems, try to determine the cause. Is the problem due to a lack of skill and knowledge? Perhaps the health worker has forgotten a skill or did not have enough opportunities to practise the skill during training. If the problem is due to a lack of skill or

knowledge, you may need to do brief re-training or refresher training on the job. (See section 5.) Remember that training can only solve a problem that is caused by a lack of skill or knowledge. If a problem is caused by a lack of resources (such as time, personnel or supplies) or a lack of motivation, other solutions will be necessary. Also, problems may have more than one cause. Once skills and knowledge have been provided through training, it may also be necessary to address other causes of the problem.

Conduct on-the-job training or organize training sessions as needed

5.1 Conduct on-the-job training On-the-job training is conducted in the workplace using real examples and carefully supervised practice with real patients. There may be just one trainee or several. On-the-job training may be used for reinforcement or re-training when a problem is identified, or to orient new staff until they can attend a full course. Some examples of situations in which on-the-job training is suitable include the following: • • You need to introduce a new procedure or policy, so you conduct brief training when making supervisory visits to each health facility in the district. During a supervisory visit, you notice that health workers have forgotten certain information, or they are no longer performing a skill as well as they used to. You want to correct the problem quickly through on-the-job training. A nurse who is trained and experienced in providing TB control services is moving to a new job. This nurse can orient and train the new nurse before leaving. The new nurse follows and works with the experienced nurse for several days on the job, learning by observation, explanations, and supervised practice.

•

On-the-job training, like all good training, should include information, examples, and practice. Practice, followed by feedback, is the most critical element of training. In a workplace setting, the following methods could be used to provide information, examples, and practice.

To provide:

Possible training methods include: Reading written explanations Studying “job-aids” Listening to an experienced, trained health worker explain procedures Following and observing an experienced, trained health worker who is performing TB-related tasks

Information

Examples

Reviewing real forms from the health facility, such as the Register of TB Suspects and TB Treatment Cards Examining TB drug kits or supplies used at a health facility Practising recording real patient data on real TB Treatment Cards

Practice

Providing information about TB to real patients, while a supervisor or trainer observes and gives feedback Doing the actual work of the health facility (detecting cases, collecting sputum, giving directly observed treatment, recording information) with real patients, while a supervisor or trainer observes and gives feedback

On-the-job training can be used to provide a needed skill or knowledge quickly and conveniently, in the work setting. On-the-job training may be a simple explanation and demonstration of the task, followed by supervised practice. Usually on-the-job training is provided for an individual health worker or for a very small group that needs the same skill or knowledge. To clearly explain a task, you may refer to the modules and Reference Booklet from the course Management of Tuberculosis: Training for Health Facility Staff. The modules in that course describe the skills and knowledge needed by health facility staff responsible for TB case detection and treatment.

Example

During a supervisory visit, a District TB Coordinator observes that two recently trained health workers are putting all patients with smear-positive sputum examination results on Category I treatment. By asking the health workers a few questions, the District TB Coordinator determines that they do not know to ask whether patients have been treated for TB before, or what to do for previously treated patients. The District TB Coordinator decides to provide on-the-job training to solve this problem. A plan is described on the next page.

On-the-job training to solve a problem:1 Problem: Health workers put all smear-positive patients on Category I treatment. Cause: Health workers do not know to ask whether patients have been treated for TB before, or what to do for previously treated patients. Steps in training: 1. Provide information Explain how to determine the disease site, the type of patient, and the treatment category. Emphasize the questions to ask about previous treatment: – Have you ever been treated for tuberculosis? – Have you ever taken injections for more than 1 or 2 weeks? Why? – Have you ever taken a medicine that turned your urine orange/red? Explain the importance of these questions. Post the questions on the wall. Also post definitions of types of patient and descriptions of treatment categories (both found at the bottom of the District TB Register). 2. Give examples Make up an example of a sputum smear-positive patient who has been treated for TB before. As you identify the type of patient, point to the appropriate definition that you have posted on the wall (relapse, treatment after failure, or treatment after default). As you describe the decision process about the patient’s treatment category, point to the descriptions of the treatment categories that you have also posted. If possible, allow health workers to observe an initial interview with a patient. Be sure to ask all of the above questions about previous treatment. After the patient has left, review how you determined the type of patient and treatment category. 3. Provide practice Make up two cases that have been previously treated (perhaps a relapse and a treatment after default). Describe what these cases say in answer to the questions about previous treatment. Ask health workers to identify the type of patient and the treatment category. When actual patients come to hear the results of sputum examinations, observe as health workers interview the patients. (These observations may occur over several visits.) Ensure that health workers ask the questions about previous treatment and select the appropriate treatment category. Give feedback.

This sample lesson plan can easily be used with parts of module C: Treat TB Patients from the course Management of Tuberculosis: Training for Health Facility Staff. Relevant information is found on pages 1–6 of the module, including Figures 1 and 2. Cases 2 and 4 from Exercise A may be used to provide practice.

STOP Now do Exercise A – Written Exercise and Group Discussion When you have reached this point in the module, turn to page 22 and follow the instructions for Exercise A.

5.2 Organize a brief training session for a group It is recommended that the entire 5-day course Management of Tuberculosis: Training for Health Facility Staff be used for initial training of staff responsible for TB case detection and treatment. However, there are circumstances in which it is appropriate to conduct a partial course, for example one or two modules, in a brief training session. This use of the course materials is described in section H of the guide How to Organize Training for Health Facility Staff on TB Control that may be ordered with the course. A partial course may be useful for solving specific problems caused by a lack of skill or knowledge, introducing a new aspect of the programme, providing refresher training on critical tasks, etc. Examples Some examples of circumstances warranting a partial course are as follows. All modules mentioned in the examples are from Management of Tuberculosis: Training for Health Facility Staff. • Health facilities are correctly detecting and managing cases of TB, but many patients are defaulting. A partial course to solve this problem might include module G: Ensure Continuation of TB Treatment and module H: Monitor TB Case Detection and Treatment. Module G would teach participants ways to prevent defaults, and module H would teach them how to monitor whether their efforts are successful. Two years ago, a province conducted a course for health facility staff that included all of the modules except module E: Identify and Supervise Community TB Treatment Supporters. At that time there were no plans to use community TB treatment supporters in the province. Now the programme is ready to introduce community TB treatment supporters. A partial course could be conducted using module E: Identify and Supervise Community TB Treatment Supporters and any other modules that need review. Health workers are correctly detecting and managing cases of TB, but they have not been taught how to communicate with patients to inform them about TB. A partial course to address this issue could include module D: Inform Patients about TB. 12

•

When planning a training session, there are a number of questions to consider, such as: • • • • • • What skills and/or knowledge should be taught? Who needs the skills and knowledge and thus should attend the training? What type of training is suitable? The type of training might be an extended training course (like this one), on-the-job training, a brief training session, or refresher training. Who should conduct the training? Where should the training be held? For example, the training could be held at a regular district meeting, at a health facility, or at a centrally located training facility. How should information, examples, and practice be provided? Can existing materials be used or adapted?

If possible, use existing training materials such as modules from the course Management of Tuberculosis: Training for Health Facility Staff. Review the training objectives for each module of that course (listed in Annex A). Based on the list of training objectives, determine which module may be appropriate for the needs of health facility staff in your district. Then study that module and the related guidelines in the Facilitator Guide to see if all or parts of the module are indeed applicable to the problem at hand. The Facilitator Guide explains exactly how to conduct the module, what supplies are needed, etc. At the end of the Facilitator Guide is a schedule that includes a time estimate for conducting each module in its entirety. If you will not use the entire module, you will need to estimate how long it will take to do the parts that you choose. If you have been trained as a facilitator, you may conduct the training yourself using materials from the course Management of Tuberculosis: Training for Health Facility Staff. Otherwise, try to arrange for a trained facilitator to conduct a specific module or modules of the course. One trained facilitator is needed for every 3–6 participants. If you do not have access to trained facilitators, refer to the guide, How to Organize Training for Health Facility Staff on TB Control, for information on how to prepare facilitators. The number of staff needing training, and their locations, will affect where the training session should be held. For example, if staff at just one facility need training, it makes sense to conduct the training session there. If staff at many facilities are involved, you may need to conduct the training at a central location. A training session could be conducted in a regular district meeting of the staff responsible for TB, as described in this course in section 6 of module H: Monitor and Evaluate TB Control. A classroom or meeting area is needed with a flipchart and seating and writing space for all participants; an overhead projector is helpful for several modules but is not necessary. Course materials may be ordered through the Ministry of Health in your country. Each participant will need a copy of module A: Introduction, each module to be taught, and a set of answer sheets. Each facilitator will need a Facilitator Guide.

Example In several health facilities in a district, health workers are correctly detecting and managing TB cases, but they do not communicate effectively with patients to inform them about TB. The District TB Coordinator learns that, in the initial training course that these health workers took (Management of Tuberculosis: Training for Health Facility Staff), module D: Inform Patients about TB was done hurriedly. Unfortunately, because of lack of time at the course, the role play sessions in that module were not done. The District TB Coordinator thinks that all staff responsible for managing TB cases could benefit from practice informing patients about TB, as in module D: Inform Patients about TB. He refers to the Facilitator Guide and finds that the module takes about 3.5 hours and requires no special supplies other than a few drug kits for use in role plays. He arranges for a trained facilitator to conduct the module at a special 4-hour meeting for six health workers, to be held near the district office. He asks participants to bring their copies of the module from the course that they previously took; he also makes photocopies of the module for participants who did not previously attend the course.

STOP Now do Exercise B – Written Exercise and Group Discussion When you have reached this point in the module, turn to page 24 and follow the instructions for Exercise B.

Summary of important points • • • • Good training is performance-based; that is, it teaches participants skills and knowledge needed to perform specific tasks required on the job. Good training incorporates information, examples, and practice. Practice, followed by feedback, is the most critical element of training. Practice should be as similar as possible to the actual task performed on the job. Training is needed when health facility staff do not know how to do tasks for which they are responsible; in other words, they lack skills or knowledge to do a task. Training cannot solve all problems; for example, problems caused by obstacles, such as lack of time or resources, require other solutions. The course Management of Tuberculosis: Training for Health Facility Staff is the recommended way to train health facility staff responsible for TB case detection and treatment. The learning objectives of each module of that course are listed in Annex A. After providing training, always follow up to determine whether the training was effective and whether the skills and knowledge taught are being used correctly on the job. Answer questions and provide feedback on performance of new skills; be sure to reinforce good performance. When staff responsible for TB case detection and treatment have been trained, and a health facility has been supplied with anti-TB drugs and other supplies, it is important to train staff who greet and register patients to identify TB suspects by asking about cough. Training to identify TB suspects can and should be conducted on the job. On-the-job training is conducted in the health facility using real examples and carefully supervised practice with real patients. Like all good training, on-the-job training should include information, examples, and practice. In certain circumstances, it may be appropriate to use one or two modules of the course Management of Tuberculosis: Training for Health Facility Staff in a brief training session. This use of the course materials is described in section H of the guide How to Organize Training for Health Facility Staff on TB Control that may be ordered with the course. Certain modules may be useful for solving specific problems caused by a lack of skill or knowledge, introducing a new aspect of the programme, providing refresher training on critical tasks, etc. It is important to have a trained facilitator conduct the module(s) if at all possible.

•

Self-assessment questions Answer the self-assessment questions below to check what you have learned. Then compare your answers with those provided on pages 18–19. 1. Good training is ______________ - ___________; that is, it teaches _________ and ________________ needed to perform specific tasks required on the job.

In a training course for mechanics who will repair and maintain cars, which of the following activities would be directly relevant to skills and knowledge needed on the job? (Tick all that are relevant.) ____ Reading about the invention of the automobile ____ Changing the oil in a car ____ Watching someone change a tyre ____ Studying a trouble-shooting guide that describes problems to consider when a car will not start ____ Looking at engines in two different types of cars ____ Re-charging a battery Next to each of the above activities, write whether it is information, an example, or practice.

True or false? a) ______ Practice is the most important element of training. b) ______ Practice should always be followed by feedback. c) ______ Written exercises are the best form of practice. d) ______ Training is the best way to solve problems caused by lack of motivation. e) ______ Training is needed when TB control services are added to a health facility. f) ______ The course Management of Tuberculosis: Training for Health Facility Staff is the recommended way to train health facility staff responsible for case detection and treatment.

___ - ____ -______ training should be used to teach health facility staff who greet and register patients to ___________ ____ ____________ by asking about cough. This type of training is conducted in the health facility using real examples and carefully supervised ___________ with real patients.

Several situations are described below. Each involves a lack of skill or knowledge. Which module of the course Management of Tuberculosis: Training for Health Facility Staff would be most relevant in each situation? (Refer to Annex A for a list of the learning objectives of each module.) a) Health facilities in the district have never before used a Register of TB Suspects. They are expected to begin using this type of register starting in the next quarter.

b) Health workers are confused about the relationship of HIV and TB. They do not know what to tell TB patients about HIV.

c) Patients are not having follow-up sputum examinations according to schedule. Health workers are not sure how the schedule differs for Category I and Category II patients. They do not understand why a follow-up examination is needed at the end of the 5th month of treatment and then again at the end of treatment.

Now compare your answers with those on the next page.

Answers to self-assessment questions If you had difficulty answering any question, turn back and study the section indicated. If you do not understand something, discuss it with a facilitator. 1. Good training is performance - based ; that is, it teaches skills and knowledge needed to perform specific tasks required on the job. (See section 1)

Ticked activities are relevant: (See section 1) ___ Reading about the invention of the automobile – This information is not relevant to job performance.

9 Changing the oil in a car – Practice 9 Watching someone change a tyre – Example 9 Studying a trouble-shooting guide that describes problems to consider when a car will not start – Information

9 Looking at engines in two different types of cars – Example 9 Re-charging a battery – Practice 3. a) True (See section 1) b) True (See section 1) c) False – Practice should be as similar as possible to the actual task performed on the job. Written exercises will sometimes be most appropriate, but for many tasks, other types of practice will be more similar to the job. For example, communication tasks can be practised in a role play. Preparing a drug kit can be practised by actually counting out the necessary drugs and assembling them in a kit. (See section 1) d) False – Training is intended to solve problems caused by a lack of skill or knowledge. Sometimes training has a positive effect on motivation, because health workers better understand the importance of their work, and they receive attention and feedback. However, training is usually not the most cost-effective way to increase motivation. (See sections 2 and 5) e) True (See section 2) f) True (See section 3.2)

On - the - job training should be used to teach health facility staff who greet and register patients to identify TB suspects by asking about cough. This type of training is conducted in the health facility using real examples and carefully supervised practice with real patients. (See section 3.4)

a) Module B: Detect Cases of TB b) Module D: Inform Patients about TB c) Module C: Treat TB Patients Note: It would not be necessary to conduct all of module D or C to address the problems described. A training session could include just the relevant sections. (See section 5 and Annex A)

The End Congratulations on finishing this module!

Exercises for Module D: Provide Training for TB Control

Exercise A Written Exercise and Discussion – Planning on-the-job training

In this exercise you will develop a brief plan for on-the-job training in how to use the Register of TB Suspects at the health facility level. Note: Copies of all forms recommended for use at the health facility level are included in the annex to module A: Introduction. A copy of the Register of TB Suspects is also provided in Annex B of this module for ease of reference. Read the situation description below. Then fill in the table on the next page to show how you would provide information, examples, and practice on the job. Situation description The Register of TB Suspects has not been used in Faba District in the past. The District TB Plan of Action for 2004 says that all health facilities offering TB control services will begin using a Register of TB Suspects in April. However, Nurse Perpetua Fonki, who is responsible for TB control tasks at Denali Health Post, is not scheduled to take the course Management of Tuberculosis: Training for Health Facility Staff until July. In the meantime, she needs to know how to use the Register of TB Suspects. Nurse Fonki already knows how to ask questions about cough, collect sputum samples and send them to the microscopy unit with a Request for Sputum Examination, interpret the results of sputum examinations received from the microscopy unit, use a TB Treatment Card, and treat TB patients. The District TB Coordinator decides to use part of the March supervisory visit to Denali Health Post to provide on-the-job training in how to use the Register of TB Suspects. Fill in the table on the next page with a plan that the District TB Coordinator could use to provide on-the-job training in how to use the Register of TB Suspects.

On-the-job training to use the Register of TB Suspects

To provide:

Use the following training methods:

Information

Examples

Practice

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 12, section 5.2, and read until the next stop sign.

Exercise B Written Exercise and Discussion – Solving problems due to lack of skill or knowledge

In this exercise you will describe an appropriate training solution for two situations in which there is a lack of skill or knowledge. Read about each situation and briefly answer the questions that follow. Situation A The new District TB Coordinator in Marina District, Dr Elisabeth Amilami, has noticed from review of laboratory records that all health facilities throughout the district send only two sputum samples for diagnosis and only one sample for follow-up examinations. Upon asking a few questions, Dr Amilami finds that “this is the way it has always been done.” There is no shortage of sputum containers. This problem seems to be a result of health workers’ not being informed about the correct number of sputum samples to send. They continue to do what has “always been done” because no one has told them what to change. 1. What is the lack of skill or knowledge in this situation? 2. Who is lacking the skill or knowledge? 3. What type of training is suitable (for example, an extended training course, on-the-job training, a brief training session, refresher training)?

4. Where should the training be held (for example, at a regular district meeting, at a health facility, or at a centrally located training facility)? 5. What key information, examples, and practice should be provided during the training?

Situation B There has been a change in the national guidelines for managing TB. Instead of using ethambutol in the continuation phase of treatment, rifampicin will be used. This means that patients will take treatment only 3 times a week instead of daily in the continuation phase. Since rifampicin requires supervision, patients will need directly observed treatment instead of taking the drugs at home. The continuation phase will also be shorter, lasting 4 months instead of 6 months. Health workers will soon be given the new guidelines. They need to know about the new drug regimen and how it affects the treatment schedule. They need to be informed about what old practices to stop, what new practices to begin, and when the change will take effect. 1. What is the lack of skill or knowledge in this situation? 2. Who is lacking the skill or knowledge? 3. What type of training is suitable (for example, an extended training course, on-the-job training, a brief training session, refresher training)?

4. Where should the training be held (for example, at a regular district meeting, at a health facility, or at a centrally located training facility)?

5. What key information, examples, and practice should be provided during the training?

Tell a facilitator when you are ready for the group discussion.

GO BACK to page 15 and read and work until the end of the module (page 19).

Annex A: Learning objectives of the course Management of Tuberculosis: Training for Health Facility Staff Each module of the course provides information, examples, and practice of certain skills necessary for detecting and managing TB cases and monitoring progress. Exercises are provided at the end of each module. The skills and information presented in each module are as follows: A: Introduction

• • • • •

What is tuberculosis? Importance of TB as a public health problem The DOTS strategy for control of TB Description of the training course Glossary (definitions of terms that may be unfamiliar)

B: Detect Cases of TB

• • • • • •

Procedures for detecting TB suspects How to use a Register of TB Suspects How to collect sputum samples How to use sputum examination results to identify TB cases Steps to inform TB suspects of results and begin additional care as needed How to check household contacts of TB cases

C: Treat TB Patients

• How to choose the appropriate treatment category • How to determine where a patient will receive directly observed treatment • How to prepare a patient’s TB Treatment Card, including specifying the treatment regimen and dose • How and when to provide preventive therapy for household contacts of the TB patient • How to give directly observed treatment and record it on the TB Treatment Card • How to recognize side-effects and what to do • How to determine when a patient is due for follow-up sputum examination • How to decide, based on sputum results, the appropriate action needed • How to determine treatment outcome

D: Inform Patients about TB

• • • • • •

Communications skills useful for informing patients How to inform the TB patient and family about TB and directly observed treatment (first meeting) Messages for the TB patient and family about TB and directly observed treatment How to continue informing the patient throughout treatment (subsequent meetings) Continuing messages for the TB patient about the treatment regimen (including the drugs, treatment schedule, side-effects, sputum examinations) Messages about HIV and TB, and pregnancy and HIV testing

E: Identify and Supervise Community TB Treatment Supporters

• • • •

How to help the patient identify a community TB treatment supporter who is likely to be effective How to train and supply a community TB treatment supporter with drugs How to resupply the community TB treatment supporter with drugs and review the patient’s TB Treatment Card on a monthly basis Steps to take if the community TB treatment supporter does not collect the next month’s drugs

F: Manage Drugs and Supplies for TB

• • •

How to ensure sufficient stock of drugs for TB patients How to plan for other needed supplies (such as sputum containers, syringes and needles, forms) Good drug management procedures for safekeeping the supply of anti-TB drugs

G: Ensure Continuation of TB Treatment

• • • • • •

How to coordinate medical referrals and ensure that the TB patient continues treatment How to coordinate transfer of a TB patient who is moving to another area How to arrange for TB patients to continue treatment when travelling How to conduct a home visit to a patient who misses a dose or fails to collect drugs for self-administration How to trace a patient who interrupts treatment How to plan so that health facility staff are able to conduct home visits and trace patients

H: Monitor TB Case Detection and Treatment

• • • • • • •

Key indicators related to TB case detection and data needed to monitor these How to compile data on TB case detection at the health facility Key indicators related to TB treatment and data needed to monitor these How to compile data on TB treatment at the health facility How to calculate indicators How to analyse indicators How to plan appropriate actions to solve problems

Annex B REGISTER OF TB SUSPECTS Age M F Complete Address Date Results Received

Year _______________ Facility ________________________

Date

TB Suspect Number

Name of TB Suspect

Date Sputum Sent to Lab

Results of Sputum Examinations 1 2 3 TB Treatment Card Opened? (record date)

Observations/ Clinician’s Diagnosis

WHO/HTM/TB/2005.347c

Management of Tuberculosis Training for District TB Coordinators

C CONDUCT SUPERVISORY VISITS FOR TB CONTROL

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Conduct Supervisory Visits for TB Control Contents Page Introduction..........................................................................................................................1 Objectives of this module ....................................................................................................2 At the beginning of each quarter: 1. Make a schedule for supervisory visits .......................................................................3 1.1 Refer to a map of the district..............................................................................3 1.2 Schedule your supervisory visits .......................................................................5 During supervisory visits: 2. Enter each new patient in the District TB Register and assign a District TB number...................................................................................................................7 3. Update the District TB Register for each patient who is currently in treatment or has completed treatment .......................................................................................11 3.1 Record follow-up sputum examination results in the District TB Register .....11 3.2 Determine whether smear-positive patients are converting by the end of the initial phase and try to solve any problems................................................12 3.3 Record treatment outcomes in the District TB Register ..................................13 4. Review the Register of TB Suspects ..........................................................................15 4.1 Compare the number of TB suspects identified with the number of adult outpatients ........................................................................................................15 4.2 Look for TB suspects who had positive results but did not begin treatment...16 4.3 Look for diagnostic delays...............................................................................17 4.4 Compare the Register of TB Suspects and the Tuberculosis Laboratory Register ............................................................................................................17 5. Check that work is done according to the national guidelines for TB control..........18 5.1 5.2 5.3 5.4 6. Assess performance of TB case detection and treatment tasks........................18 Describe a performance problem .....................................................................22 Investigate the causes of a problem .................................................................22 Determine possible solutions ...........................................................................23

Promote the DOTS strategy and the TB control programme and motivate health facility staff responsible for TB control services ...........................................26 Identify training needs of health workers responsible for TB case detection and treatment .............................................................................................................26

7.1 Record the names of health workers responsible for TB case detection and treatment ...................................................................................................27 7.2 Determine whether health workers responsible for TB case detection and treatment are competent or need training..................................................27 7.3 Periodically check for changes in staff responsible for TB case detection and treatment ...................................................................................................29 8. Write a brief report of your supervisory visit............................................................30

Summary of important points ............................................................................................32 Self-assessment questions..................................................................................................33 Answers to self-assessment questions ...............................................................................35 Exercises Exercise A.................................................................................................................38 Exercise B .................................................................................................................41 Exercise C .................................................................................................................57 Exercise D.................................................................................................................59 Annexes A: Quarterly planning calendar ................................................................................64 B: Standard number of doses for TB treatment regimens ........................................65 C: Schedule for follow-up sputum examinations......................................................66 D: Checklist for Supervisory Visits to Health Facilities Providing TB Control Services.................................................................................................................68 E: Summary Worksheet: Indicators to monitor TB case detection and treatment at health facility level ...........................................................................................71 F: Training Needs for TB Control ............................................................................73 G: Blank TB forms District TB Register .........................................................................................74 TB Treatment Card ..........................................................................................76 Tuberculosis Referral/Transfer form ...............................................................78 Register of TB Suspects....................................................................................79

Conduct Supervisory Visits for TB Control Introduction A District TB Coordinator oversees the activities carried out in the district for TB control in several ways, for example, by observing at health facilities, talking with health staff, and reviewing records. Regular visits to health facilities are essential for gathering information in these ways as well as for giving support and encouragement to health workers. For a District TB Coordinator, the purposes of making supervisory visits to health facilities include: • • Entering in the District TB Register all cases of TB detected at the health facility. Adding to the District TB Register information on progress of treatment of TB patients, including results of follow-up sputum smear examinations and finally, their treatment outcomes. Assessing how staff are performing TB case detection and treatment by observing, talking with staff and reviewing records. Determining quantities of anti-TB drugs and TB-related supplies in stock.1 Identifying problems in different ways and solving them to improve the effectiveness of TB case detection and treatment. Identifying health workers who need training in TB case detection and treatment. Supporting staff by listening to their concerns and providing feedback and encouragement.

• • • • •

All health workers need help to solve problems and overcome difficulties. They also need feedback on their performance and encouragement in their work. Supervision should be intensified after training, to ensure that health workers have fully acquired the skills taught and to provide any guidance needed. Supervisory visits must be planned carefully. Before each visit, review the findings of the last supervisory visit, any notes of actions taken since the last visit, and any additional information or questions about the health facility or its patients. A supervisor’s personality is important. Good supervisors have a pleasant and friendly manner, and are quick to establish rapport with health workers of all categories. They are ready to listen with an open mind to any problems and to seek solutions that will take into account the suggestions of the health worker concerned.

Information on anti-TB drugs in stock at each health facility is used to plan quantities of drugs to distribute for the next quarter and to identify any problems with supply. How to calculate quantities to distribute to each health facility is described in module E: Manage Drugs and Supplies for TB Control.

Objectives of this module Participants will learn how to: • • Refer to section:

• • • • • •

Make a quarterly schedule for supervisory visits to health facilities 1 Maintain the District TB Register: register patients who were detected recently at the health facility; at later supervisory visits, record their follow-up sputum results and finally their treatment outcomes 2, 3 Determine whether smear-positive patients are converting by the end of the initial phase and try to solve any problems with treatment 3.2 Review the Register of TB Suspects to identify any problems with case detection 4 Assess performance of TB case detection and treatment to identify problems; analyse causes and possible solutions 5 Promote the DOTS strategy and the TB control programme at health facilities 6 Identify training needs of health workers responsible for TB case detection and treatment 7 Write a brief report of a supervisory visit 8

If you need to look up an unfamiliar word, refer to the glossary at the end of module A: Introduction.

At the beginning of each quarter, make a schedule for supervisory visits

As the District TB Coordinator, you will make a District Plan of Action for TB Control for the year. A District TB Plan for Faba District is in module B: Faba District. Your plan should include a general plan for supervision, including the number of visits that you will make to health facilities in your district. It will help you to plan your workload and transportation costs. Quarterly, you will need to make a more detailed schedule for supervisory visits, naming each health facility and specifying the dates of your visits. 1.1 Refer to a map of the district A map is an important tool for a District TB Coordinator. To plan your schedule of supervisory visits, refer to a map that shows all the public and non-public health facilities in the district. If you do not already have such a map, draw or obtain a map of the district. Mark on that map: • • • • health facilities (public and non-public) TB microscopy units population centres (towns, villages, settlements, etc.) roads.

Develop a key for the map that shows names and locations of health facilities, description of services provided, organization (e.g. MOH, NGO, religious, military, private), outpatient load, and number of TB cases. Also specify names and locations of facilities offering HIV voluntary counselling and testing.

Example: Map of Faba District On the next page is a map of Faba District. Study the map. Notice the key below the map that provides information about the items on the map.

Post a copy of the map in a visible place in the district office. The map will be helpful for your reference and also when your supervisor visits. Update the map and key when items change. You will consult this map whenever you make your quarterly schedule.

FABA DISTRICT

Population of Faba District: 150 000 Population of Agraville: 45 000 1 cm _____ = 4 km = paved road = dirt road = private clinic

Ferro Health Post

Ferro River bed

Irini village

H* B* Bella Health Centre

High Road Health Post

Prison

A* Agraville

Agraville Hospital

G* Gadara Health Post

Denali Health Post

Cara Health Centre

Emeral Health Post

Health facility A*

Type MOH

Services provided

Outpatient load (2003) 52 800 21 100 16 000 8 000 6 000 4 000 8 000 6 000

TB cases (2003) 132 72 – 17 – – 12 7

1.2 Schedule your supervisory visits A schedule for supervisory visits should show the dates that you will visit each health facility in the district during the quarter. Make this schedule based on: • • • • the number of facilities in the district how often you will visit each facility where the facilities are located, travel required to reach them, and whether some are close to others whether you know a facility is having problems that require your attention.

Study the map of your district and the relative locations of the facilities, where they are in relation to towns and villages, and how you can travel to them. The schedule must be feasible so that you can make the visits on the scheduled dates and arrive on time. You must be able to spend enough time at each facility to accomplish all your supervisory tasks, including talking with health workers. If the schedule is too difficult, you may not be able to follow it. It is recommended to visit each facility once per month to complete the District TB Register. Monthly visits enable you to register new cases and record follow-up sputum results or treatment outcomes in a timely way. Monthly visits also enable you to identify any problems quickly enough to have some impact. For example, you can identify patients who are late for follow-up sputum examinations and remind health staff. You can check that treatment failures are changed to the re-treatment regimen. You can be aware of patients who have transferred out of that facility and look for them at another facility. Although monthly visits are recommended, you may decide to visit some facilities less frequently if they are smaller and have few outpatients and TB cases. Every facility must be visited once a quarter at a minimum. If you have previously identified problems at a facility, either from reviewing the District TB Register, talking to staff or observing there, you may need to return more frequently to help solve the problem or give support. For example, if a facility has a drug supply problem or a problem that you can solve with training, you may visit sooner or more frequently. On a calendar of the quarter, mark when you will visit each facility. (Annex A is a blank quarterly planning calendar that can be photocopied.) Notify health facilities in advance of the date and purpose of your visit. If you find that you will be late, you must let the staff know quickly. It will frustrate the staff and damage your credibility if you do not come when expected. If for any reason the visit cannot be made that day, contact the health facility to inform them and to agree on another day. Record the new date on your calendar. When you make supervisory visits during the quarter, mark the calendar to show completed visits.

STOP Now do Exercise A – Written Exercise and Discussion When you reach this point, you are ready to do Exercise A. Turn to page 38 and follow the instructions. When everyone is ready, there will be a group discussion.

The rest of this module describes the steps to perform during a supervisory visit to each health facility.1

_________________________________ Typically, the District TB Coordinator reviews TB Treatment Cards and updates the District TB Register during supervisory visits to each health facility. Alternatively, health facility staff could bring their TB Treatment Cards to the District TB Coordinator. However, this approach has disadvantages: health staff may not bring all of the relevant cards, and the District TB Coordinator has fewer opportunities to observe other aspects of TB services at each health facility. 1

Enter each new patient in the District TB Register and assign a District TB number

At the health facility, ask to see the TB Treatment Cards for all current TB patients, including new cases, cases currently receiving treatment, and those who recently completed treatment or had some other treatment outcome (such as transferred out, failure). Examine all the TB Treatment Cards to identify cases detected since you last visited this health facility and registered cases in the District TB Register. Newly-detected cases will have no District TB number recorded on their TB Treatment Card. This is a TB Treatment Card from Kanebo Health Centre in Chalo District, a neighbouring district to Faba District. Bubbles explain items to be recorded in the District TB Register: Ticks indicate disease site and type of patient. This is a newly-detected case. A District TB number has not yet been assigned. When this patient is entered in the District TB Register, the District TB Coordinator will assign a District TB number and copy it here.

Example

Patient’s name and address

Sex and age

Treatmen regimen (Cat I, II, III, or IV)

Health facility

Date Treatment Started is the date of the first tick.

Copy results into District TB Register in “Before treatment” column.

You should assign a District TB number to each newly-detected case and register the patient in the District TB Register. The District TB number should consist of a letter or letters designating the district and then a number in sequence beginning with 1 at the beginning of the year. For example, in Chalo District, the 28th patient registered in 2004 would have the number C-28. The register book pages should be labelled clearly 2004. 7

Look at the District TB Register for Chalo District on the next page as you read the instructions below. Register each newly-detected patient by completing the columns from left to right in the District TB Register as follows: • • • On the first available (blank) line in the District TB Register, enter today’s date (the day you are visiting the health facility) as the date of registration. Enter the next District TB number in sequence. Copy from the TB Treatment Card: − the patient’s name − sex − age − complete address − health facility.

If any information is missing, ask a health worker.

• •

Look for the first tick indicating treatment administered and record that date under “Date Treatment Started.” Read the ticks on the TB Treatment Card and enter in the register: 1 − treatment category (I, II, or III) − whether the patient’s TB is pulmonary or extrapulmonary (P or EP) − type of patient. (Enter the appropriate code shown in Figure 1 below and at the bottom of the left side of the register book.) Copy the date and results of the diagnostic sputum examination (month 0) in the “Before Treatment” columns. The rest of the columns will be completed during the patient’s treatment. Finally, copy the assigned District TB number onto the patient’s TB Treatment Card. Figure 1: Definitions of type of patient Code Type of patient N R F D T O a

•

New Relapse Treatment after failure Treatment after default Transfer in Other

Definition A patient who has never had treatment for TB or who has taken anti-TB drugs for less than 1 month A patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB A patient who is started on a re-treatment regimen after having failed previous treatment A patient who returns to treatment, positive bacteriologically,a following interruption of treatment for 2 months or more A patient who has been transferred from another TB register to continue treatment All cases that do not fit the above definitions. (This group includes chronic case, a patient who is sputum-positive at the end of a retreatment regimen.)

A previously-treated patient with extrapulmonary or pulmonary TB who returns to treatment and is not bacteriologically positive should be registered as “other.”

If the patient is not receiving the standard regimen of anti-TB drugs for the category, for example because of pregnancy or adverse drug effects, write the initials of the anti-TB drugs being taken. If the treatment regimen is not consistent with the type of patient, for example a new smear-positive patient given Category III or a previously treated patient given Category I, check for errors.

Example

Excerpt from District TB Register, Chalo District The District TB Coordinator in Chalo District copies Joseph Mabayo’s information from his TB Treatment Card into the District TB Register. The District TB Coordinator records that Joseph has pulmonary TB, is a new patient, and is receiving Category I treatment.

The Chalo District TB Coordinator is visiting the Kanebo Health Centre on 30 December 2003. This is the date of registration for Joseph Mabayo.

The District TB Coordinator assigns to Joseph Mabayo the next District TB number, that is, C-211.

The date that drugs were first administered (first tick on the TB Treatment Card) was 9 December 2003.

The District TB Coordinator copied the results of Joseph’s sputum examination for month 0 from the TB Treatment Card to the register.

Transfers When the type of patient is “Transfer in,” you must determine whether the patient has transferred from another facility within your district or from another district. • If the patient has transferred from another facility in your district: This patient will already be listed in the District TB Register. Do not assign a new District TB number. Find the patient in the register. In the “Remarks” column for the patient’s original entry, note the name of the facility where the patient is now being treated. If the patient has transferred from a different district: Register this patient in your District TB Register and assign a new District TB number. If you know the District TB number that was assigned to the patient in the other district, write the former number in the “Remarks” column.

•

When a patient is transferred to another facility to continue treatment, the original health facility should send a copy of the Tuberculosis Referral/Transfer Form (see Annex G) to the District TB Coordinator and to the receiving health facility. This form provides information about the patient and specifies the name of the facility that the patient is being transferred from and the facility the patient is going to, as well as the patient’s District TB number. When you make supervisory visits to different facilities, determine whether any patient who was transferred to a particular facility has arrived; that is, determine whether the transferred patient has a TB Treatment Card at the new facility and is coming for treatment. If there is no record of the patient, ask both the original facility and the new facility to search for the patient.

At the beginning of each quarter, start a new page in the District TB Register and label it with the quarter (for example, 2nd Quarter 2003). Then, at your next supervisory visit to a health facility, begin registering the newly-detected TB cases on this new page. It will be important to see easily where one quarter ends and the next quarter begins when you are compiling data for quarterly reports. The extra blank lines at the end of a quarter can also be helpful to add patients if needed, record totals, etc. January, February, March = 1st quarter April, May, June = 2nd quarter July, August, September = 3rd quarter October, November, December = 4th quarter

Update the District TB Register for each patient who is currently in treatment or has completed treatment

Once you have entered newly-detected patients in the District TB Register, review the remaining TB Treatment Cards. Check each card to see whether the patient has had a followup sputum examination since you last updated the District TB Register, or whether the patient has completed treatment or has had another treatment outcome. 3.1 Record follow-up sputum examination results in the District TB Register Remember that all TB patients should have a follow-up sputum examination at the end of the initial phase of treatment. For Category I and III patients, this examination is due during the last week of the initial 2 months of treatment;1 for Category II patients, it is due during the last week of the initial 3 months of treatment. The results of follow-up examinations are essential to determine whether smear-positive patients have converted to smear-negative. Sputum conversion is an important indicator of effective treatment. Patients who are smear-positive at the end of the initial 2 months of treatment (3 months for re-treatment) have an additional month of intensive phase treatment. These patients should have another smear examination at the end of the additional month. All sputum smear-positive patients should also have a follow-up sputum examination in the last week of the 5th month of treatment (to identify treatment failures) and during the last month of treatment to confirm cure. Annex C provides the schedule for follow-up sputum examinations.

Examine each patient’s TB Treatment Card to see whether any follow-up sputum examination results have been recorded since you last visited. If so, copy those results into the appropriate column of the District TB Register. If not, check whether the patient was due for follow-up sputum examination. If a patient was due for a follow-up sputum examination, but results are not recorded on the TB Treatment Card, ask health facility staff whether sputum samples have been taken and sent to the TB microscopy unit. If not, remind health facility staff to do so. If a sputum examination at the end of the initial phase of treatment has a positive result, make a slash (/) to divide the boxes in which you will record the date, result and lab number on the District TB Register. Write the positive result and related information above the slash, so that

When checking whether a patient is due for a follow-up sputum examination, determine whether the patient has nearly completed the required doses for the phase of treatment. The time elapsed might not correspond to the number of calendar months since the beginning of treatment. For example, 2 months after starting treatment, a patient might have taken only 43 of the required 56 daily doses. Therefore, the patient is not due for sputum examination for another week or so, when he has taken about 51 doses. See Annex B for the standard number of doses for TB treatment regimens.

•

default is defined as 2 months’ interruption or more. After 2 months, record an outcome of default; the health worker may stop looking for the patient.) If the ticks on the card indicate that the patient’s treatment has been irregular, discuss the need to find out the reasons and help the patient attend regularly. A community treatment supporter may be needed. If the patient has been given treatment by a community treatment supporter, ask the health worker to check with the treatment supporter and patient to confirm whether the treatment was actually taken correctly.

If there is a common problem, for example, patients are not having sputum examinations at the end of the initial phase, it is especially important to solve this problem as soon as possible. Discuss the problem with the health workers in order to find out causes and take action as necessary. 3.3 Record treatment outcomes in the District TB Register If a patient has completed treatment or had some other treatment outcome, record the treatment outcome and the date of the decision in the District TB Register. • If no outcome has yet been recorded on the TB Treatment Card, review the card to decide the treatment outcome, write it on the TB Treatment Card, and then copy it into the District TB Register. If the health worker has already recorded a treatment outcome on the TB Treatment Card, check it before copying it into the District TB Register. A common error is to record “Cure” when a patient can only qualify as “Treatment completed.” (If you disagree with a recorded treatment outcome, discuss it with the health worker and agree to change it if appropriate.) Figure 2: Definitions of treatment outcomes Treatment outcome Cure Definition Sputum smear-positive patient who is sputum smear-negative in the last month of treatment and on at least one previous occasion Patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure Patient who is sputum smear-positive at 5 months or later during a treatment Patient who dies for any reason during the course of treatment Patient whose treatment was interrupted for 2 consecutive months or more Patient who has been transferred to another recording and reporting unit and for whom the treatment outcome is not known

•

Treatment completed Treatment failure Died Default Transfer out a

Also sputum smear-negative patients who become sputum smear-positive at 2 months.

If a patient is a “Treatment failure,” record the date in the column for this outcome in the District TB Register, and then re-register the patient. To re-register a patient: • • • •

Enter the patient’s information on a new line in the District TB Register. Assign a new District TB number. Enter the patient’s sputum examination results after 5 months of treatment in the “Before treatment” column. Enter the patient’s previous District TB number in the “Remarks” column. (It would be useful also to note it in “Observations” in the new TB Treatment Card.)

Notice that “Transfer out” can be recorded as a treatment outcome in the District TB Register only if the patient transferred out of your district and no other treatment outcome is known. (However, you should contact the other District TB Coordinator to try to find out the actual treatment outcome.) If the patient transferred to another facility within your district, you will know or can find out the treatment outcome. When a “Transfer in” patient has a treatment outcome, make a note to inform the original health facility of that treatment outcome, even if that health facility is in another district.

STOP Now do Exercise B – Written Exercise When you reach this point, you are ready to do Exercise B. Turn to page 41 and follow the instructions. Do the exercise by yourself and then discuss your answers with a facilitator.

Review the Register of TB Suspects

Each health facility should maintain a Register of TB Suspects (see Annex G) to record information about all TB suspects and to track sputum samples sent to the TB microscopy unit for examination and results received. If the health facility includes a TB microscopy unit, it may or may not have a Register of TB Suspects in addition to the Tuberculosis Laboratory Register maintained in the microscopy unit. 4.1 Compare the number of TB suspects identified with the number of adult outpatients The number of TB suspects identified should be approximately 30–50 for every 1 000 adult outpatients (that is, 3–5% of adult outpatients) attending the facility for any reason. If fewer TB suspects are identified, ask whether health workers are asking all adults whether they 15

register the patient in the District TB Register or open a TB Treatment Card until the patient is confirmed to have TB by sputum examination or a clinician’s assessment.) Reviewing the Register of TB Suspects is a good way to identify smear-positive patients who have not started treatment. However, some facilities may not have a Register of TB Suspects (or a microscopy unit). In this situation, you may visit the microscopy unit that performs the facility’s sputum examinations and review the Tuberculosis Laboratory Register as described in module F: Ensure Laboratory Support for TB Control. In the Tuberculosis Laboratory Register, you may identify some smear-positive cases who have not yet started treatment. Register any such cases in the District TB Register, and ask health workers in the health facility to locate the individuals to begin treatment. 4.3 Look for diagnostic delays Examine the Register of TB Suspects to determine the number of days between sending the sputum sample to the microscopy unit and receiving the result. The period should be 4 days or less. The microscopy unit should send microscopy results as soon as they become available and preferably within 24 hours of receipt of the sputum samples; additional time is required for travel and the weekend. If there is a delay of more than 4 days, make a note to discuss the delay with the staff or supervisor at the microscopy unit. 4.4 Compare the Register of TB Suspects and the Tuberculosis Laboratory Register If the health facility maintains both a Register of TB Suspects and a Tuberculosis Laboratory Register, compare entries in the two to be sure that the sputum examination results were recorded correctly in the Register of TB Suspects.

5. 5.1

Check that work is done according to the national guidelines for TB control Assess performance of TB case detection and treatment tasks

This module has described how to get information about TB case detection and treatment at a health facility by reviewing TB Treatment Cards and the Register of TB Suspects. In addition, you will assess how work is done in the health facility by: • • • • • talking with health facility staff observing staff at work, if possible examining supplies of anti-TB drugs, sputum containers, and drugs for TB/HIV patients talking to TB patients, if possible talking to community TB treatment supporters, if possible.

A District TB Coordinator must know the national guidelines for TB control. It is helpful to attend or study the training course for health facility staff titled Management of Tuberculosis: Training for Health Facility Staff. Experience managing patients with TB according to the guidelines will deepen your understanding; experience observing at health facilities and solving problems will build your skill in assessing performance. As you observe health staff at work, talk with them and review records, keep in mind the national guidelines and how the tasks should be done. Notice tasks that are done correctly and tasks that are done incorrectly. Also note what health workers are concerned about. Give special attention to any health workers who were recently trained in TB case detection and treatment. Observe their work and talk with them to ensure that they have fully acquired the skills taught. Ask them if they have any questions or have had difficulty using what they learned. Provide any guidance needed and praise them for using the skills obtained in the training. Discuss with health workers the ways in which community members are involved, or could be involved, in supporting TB patients and promoting their adherence to treatment. Ensure that the national TB control programme guidelines and descriptions of other procedures, such as referral to HIV testing services, are easily available for reference by all staff responsible for TB case detection and treatment. On pages 19–21 is a checklist to use during a supervisory visit. It reminds you of what to do and look for during a visit and provides an easy way to record your findings. There are spaces to tick yes or no, write figures, and make notes. Annex D provides a blank checklist. Example The Chalo District TB Coordinator visited Kanebo Health Centre and used the supervisory checklist. The District TB Coordinator filled in the checklist on the next three pages as he assessed performance by reviewing records, interviewing staff, examining supplies of drugs and sputum containers, and observing a nurse providing TB treatment.

This section reminds you to review TB Treatment Cards and update the District TB Register (sections 2 and 3 in this module).

Checklist for Supervisory Visits to Health Facilities Providing TB Control Services Kanebo Health Centre Edwin Carlton Health facility .............................. District TB Coordinator................................... Hopeful Nabawe 23 March 2004 Health worker responsible for TB control .............................................. Date ............................ Review TB Treatment Cards for all current TB patients and those who recently completed treatment. Register all newly-detected cases. Update the District TB Register for other patients. Also check TB Treatment Cards: 1. Is each patient on the correct treatment regimen? 2. Are sputum examination results recorded correctly? 3. Do TB Treatment Cards indicate that all patients are receiving directly observed treatment? Is treatment regular and correctly recorded? 4. Are patients undergoing smear examination at 2 months (3 months if Category II)? 5. Are patients undergoing smear examination at 5 months and during the last month of treatment? 6. Are patients who are smear-positive at 2 months (at 3 months for Category II) receiving 1 more month of initial-phase drugs? 7. For each patient who has completed treatment, is the information on the TB Treatment Card sufficient to determine treatment outcome? YES*

These two sections list particular items to check as you review TB Treatment Cards and the Register of TB Suspects and/or the TB Laboratory Register, as described already in this module. Tick yes or no for each.

NO*

9 9 9 9 Not at end

9 9 YES NO

Review Register of TB Suspects and/or TB Laboratory Register (if available): 1. Does the facility have a Register of TB Suspects? 2. If yes, are the results of sputum smear microscopy written in the Register of TB Suspects? 3. Is there only a reasonable delay between sending sputum to receiving microscopy results? 4. If the facility has both a Register of TB Suspects and a TB Laboratory Register in the facility, do the microscopy results recorded in them match? 5. Do results in the Register of TB Suspects match the results recorded on the TB Treatment Card? 6. Have all the smear-positive patients started treatment?

9 9 9 NA

9 9 NO

YES Examine and ask about supplies. Is there: 1. An adequate supply of anti-TB drugs? Are anti-TB drugs well-maintained, not expired? Note quantities in stock: : Cat I/III kits--6, Cat II kits--3 9 HRZE tabs--600; HR--800; E--150; H--500; S vials--130 2. An adequate supply of needles, syringes and diluent for injections? 9 3. A system for safe disposal of needles and syringes? 9 4. An adequate supply of co-trimoxazole for TB/HIV patients? 5. An adequate supply of sputum containers? Number in stock: Only 200 9 6. A sterilizer in good working condition (if required)? 7. An adequate supply of: 9 Write down the approximate quantities of – TB Treatment Cards? anti-TB drugs and sputum containers in 9 – Request for Sputum Examination Forms? stock. You will use these numbers when 9 ordering drugs and supplies for this health – Tuberculosis Referral/Transfer Forms? facility for next quarter.

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* Tick YES or NO for each question. Any NO answer indicates a problem that should be addressed. For each problem, investigate to determine causes of the problem and possible solutions.

Were there changes in staff responsible for TB case detection and treatment? Fill in the chart, Training Needs for TB Control, every 6 months. Ask whether health workers have any questions or problems. Notes: They are worried they will run out of anti-TB drugs later in the year, because the health centre often runs short of other drugs and syringes then. You can complete these sections only when TB patients are present during your visit.

Update the chart when there are changes. At every visit, talk with health workers. Try to answer their questions. Make notes of any concerns or problems in this box.

Observe health workers with patients if possible. Do they: 1. Ask all adult outpatients about cough and correctly identify TB suspects? 2. Send TB suspects to laboratory or collect sputum samples for examination? 3. Collect sputum outdoors or in a well-ventilated area? 4. Administer the correct drugs for the treatment regimen? 5. Watch patients swallow the tablets? 6. Tick the TB Treatment Card after watching the patient swallow the tablets? 7. Correctly give a streptomycin injection after the tablets have been swallowed? (if applicable) 8. Give each injection with a sterile syringe and needle? (if applicable) 9. Inform TB suspects/patients about TB in a considerate and appropriate manner? 10. Inform TB patients about HIV testing? Provide or refer patients to HIV testing services? Talk to TB patients, if available. Do patients know: 1. What disease they are suffering from? 2. The number of tablets per day to take? 3. When to come back for the next appointment? 4. The duration of treatment? 5. What to do when they experience problems (side-effects)? 6. Why sputum examinations are needed? 7. How TB spreads? 8. Who else in the household should be examined or tested for TB? Ask whether the patient has any problems that may prevent completing treatment. P1 yes yes yes yes yes No yes yes moving

YES

9 9 9 9 9

9 9

P2 P3 yes yes yes yes P1 is the first yes yes patient interviewed, P2 is yes No the No second, etc. yes No yes No yes yes mentions yes If a patient a problem, record it here.

Talk to community TB treatment supporters, if available. Ask: TS 1 1. How many TB patients do you currently support? 3 2. Examine each patient’s TB Treatment Card, if available. Is it yes marked correctly? 3. Did you receive sufficient training to prepare you to be a TB yes treatment supporter? 4. How often does a supervisor from the health facility check your monthly work and your patients’ TB Treatment Cards? yes 5. Have you ever run out of drugs to treat your TB patients? home 6. What do you do when a TB patient interrupts (stops coming for) TB visit treatment? Answer any questions from the TB treatment supporter.

TS 2 1 yes yes monthly No don’t know

TS 3

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Quarterly Ask the health worker responsible for TB control about recent monitoring results. Has the health worker calculated the following for appropriate quarters? If so, what are the results? 1. The total number of TB cases currently on treatment? 2. The proportion of outpatients aged 15 years and older who were identified as TB suspects? 3. The proportion of TB suspects tested who were sputum smear-positive? 4. The proportion of new sputum smear-positive TB cases that converted at 2 or 3 months (sputum conversion rate)? 5. The proportion of new sputum smear-positive cases that – were cured? – completed treatment? Look at the work environment. 1. Is there good ventilation in the waiting area, in patient care areas, and where TB treatment is directly observed? 2. Is the patient flow arranged to minimize the time that TB suspects and TB patients are with or pass by other patients? 3. If there is a microscopy unit, does it have good air flow? Are the work area, slides, and supplies well organized and maintained?

Write the figures below

32 NA How to calculate these health facilitylevel indicators is summarized in Annex E.

YES

9 9 9

Observations from this supervisory visit:

Staff are worried about availability of anti-TB drugs and sputum containers and try to conserve them. TB Treatment Cards have complete information and are very neat.. This area inside the bold outline is for recording your conclusions about the visit. Actions and recommendations can include solutions suggested or implemented, and follow-up actions needed.

Describe problems identified during this visit:

Adul Kwandullah--smear-positive but not on treatment Not sending sputum from all TB suspects Not sending sputum for follow-up examination at end of treatment Co-trimoxazole supply insufficient for TB/HIV patients Possible causes of the problems:

Inadequate supply of sputum containers

Actions and recommendations:

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5.2 Describe a performance problem When an important task is done incorrectly or not done at all, this can be called a performance problem. When you find a difference between what should be done and what is actually done, you have identified a performance problem. It is helpful to state the problem in terms of who is not doing what. Describing a performance problem in this way helps to focus on whose performance needs improvement. For example, the Chalo District TB Coordinator noticed that TB Treatment Cards are missing results from follow-up sputum examinations at the end of treatment. Upon investigation, he found that the problem was: Health workers are not collecting sputum for follow-up examination during the last month of treatment. The more precisely you describe a performance problem, the easier it will be to find the cause and solution. Try to answer as many of the following questions as possible: • • • • Where does the problem occur? Does the problem occur with one health worker or several health workers? Does it occur in one health facility or several health facilities? When and how often does the problem occur? When did the problem start occurring?

Then the next step is to determine the probable cause or causes. There may be several causes contributing to the problem. Only when you know the true causes can you select an appropriate solution. 5.3 Investigate the causes of a problem Finding a solution to a problem depends on understanding what is causing the problem. To discover the causes of the problem, consider questions such as: • • Has the health worker been assigned to do the task? If not, making clear assignments of work and describing what the health worker should do may solve the problem. Does the health worker lack skill or knowledge to do the task? You can assess skill and knowledge by observing the health worker doing the task, or asking the health worker to describe the task to you. If the health worker cannot demonstrate or describe how to do the task, he or she lacks necessary skill and knowledge and will require training. However, ask whether this health worker could do the task in the past. If so, perhaps the health worker has just forgotten, and brief refresher training will be sufficient. Does the health worker want to do the task? Does the health worker know how to do it but not want to do it (that is, lacks motivation)? A health worker may lack motivation because the task is difficult, time-consuming, or distasteful; because it brings ridicule from peers, creates conflict, or seems less important or rewarding than other tasks; or because the health worker fears for his or her own safety (e.g. fear of infection).

•

Are there obstacles preventing the health worker from doing the task correctly, such as lack of time, lack of authority to do the task, lack of drugs, lack of necessary materials, lack of money, barriers such as taboos, geographical location?

Several important causes may contribute to a problem, so you should consider all the different possible causes. Example Hopeful Nabawe, the nurse responsible for TB control at Kanebo Health Centre, asks outpatients about cough to identify TB suspects. However, she does not collect sputum from all of the TB suspects. The District TB Coordinator talked with the nurse and found that she was assigned to collect sputum from all TB suspects, and she knows how to collect sputum, so lack of skill and knowledge is not a cause. However, she says that she does not do it because there are not enough sputum containers to collect sputum from every adult who coughs for 2 weeks or more. She worries the health centre will run out of containers and so saves the available sputum containers for the patients who are very ill with cough. The nurse says that she does not want to waste containers on patients whose sputum results are negative. Thus, the District TB Coordinator finds multiple causes that need to be addressed: • • Not enough sputum containers Lack of motivation to collect sputum from all TB suspects. It is more important and rewarding to have containers to collect sputum from patients who are very ill with cough. She feels that she wastes containers on patients whose results come back negative.

5.4 Determine possible solutions Solutions will depend on the causes of the problem. Solutions should: • • • remove the cause of the problem, or reduce its effects be feasible (affordable, practical, realistic) not create another problem.

If the cause of a problem is a lack of skill and knowledge, some form of training is needed. Training options include on-the-job training as well as classroom training. (How to plan and conduct training is described in module D: Provide Training for TB Control.) If a solution requires improving motivation, you can have an important impact during your regular supervisory visits. By talking with health workers, you can help them see that their work is important. Describe the importance of their work to reducing TB in the community and curing TB patients. Give health workers encouragement and support on a regular basis. Praise them for sustaining their efforts, doing a good job or making improvements.

Figure 3: Analysing a performance problem State a problem. Describe the problem, if possible, in terms of who is not doing what. Ask: Is it important? If not, describe a different problem to analyse. If the problem is important, analyse the causes of the problem in order to find a solution. A problem may have several causes, so consider them all. Consider all these causes Has the task been clearly described and assigned? Then plan solutions to address the causes •

If not, assign it

Clearly describe and assign the task to one or more health workers. If the health worker used to do the task, arrange for him or her to have brief refresher training with practice and feedback. If the task is new to the health worker, arrange for training to provide the skill and knowledge.

•

Does the health worker lack the skill or knowledge to do the task?

If yes, training is needed •

•

Does the health worker lack motivation to do the task (e.g. it is difficult, distasteful, less rewarding than other tasks, brings ridicule)? Are there obstacles that prevent or hinder the health worker from doing the task (e.g. lack of time, supplies, authority)?

If yes, positive consequences are needed

•

If there is a disadvantage to the health worker for doing this task, remove the disadvantage. If there is an advantage to doing this task poorly or not at all, arrange a positive consequence for doing the job well. If the performance is not important to the health worker, make it important.

If yes, obstacles should be removed

•

Remove the obstacles or decrease their effect.

STOP

Now do Exercise C – Written Exercise

When you reach this point, you are ready to do Exercise C. Turn to page 57 and follow the instructions. Do the exercise by yourself and then discuss your answers with a facilitator.

Promote the DOTS strategy and the TB control programme and motivate health facility staff responsible for TB control services

When you visit health facilities, speak positively and confidently about the DOTS strategy and the TB control programme. Health staff work with greater enthusiasm and dedication when they are confident that their work addresses an important health issue and they are using effective procedures. They are motivated to help people in their community and appreciate information and support. As the District TB Coordinator, you have responsibility for technical and managerial supervision of TB control, but you do not have administrative authority over staff at health facilities. Therefore, you can only accomplish work through cooperation. An important part of a supervisory visit is talking with the facility staff to build and maintain a good working relationship. You can greatly influence the work of the health facility in TB control by providing helpful information and guidance as well as ensuring necessary supplies of anti-TB drugs and items such as sputum containers. In addition, demonstrating enthusiasm for the programme, showing respect, and recognizing health staff for their hard work will inspire cooperation and motivate staff. When you are first developing this relationship, provide information about the TB control programme and the DOTS strategy, its objectives, and its effectiveness. Speak about the benefits of improved procedures such as directly observed treatment and use of fixed-dose combinations. Meet with the officer in charge of the health facility and the health workers responsible for TB case detection and treatment to discuss how to carry out TB control services as a team. Listen to their concerns and requests. Maintain a good working relationship by sustaining your interest and support. Whenever you visit, update the staff on interesting issues, and reinforce the importance of the TB control programme and the effectiveness of certain procedures. Support staff by listening to their concerns and providing feedback and encouragement. Recognize the continued efforts of health workers at the health facility. Congratulate staff for accomplishments such as increases in the number of cases detected or improvements in the rate of successful treatment. When problems occur, cooperate to find and implement a solution.

Identify training needs of health workers responsible for TB case detection and treatment

Every 6 months, during a supervisory visit to each health facility, check that enough health workers are designated as responsible for TB case detection and treatment. Also check whether they are competent to perform these tasks. The Training Needs for TB Control chart shown on page 28 is designed for this purpose. A blank chart for photocopying is in Annex F. When you identify needs for training, you may fill them immediately with on-the-job training or you may plan how health workers can get training. Module D: Provide Training for TB Control describes more about planning for training.

7.1 Record the names of health workers responsible for TB case detection and treatment It is important to maintain a record of the names of health workers responsible for TB control in each health facility as a way to identify changes in staff and needs for training. Even when TB control services are well established and functioning effectively, changes in staff create continuing needs for training. By talking with the officer in charge of the health facility, find out the names of the health workers who are responsible for TB control. There should be at least one health worker who has primary responsibility, and a second person who can substitute when needed. On the chart, Training Needs for TB Control, write the names of health workers responsible for TB control and list their TB-related responsibilities (see the example on the next page). 7.2 Determine whether health workers responsible for TB case detection and treatment are competent or need training Health workers who are responsible for TB case detection and treatment need good training. To assess the training needs of staff responsible for TB control, ask the officer in charge of the health facility about each health worker’s performance and previous training. Also ask the health worker about any previous training and any problems, and observe when the health worker does tasks related to TB case detection and treatment. Both the primary worker responsible for TB control and the back-up person must be competent performing the key tasks. Keep in mind the skills and knowledge that an individual needs. Ask questions of the worker and officer in charge of the health facility to find out about relevant training received so that you can assess whether it was sufficient. For example: • • • Were you trained in TB case detection and treatment? What was the duration of the training? How long ago was the training?

If the training was very short (e.g. a few hours in duration) or occurred more than 3 years ago, additional training is probably needed. If a health worker has completed the course, Management of Tuberculosis: Training for Health Facility Staff, he or she has been trained to detect and treat TB cases according to the DOTS strategy as outlined in the national guidelines.

Training Needs for TB Control Health facility: Kanebo Health Centre Responsibilities for TB case detection and treatment Date of visit or a training Enter C (competent), NT (needs training), RT (received training), or X (no longer on staff). Enter comments on the right.

Health worker

Hopeful Nabawe

Sputum collection, treatment of TB patients, recordkeeping (4 days per week)

Dec 2003 23/3/03 30/9/04

RT C C

Attended Management of TB training course Received on-the-job training on TB suspect identification and follow-up schedule

Catherine Campbell

Substitute for Hopeful Nabawe (2 days per week)

23/3/04 30/9/04

NT X

Received some instruction from Hopeful. Needs to attend TB course next quarter

Transferred to Patanga District

Update information every 6 months, or whenever there are changes in staff who perform TB case detection and treatment. Also update when staff receive training.

If it is possible, the best way to assess whether a particular health worker is competent is to observe closely when that health worker interacts with a TB patient. Use the part of the checklist for supervisory visits that relates to performance of the health worker.

YES

Also review the Register of TB Suspects, TB Treatment Cards and other records to see whether the worker is completing them correctly. Determine whether the worker is sending sputum for follow-up examination on schedule. If you detect performance problems, assess whether the health worker lacks necessary skill and knowledge and therefore needs training. Also assess whether there are other causes of performance problems. On the chart, Training Needs for TB Control, record the approximate date of the initial or most recent training in TB case detection and treatment received by each health worker and a title or description of that training in the comments section. Also record the date of today’s supervisory visit and your assessment of whether each health worker is competent or needs training. Make notes about the type of training needed in the comments section. When you identify staff who need training, arrange for the training as soon as possible. How to provide training is described in module D: Provide Training for TB Control. 7.3 Periodically check for changes in staff responsible for TB case detection and treatment Keep the chart, Training Needs for TB Control, for each health facility and bring it with you on supervisory visits. Every 6 months, review and update the chart with the officer in charge of the health facility. Check the names and TB-related responsibilities of each health worker on the chart. If a health worker has received training, record it. Record whether each health worker is competent or needs training.

If you find that a health worker is no longer on staff, enter X. Note whether the person quit or was transferred, if known. If a new health worker was added, enter the health worker’s name on a new row. Assess whether the new individual is competent to perform TB case detection and treatment or needs training. If necessary, arrange training as soon as possible. If performance problems are evident, add appropriate notes and date them. If a health facility does not have enough health workers, such as because a health worker has left and has not been replaced or because the workload is very heavy, discuss this problem with your supervisor and relevant authorities responsible for staffing.

STOP Now do Exercise D – Written Exercise When you reach this point, you are ready to do Exercise D. Turn to page 59 and follow the instructions. Do the exercise by yourself and then discuss your answers with a facilitator.

8. Write a brief report of your supervisory visit During supervisory visits, keep notes of your observations. If you record ticks and notes on a copy of the Checklist for Supervisory Visits to Health Facilities Providing TB Control Services, this will be your report. If you do not have copies of the checklist to write on, record your findings on another sheet of paper. A helpful report includes brief but specific information on important observations, achievements, problems, an analysis of problems and their causes, solutions suggested or implemented, and follow-up actions needed. The purpose of the report is to document your findings, actions and recommendations. If you leave a copy with the officer in charge, the staff will know what is good and what to correct. The report is helpful because it tracks problems or issues that should be followed up. The example below shows the entries made by the Chalo District TB Coordinator after completing his visit to the Kanebo Health Centre.

Example

Excerpt from page 3 of Supervisory Checklist (page 21)

Observations from this supervisory visit:

Staff are worried about availability of anti-TB drugs and sputum containers and try to conserve them. TB Treatment Cards have complete information and are very neat.

Describe problems identified during this visit:

Adul Kwandullah – smear-positive but not on treatment Not sending sputum for most TB suspects Not sending sputum for follow-up examination at end of treatment Co-trimoxazole supply insufficient for TB/HIV patients

Possible causes of the problems:

Inadequate supply of sputum containers Nurse believes it is better to save sputum containers for very ill patients; she is worried that identifying too many suspects will make trouble Lack of understanding of need for final sputum examination for proof of cure

Actions and recommendations:

Gave refresher training and rationale for testing all TB suspects, schedule for follow-up examinations and need for examination during last month of treatment Asked Hopeful Nabawe to locate Adul Kwandullah to start treatment Reminded health workers to use Tuberculosis Referral/Transfer form Check reasons why too few sputum containers and increase supplies (quickly) Send Mary Campbell to TB Management training course next quarter Discuss with regional TB coordinator need to increase supplies of co-trimoxazole if health centres are expected to provide it to TB/HIV patients

Keep reports of your visits together in a binder. At the end of the quarter and at other times, you can refer to the reports of supervisory visits. They can remind you of activities to schedule, such as training, and other actions needed to address problems. You can also trace progress at a particular health facility over time. These reports provide good documentation for your supervisor to show that you are making thorough supervisory visits.

Summary of important points • • Refer to a map of the district when scheduling supervisory visits to health facilities. Monthly visits are recommended. The District TB Register is the record of all TB cases in the district. When visiting each health facility, review the TB Treatment Cards of current TB patients. Enter each newlydetected patient in the District TB Register and assign a District TB number. Record the District TB number on the patient’s TB Treatment Card. Also record results of follow-up sputum examinations in the District TB Register. Followup sputum examinations are due in the last week of the initial phase of treatment, in the last week of the 5th month of treatment, and in the last month of treatment. Ideally, all patients with smear-positive pulmonary TB should convert to negative by the end of the initial phase of treatment. If any patient did not convert, examine the patient’s TB Treatment Card and investigate whether there is something that can be done to improve this situation for this patient or future patients. When a patient has completed treatment or had some other treatment outcome, record the outcome and the date of the decision in the District TB Register. Review the Register of TB Suspects at each facility to identify any TB suspects who had positive results but did not begin treatment. If you find such a patient, register the patient in the District TB Register. Also ask the health worker to open a TB Treatment Card and to find the patient to initiate treatment. Assess performance of TB case detection and treatment by talking with staff, observing them at work and, if possible, talking to TB patients and TB community treatment supporters. Use the Checklist for Supervisory Visits to Health Facilities Providing TB Control Services. State performance problems in terms of who is not doing what. Investigate the causes of the problem in order to plan appropriate solutions. Causes may include: task was not assigned; health worker lacks skill and knowledge; health worker lacks motivation; obstacles prevent or hinder the health worker. Promote the DOTS strategy and the TB control programme by speaking about them to health facility staff. Support staff by listening to their concerns and providing feedback and encouragement. Use the chart titled Training Needs for TB Control to record the names of the individuals responsible for TB case detection and treatment at each health facility and whether they are competent to perform these tasks. When you identify training needs, fill them immediately with on-the-job training or plan for the health worker to receive training. Write a brief report of your observations, any problems and analysis of their causes, solutions suggested or implemented, and follow-up actions needed. Use the report as documentation of the visit and issues to follow up. 32

•

• •

•

Self-assessment questions Answer the self-assessment questions below to check what you have learned. Then compare your answers with those on page 35. 1. When visiting the Butswalo Health Centre, the Chalo District TB Coordinator reviews the TB Treatment Cards of all the current TB patients. Read about each patient and answer the questions. a) The first TB Treatment Card is for a patient who started treatment last week. The District TB Coordinator registers the patient in the District TB Register and assigns the next District TB number, C-125. Where else should the District TB Coordinator write the patient’s District TB number? b) The next card is for a TB patient who has completed 2 months of Category I initialphase treatment. However, there are no results recorded for a follow-up sputum examination. What should the District TB Coordinator do?

c) The District TB Coordinator examines the TB Treatment Card of another TB patient. This patient finished taking all the anti-TB drugs in the Category I regimen on 12 August 2004. To decide the treatment outcome, the District TB Coordinator reviews the Results of Sputum Examination on the front of the TB Treatment Card (shown below). Results of sputum examination Month Date Smear Lab. No. Weight (kg)

0 2 5

5/1/04 26/3/04 30/6/04

+++ neg neg

630 801 1119

46 46 47

• •

What is this patient’s treatment outcome? What are the two places that the District TB Coordinator should record this treatment outcome?

The District TB Coordinator reviewed the Register of TB Suspects at Butswalo Health Centre and found one TB suspect with positive results several weeks ago who had not yet started treatment. What should the District TB Coordinator do about this patient?

Which of the following is stated as a performance problem? (Tick one or more) ____ Health workers do not get paid enough to work long hours. ____ The nurse does not watch TB patients swallow their tablets. ____ Directly observed treatment requires the health worker to take time with the patient every day. ____ The health centre sometimes runs out of some of the anti-TB drugs.

The Chalo District TB Coordinator observed that both of the health workers who are responsible for TB control at the Butswalo Health Centre do not do follow-up sputum examinations according to the schedule. Upon investigation, the District TB Coordinator found that the causes listed below all contributed to this problem in some way. ____ The health workers do not want to collect sputum for examination because it is a lot of work. ____ The health workers do not have a job description that assigns responsibility for follow-up sputum examinations. ____ Health workers rarely see the TB patients who are administered TB treatment by community TB treatment supporters. ____ The health workers do not know the schedule for follow-up sputum examinations. ____ There are not enough sputum containers. a) Next to each cause listed above, write the letter of the category of cause. NA – Task not assigned S – Lack of skill or knowledge M – Lack of motivation O – Obstacles that prevent or hinder b) The District TB Coordinator met with the clinician and clarified that the two health workers are responsible for collecting sputum from TB patients according to the schedule for follow-up sputum examinations. Then the District TB Coordinator conducted an on-the-job training session to assign this responsibility to the health workers and to teach them the schedule for sputum examinations. He also stressed the importance and explained how the results are used. Does this training solution address all of the causes above? ______ If not, circle any causes that will require an additional solution.

When the Chalo District TB Coordinator visited the Kacheka District Hospital, she learned that the two health workers listed on the hospital’s Training Needs for TB Control chart have moved away from the area. How should the chart be updated today?

Now compare your answers with those on the next page.

Answers to self-assessment questions If you had difficulty answering any question, turn back and study the section indicated (in parentheses). If you do not understand something, discuss it with a facilitator. 1. a) The Chalo District TB Coordinator should also write the patient’s District TB number on the patient’s TB Treatment Card. b) The District TB Coordinator should ask the health worker to collect sputum from this patient for a follow-up sputum examination. The District TB Coordinator should also check that the health worker knows the schedule for follow-up sputum examinations and why these are important. c) Answers are: •

The treatment outcome is “Treatment completed.” The treatment outcome cannot be “Cure” because there was no sputum examination during the last (6th) month of treatment.

The District TB Coordinator should record the treatment outcome on the patient’s TB Treatment Card and in the District TB Register. (See sections 2 and 3) •

The District TB Coordinator should: register the patient in the District TB Register ask the health worker to open a TB Treatment Card ask the health worker to find the patient to initiate treatment. (See section 4.2) • • •

9 The nurse does not watch TB patients swallow their tablets. This is stated as a performance problem, that is, who is not doing what. The fourth choice, the health centre sometimes runs out of some of the anti-TB drugs, implies that a performance problem exists somewhere, but it is not stated as a performance problem. (See section 5.2)

The health workers do not want to collect sputum for examination because it is a lot of work. NA The health workers do not have a job description that assigns responsibility for follow-up sputum examinations. O Health workers rarely see the TB patients who are administered TB treatment by community TB treatment supporters. S The health workers do not know the schedule for follow-up sputum examinations. O There are not enough sputum containers. (See section 5.3) The chart should be updated by entering an X for each of these two health workers to show that they are no longer on staff. Also write a note that they have left the area. The Chalo District TB Coordinator should find out and record the names of the health workers now responsible for TB case detection and treatment and assess whether they are competent or need training. (See section 7) 35

The End Congratulations on finishing this module!

Exercises for Module C: Conduct Supervisory Visits for TB Control

Exercise A Written Exercise and Discussion – Assessing a schedule for supervisory visits

In this exercise you will assess whether the schedule for supervisory visits planned by the Faba District TB Coordinator, Dr Oke Karimi, is feasible. Write answers to the questions below. Then there will be a group discussion. Turn to the map of Faba District in module B: Faba District. Study the map to identify the number and locations of the health facilities in Faba District. Faba’s District TB Plan for 2004 says that the District TB Coordinator will make monthly visits to each health facility that provides TB services. Dr Karimi can borrow a car from the DMO to make supervisory visits, but only on days when the DMO is not using it. Usually money for fuel is available, but sometimes it is not. Study the map of Faba District and write answers to the questions below: 1. How many facilities are providing TB control services now? Which facilities?

2. Can Dr Karimi easily travel by road to each of these facilities?

3. How often should Dr Karimi make a supervisory visit to each health facility?

Dr Karimi believes that he should be able to visit each of the facilities that provide TB control services once per month. Study the detailed calendar of visits he has planned on the next page. Then answer the questions that follow.

Month: January Monday

Quarterly Planning Calendar Tuesday Wednesday Thursday Friday

Year: 2004 Saturday Sunday

1 Sup visit to Agraville Hosp

8 Sup visit to Bella HC, High Rd HP

15 Sup visit to Gadara HP

16 Sup visit to Denali HP

Month: February Monday Tuesday Wednesday Thursday Friday Saturday Sunday

5 Sup visit to Agraville Hosp

12 Sup visit to Bella HC, High Rd HP

19 Sup visit to Gadara HP

20 Sup visit to Denali HP

Month: March Monday Tuesday Wednesday Thursday Friday Saturday Sunday

1 8 15 22

2 9 16 23

3 10 17 24

4 Sup visit to Agraville Hosp

5 12 19 Sup visit to Denali HP

6 13 20 27

7 14 21 28

11 Sup visit to Bella HC, High Rd HP

18 Sup visit to Gadara HP

31 Exercise continued on next page

4. Is this schedule feasible? Why or why not?

5. What might prevent Dr Karimi from making supervisory visits according to this schedule?

6. What might be done to increase the chances that Dr Karimi can visit all the health facilities as scheduled?

When you have finished writing answers to the questions, tell your facilitator that you are ready for the discussion.

When the group has finished this discussion, GO BACK to page 6 and read until the next stop sign (page 15).

Exercise B Written Exercise – Updating the District TB Register

In this exercise you will review TB Treatment Cards for current patients from Gadara Health Post and update the District TB Register. 1. Read the information below about this supervisory visit. Pretend that you are the Faba District TB Coordinator and are visiting the Gadara Health Post today. Today’s date is 26 August 2004. The last time you visited Gadara Health Post was 22 July, so you will be looking for any entries made on the TB Treatment Cards during the period 22 July – 26 August (that is, 22/7 – 26/8). The medical assistant at Gadara Health Post gives you the TB Treatment Cards for the TB patients currently in treatment there. You have the District TB Register with you and will update this register to reflect new information on the TB Treatment Cards that was added since your last visit. (On pages 53–55 are excerpts from the District TB Register that apply to Gadara Health Post. Fold out these pages now.) 2. Review each TB Treatment Card (pages 42–50) and enter any new information in the District TB Register (on page 53–55). Enter in the District TB Register any results of follow-up sputum examinations or treatment outcomes recorded on patient treatment cards since 22 July. Also register any recently-detected TB patients. If you enter a new patient in the District TB Register, remember to copy the District TB number that you assign onto the patient’s TB Treatment Card. Also determine when reviewing each TB Treatment Card whether there is any problem that you should discuss with the health worker, such as irregular treatment, interruption of treatment, or treatment failure.

Exercise continued on next page

3. When you have finished updating the District TB Register, answer the following questions. a) Is any patient almost due for a follow-up sputum examination? Who?

b) Is any patient a treatment failure? If so, who?

c) What should the District TB Coordinator do about a treatment failure?

When you have finished this exercise, review your answers with a facilitator.

GO BACK to page 15, section 4. Read to the next stop sign (page 25).

Exercise D Written Exercise – Identifying training needs In this exercise you will assess the training needs of staff at a health facility and complete a Training Needs for TB Control chart. 1. 2. Fold out the chart titled Training Needs for TB Control on page 61. Read the following information that Dr Oke Karimi, the District TB Coordinator, learned about staff at Bella Health Centre when he visited on 18 December 2003. The officer in charge at Bella Health Centre explained that two staff members do TB case detection and treatment. Mary Lang is the primary person with responsibility for TB detection, treating TB patients, and record keeping. She works Monday–Friday. AJ Perera also helps to treat TB patients when the health centre is very busy and on Saturday mornings. Neither of these staff has been trained about TB in the past few years. The officer in charge says that Mary Lang is particularly good at managing the supplies of anti-TB drugs, keeping records of treatment, and relating to the female patients. 3. Record these two staff members and their TB-related responsibilities, as of 18 December 2003, on the Training Needs for TB Control chart for Bella Health Centre. Indicate whether they need training or are competent. Note the type of training needed in the comments column. Remember that the provincial level is planning to conduct the course, Management of Tuberculosis: Training for Health Facility Staff, in February and July 2004 for staff in Faba and neighbouring districts. This course is suitable to train health facility staff who detect and treat TB patients. 4. Read the following information that the District TB Coordinator gathered at Bella Health Centre when he visited 6 months later, on 10 June 2004. Mary Lang attended the course, Management of Tuberculosis: Training for Health Facility Staff, in February 2004. She says it was a very good course and she has used what she learned. When Dr Karimi observed her at work, he saw good performance of all observed tasks and no problems. The officer in charge explained that AJ Perera had been transferred to Patanga District to work for the child health unit. Samia Shiva was recently assigned to Bella Health Centre. She is able to help Mary Lang with TB patients and fill in for her when she is not there. She is able to treat current patients, but does not know how to collect sputum or open a TB Treatment Card for a new patient. If there is any problem, she tells patients to come back when Mary is there. Exercise continued on next page

Samia Shiva asks to go to the same training course that Mary Lang attended. Mary has told her that it will help her a lot. 5. Write entries on the chart, Training Needs for TB Control, for Bella Health Centre to update it as needed.

When you have finished completing the chart, review your answers with a facilitator.

Then GO BACK to page 30, section 8. Read and work to the end of the module (page 36).

Training Needs for TB Control Health facility: ______________________

Health worker

Responsibilities for TB case detection and treatment Date of visit or traininga

Enter C (competent), NT (needs training), RT (received training), or X (no longer on staff). Enter comments on the right.

Update information every 6 months, or whenever there are changes in staff who perform TB case detection and treatment. Also update when staff receive training.

Annexes A: Quarterly planning calendar ..............................................................................................64 B: Standard number of doses for TB treatment regimens .....................................................65 C: Schedule for follow-up sputum examinations ...................................................................66 D: Checklist for Supervisory Visits to Health Facilities Providing TB Control Services ..............................................................................................................................68 E: Summary Worksheet: Indicators to monitor TB case detection and treatment at health facility level.........................................................................................................71 F: Training Needs for TB Control .........................................................................................73 G: Blank TB forms District TB Register ...............................................................................................74 TB Treatment Card ................................................................................................76 Tuberculosis Referral/Transfer form .....................................................................78 Register of TB Suspects ..........................................................................................79

Annex B: Standard number of doses for TB treatment regimens In the standard code for TB treatment regimens, the duration of each phase is stated in months. How many doses is that? The number of doses is standardized as follows: • • • •

One month is considered to be 4 weeks. For a daily regimen, a patient needs 28 doses per month (4 weeks x 7 days). For a 3 times per week regimen, a patient needs 12 doses per month (4 weeks x 3 doses per week). Multiply either 28 or 12 by the number of months in the phase to determine the total doses required.

For a daily regimen (1 month = 28 doses): 2 months = 56 doses 3 months = 84 doses 5 months = 140 doses 6 months = 168 doses

For a 3 times per week regimen (1 month = 12 doses): 4 months = 48 doses 5 months = 60 doses

Actually, a patient may require more than the stated number of months to take all the doses, as will happen, for example, when a patient on a daily regimen skips Sundays. National TB control programmes may define “daily” drug administration as only 6 days per week for directly observed regimens, for instance, because health facilities do not work on Sundays. Taking all 56 doses of a 2-month initial phase of treatment may then require 9–10 weeks, and this is acceptable. The phase is completed when the patient has taken all the doses for the phase.

Annex C: Schedule for follow-up sputum examinations (for pulmonary TB cases only) Months of treatment Treatment category Category I new smear-positive pulmonary

2 ●

5 ●

6 ●

[===== =====] [--------- ---------- ---------- ---------] [===== =====] [

]

Category II previously treated smearpositive pulmonary

● ●

●

[=========== =====] [--------- ---------- ---------- ---------- ---------]

Category III smear-negative pulmonary

[===== =====] [--------- ---------- ---------- ---------]

[========] Initial phase of treatment [--------------] Continuation phase of treatment (directly observed) [ ] Alternative continuation phase of treatment (HE self-administered) ● Follow-up sputum examination due during the last week of the month of treatment

Follow-up sputum examination for regimens with 6 months’ HE self-administered in the continuation phase

→ →

If sputum examination result is negative: Begin or complete continuation phase of treatment. If the sputum examination result is positive: At end of initial phase of treatment (Category I or II):

− − − − − − − − −

Extend the initial phase of treatment by 1 extra month. Review whether treatment has been irregular. If so, discuss with patient the importance of regular treatment. Adjust the schedule for follow-up sputum examination as shown on the next page.

At 5 months or later: Consider the case a treatment failure. Close the TB Treatment Card (Outcome = Treatment failure) and open a new TB Treatment Card (Type of patient = Treatment after failure). Begin Category II treatment (or Category IV if proven multidrug-resistant).

At end of initial phase of treatment for a smear-negative pulmonary case (Category III): Consider the case a treatment failure. Close the TB Treatment Card (Outcome = Treatment failure) and open a new TB Treatment Card (Type of patient = Other). Begin Category II treatment (or Category IV if proven multidrug-resistant).

Annex C, continued

Adjusted schedule for subsequent follow-up sputum examinations (after extra month of initial-phase drugs given) Months of treatment Treatment category Category I with extra month of initialphase drugs

2 ●

3 ●

5 ●

7 ●

[===== ====== =====] [--------- ---------- ---------- ---------] [ ====== =====] [===== ]

Category II with extra month of initialphase drugs

●

[=========== ====== =====] [--------- ---------- ---------- ---------- ---------]

Follow-up sputum examination for regimens with 6 months’ HE self-administered in the continuation phase

Annex D Checklist for Supervisory Visits to Health Facilities Providing TB Control Services Health facility .............................. District TB Coordinator................................... Health worker responsible for TB control .............................................. Date ............................ Review TB Treatment Cards for all current TB patients and those who recently completed treatment. Register all newly-detected cases. Update the District TB Register for other patients. Also check TB Treatment Cards: 1. Is each patient on the correct treatment regimen? 2. Are sputum examination results recorded correctly? 3. Do TB Treatment Cards indicate that all patients are receiving directly observed treatment? Is treatment regular and correctly recorded? 4. Are patients undergoing smear examination at 2 months (3 months if Category II)? 5. Are patients undergoing smear examination at 5 months and during the last month of treatment? 6. Are patients who are smear-positive at 2 months (at 3 months for Category II) receiving 1 more month of initial-phase drugs? 7. For each patient who has completed treatment, is the information on the TB Treatment Card sufficient to determine treatment outcome? Review Register of TB Suspects and/or TB Laboratory Register (if available): 1. Does the facility have a Register of TB Suspects? 2. If yes, are the results of sputum smear microscopy written in the Register of TB Suspects? 3. Is there only a reasonable delay between sending sputum to receiving microscopy results? 4. If the facility has both a Register of TB Suspects and a TB Laboratory Register in the facility, do the microscopy results recorded in them match? 5. Do results in the Register of TB Suspects match the results recorded on the TB Treatment Card? 6. Have all the smear-positive patients started treatment? Examine and ask about supplies. Is there: 1. An adequate supply of anti-TB drugs? Are anti-TB drugs well-maintained, not expired? Note quantities in stock: ………………………………………………. 2. An adequate supply of needles, syringes and diluent for injections? 3. A system for safe disposal of needles and syringes? 4. An adequate supply of co-trimoxazole for TB/HIV patients? 5. An adequate supply of sputum containers? Number in stock: ………………. 6. A sterilizer in good working condition (if required)? 7. An adequate supply of: – TB Treatment Cards? – Request for Sputum Examination Forms? – Tuberculosis Referral/Transfer Forms? Page 1 * Tick YES or NO for each question. Any NO answer indicates a problem that should be addressed. For each problem, investigate to determine causes of the problem and possible solutions. YES* NO*

YES

Annex D, continued Were there changes in staff responsible for TB case detection and treatment? Fill in the chart, Training Needs for TB Control, every 6 months. Ask whether health workers have any questions or problems. Notes:

Update the chart when there are changes.

YES

TS 1

TS 2

TS 3

Page 2

Annex D, continued Quarterly Ask the health worker responsible for TB control about recent monitoring results. Has the health worker calculated the following for appropriate quarters? If so, what are the results? 1. The total number of TB cases currently on treatment? 2. The proportion of outpatients aged 15 years and older who were identified as TB suspects? 3. The proportion of TB suspects tested who were sputum smear-positive? 4. The proportion of new sputum smear-positive TB cases that converted at 2 or 3 months (sputum conversion rate)? 5. The proportion of new sputum smear-positive cases that – were cured? – completed treatment? Look at the work environment. 1. Is there good ventilation in the waiting area, in patient care areas, and where treatment of TB patients is directly observed? 2. Is the patient flow arranged to minimize the time that TB suspects and TB patients are with or pass by other patients? 3. If there is a microscopy unit, does it have good air flow? Are the work area, slides, and supplies well organized and maintained? Observations from this supervisory visit: Write the figures below

YES

Describe problems identified during this visit:

Possible causes of the problems:

Actions and recommendations:

Page 3

Summary Worksheet: Indicators to monitor TB case detection and treatment Record time frame:a How to calculate (numerator / denominator) Number TB suspects identified Total outpatients aged 15 years and older = _____ Number TB suspects whose sputum was tested Number TB suspects identified = _____ Number smear-positive cases detected Number TB suspects whose sputum was tested = _____ previous quarter:

To monitor:

Measure these indicators:

Calculate and record result here:

TB case detection previous quarter:

Proportion of outpatients aged 15 years and older who were identified as TB suspects

(using data from Register of TB Suspects) previous quarter:

Proportion of TB suspects whose sputum was tested for TB

Proportion of TB suspects tested who were sputum smear-positive

= _____

71 quarter that ended 12 months ago: quarter that ended 12 months ago: quarter that ended 12 months ago:

Conversion rate: Proportion of new sputum smear-positive TB cases that converted at 2 or 3 months quarter that ended 3 months ago:

Number new smear-positive cases that converted at 2 or 3 months Number new smear-positive cases put on treatment

TB treatment

Treatment outcomes: Proportion of new sputum smear-positive cases that:

– were cured

Number new smear-positive cases cured Number new smear-positive cases put on treatment Number new smear-positive cases that completed treatment Number new smear-positive cases put on treatment Number new smear-positive cases that defaulted Number new smear-positive cases put on treatment

= _____

(using data from Register of TB Suspects and TB Treatment Cards)

– completed treatment

= _____

– defaulted

= _____

The time frame applies to the denominator. The persons in the numerator are part of this group.

Annex E

Annex F

Health worker

Update information every 6 months, or whenever there are changes in staff who perform TB case detection and treatment. Also update when staff receive training.

Date of Registration

District TB No.

Name

74 **Enter only one code:

*Enter the treatment category:

CAT I: New smear-positive case, or New case (seriously ill smear-negative or seriously ill EP), e.g. 2(HRZE)/4(HR)3

CAT II: Re-treatment, e.g. 2(HRZES)/1HRZE/5(HR)3E3

Annex G

CAT III: New case (smear-negative or EP), e.g. 2(HRZ)/4(HR) 3

DISTRICT TUBERCULOSIS REGISTER – RIGHT SIDE OF THE REGISTER BOOK Outcome of Treatment and Date †† End of treatment Date Result Lab No. Cure Failure Died Default Completed Transfer out

Results of Sputum Examination Date 5 months Result Lab No.

Before treatment Date Result Lab No.

2 or 3 months † Date Result Lab No.

Remarks

75 †† Enter date in the appropriate column: Cure……………Sputum smear-positive patient who is sputum smear-negative in the last month of treatment and on at least one previous occasion Treatment completed…….Patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure Treatment failure………… Patient who is sputum smear-positive at 5 months or later during treatment (also a patient who was initially smearnegative and became smear-positive at 2 months) Died……………Patient who dies for any reason during the course of treatment

† CAT I patients have follow-up sputum examination at 2 months; CAT II patients have follow-up sputum examination at 3 months.

Annex G

75 Default………...Patient whose treatment was interrupted for 2 consecutive months or more Transfer out… Patient who has been transferred to another recording and reporting unit and for whom treatment outcome is not known

Annex G

Annex G TUBERCULOSIS REFERRAL/TRANSFER FORM

(Complete top part in triplicate) Tick and comment to indicate the reason for this referral or transfer: ❒ Referral to register and begin TB treatment

❒

Referral for __________ ____________________ ____________________

❒

Transfer (registered patient is moving)

Name/address of referring/transferring facility_________________________________

________________________________________________________________ Name/address of facility to which patient is referred/transferred ______________________ ___________________________________________________________________ Name of patient __________________________ Age _______ Sex: M ❒ F ❒ Address (if moving, future address) _______________________________________

_________________________________________________________________ Name and address of contact person for patient _________________________________ ________________________________________________________________________ Diagnosis*_______________________________________________________ District TB No.* __________________ Date treatment started*____________________ Category of treatment:* ❒ CAT I New case, smear-positive ❒ CAT II Re-treatment ❒ CAT III New case, smear-negative or extrapulmonary ❒ CAT IV Chronic or MDR-TB Drugs patient is receiving ______________________________________________ ___________________________________________________________________ Remarks (e.g. side-effects observed) _____________________________________ ____________________________________________________________________

______________________________________________________________ Signature ___________________ Position _________ Date of referral/transfer_______ *Complete if known. If this is a referral for diagnosis, these items may be unknown.

For use by facility to which patient has been referred or transferred: Name of facility ______________________________________________ District __________________________ Date ____________________ Name of patient __________________________ District TB No. _______________ The above patient reported at this facility on ____________________(date) Signature __________________________ Position________________________ Send this part back to referring/transferring facility as soon as patient has reported.

Year _______________

Facility ________________________

Date

TB Suspect Number

Name of TB Suspect

Date Sputum Sent to Lab

Results of Sputum Examinations 1 2 3 TB Treatment Card Opened? (record date)

Observations/ Clinician’s Diagnosis

79 Annex G

WHO/HTM/TB/2005.347b

Management of Tuberculosis Training for District TB Coordinators

FABA DISTRICT

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Faba District Contents Page Description of Faba District.................................................................................................1 Faba District Plan of Action for TB Control for 2004 .........................................................7

FABA DISTRICT

Population of Faba District: 150 000 Population of Agraville: 45 000 1 cm _____ = 4 km = paved road = dirt road = private clinic

Ferro Health Post

Ferro River bed

Irini village

H* B* Bella Health Centre

High Road Health Post

Prison

A* Agraville

Agraville Hospital

G* Gadara Health Post

Denali Health Post

Cara Health Centre

Emeral Health Post

Health facility A*

Type MOH

Services provided

Outpatient load (2003) 52 800 21 100 16 000 8 000 6 000 4 000 8 000 6 000

TB cases (2003) 132 72 – 17 – – 12 7

Description of Faba District The year in Faba District For the purposes of this training course, the present year in Faba District is 2004. Faba District is currently implementing a District Plan of Action for TB Control developed in October 2003 for the year 2004. A copy of that District TB Plan is at the end of this module.

Geography, transportation, and population Faba District is generally a flat area with no mountains. There are some hills and a dry river bed (the Ferro River) in the northern part of the district. There is some bus transportation, but it is not frequent or reliable. Trucks travel along the paved roads and will carry passengers. The population of the district is about 150 000. Almost one third of the population (45 000) lives in the capital of the district, Agraville. There is not much migration in and out of the district. Nearby districts include Chalo District, Cipo District, Marina District, and Patanga District. In Faba District, the average number of visits for health care is estimated at 1 per person per year to public health facilities (150 000 visits) and 1 visit to private providers such as private physicians and clinics (150 000 visits). About half of the population of Faba District chooses to use private practitioners rather than public health services.

Past and current TB control efforts The district TB control programme was not very strong until a new District TB Coordinator (Dr Oke Karimi) was appointed in 2003. Dr Karimi reports to the provincial TB coordinator. Five years ago, there was some training in Faba District for health workers who had responsibilities related to TB control. After that training, there was just routine work with no push for improvements or expansion to additional health facilities. The provincial level now plans to conduct the training course Management of Tuberculosis: Training for Health Facility Staff twice a year (in February and July). Health workers from health facilities in Faba District and neighbouring districts can attend this course when recommended by their District TB Coordinator. Dr Karimi and his predecessors have maintained a District TB Register and submitted Quarterly Reports regularly for the past few years. Module K: District Tuberculosis Register shows complete registers for several quarters in Faba District. In October 2003, Dr Karimi did an assessment of the district TB control programme as a basis for planning. He found that TB control services were relatively good in Faba District, with about 80% sputum conversion among new sputum smear-positive TB cases registered in the 2nd quarter of 2003. However, he recognized that much of the population lacked convenient access to TB control services. Community TB treatment supporters were not

being used in Faba District. No promotional information about TB control services had been given to the community. Private practitioners had not been formally involved in TB control activities. Selected treatment outcome rates, calculated in October 2003 for the cohort of patients

registered in the 3rd quarter of 2002, were as follows: • • • • • • • Cure: 54% Completion: 18% Treatment success: 72% Default: 17% Died: 5% Failure: 3% Transfer out: 3%

Problems in Faba District in 2003 and earlier included: • • The proportion of new smear-positive cases that died was high (5%) because patients did not come for treatment until they were extremely sick. Except for patients who came to Agraville Hospital, only a small percentage of outpatients (1–2%) had sputum smear examinations. The average positivity rate for the district was about 10%; in other words, 10% of TB suspects tested were sputum smearpositive. In past years in Agraville Hospital, an average of 20 out of 120 beds per month were occupied by TB patients, because it was common to hospitalize patients who could not go for directly observed treatment (because of lack of access, lack of transport, etc.). The typical TB inpatient stayed 3 months, and approximately 80 patients were hospitalized per year. The hospital needed to empty the beds of the TB patients, who were possibly infectious and were often physically able and bored. This problem has been resolved, and now only a few beds are occupied by TB patients.

•

Agraville Hospital Agraville has a hospital with 120 beds as well as an outpatient department. The hospital is widely used. Of the total outpatients seen for any reason at public health facilities throughout the district, about half are seen at the hospital outpatient department. The outpatient department sees a total of about 200 patients per day for all causes, of whom: • • about 80 are children coming for paediatric care or immunizations, and about 120 are adults.

In 2003, the hospital identified about 80 TB suspects per month and detected about 11 TB cases per month, including 6 sputum smear-positive cases, 4 of whom were new cases. The hospital is currently providing TB control services according to the DOTS strategy, including providing directly observed treatment in the outpatient department.

Public health facilities outside Agraville There are 7 more public health facilities in the rest of the district outside Agraville, including 2 health centres and 5 smaller health posts. Of these 7 public health facilities, 4 are currently providing TB services. (See the map at the beginning of this module.) One is Bella Health Centre (with good road transport to Agraville Hospital), and 3 are health posts (Denali, Gadara, and High Road health posts). All of these facilities must send sputum samples to Agraville Hospital for examination by microscopy. While the hospital detected an average of 11 TB cases per month in 2003, the health facilities in the rest of the district detected a total of about 9 TB cases per month, including 7 sputum smear-positive cases, 6 of whom were new cases.

Summary of patient data In 2003, there were approximately 60 TB cases per quarter in Faba District, and a total of 240 TB cases during the year. Approximately 66% of the TB cases were sputum smear-positive. There were about 30 new sputum smear-positive cases per quarter, and 120 new smearpositive cases during the year; 120 new sputum smear-positive cases in Faba District’s population of 150 000 yields a reported incidence of 80 per 100 000. There were about 2 male TB cases for every female case. Most cases were aged 20–40 years, with the peak risk at 25–35 years; 8% of TB cases were aged less than 15 years.

TB treatment regimens and packaging In Faba District, anti-TB drugs are provided to health facilities in pre-packaged kits. There are two different types of pre-packaged kits of oral drugs. According to national policy, the same regimen is provided for Category I and Category III patients, and a different regimen is provided for Category II patients. Category I and III: Category II: 2(HRZE) / 4(HR)3 2(HRZE)S / 1(HRZE) / 5(HR)3E3

Treatment in the initial phase is 6 days a week, skipping Sundays. Treatment in the continuation phase is intermittent (3 times per week). A national drug resistance study has shown that MDR-TB is not a problem in the country.

The district health office The District Medical Officer (DMO) and the District TB Coordinator have offices near the hospital in the District Health Office building in Agraville. The district storeroom is also located in this building. The district storeroom receives drugs from the provincial warehouse and stores drugs and supplies for distribution to the hospital outpatient facility and to the

health centres and health posts throughout the district. (Drugs for hospital inpatients are stored separately at the hospital.) The District TB Coordinator must borrow a car from the DMO to do supervisory visits. An ambulance is available that can occasionally be used for communications or for transportation of drugs or sputum samples. The health facilities in Faba District have different ways of transporting drugs. For example, a nurse from one health centre may collect the drugs, while another facility may make use of the ambulance for drug deliveries. Although the transportation methods vary from one facility to another, they generally stay the same from one quarter to the next.

Laboratory support The laboratory at Agraville Hospital is currently the only public health facility in the district that does sputum smear miscroscopy. The microscopy unit at Agraville Hospital has one microscope, and there are two trained microscopists who perform multiple hospital laboratory functions. The more senior of these was recently appointed as district laboratory supervisor. The district laboratory supervisor does quality control, provides back-up, and performs other laboratory functions, so he will no longer read sputum smears. The other microscopist principally does sputum smears. There is one Tuberculosis Laboratory Register for the district, and it is kept at Agraville Hospital by the District Laboratory Supervisor. The hospital microscopy unit examines smears for the hospital outpatients and inpatients, as well as for other health facilities that send sputum samples. In 2003, there were about 130 TB suspects tested in the district per month. On average, there were about 24 sputum smears to be read per day (for diagnosis and follow-up). Private clinics in Faba District have laboratories that can do sputum smear microscopy, but they charge for their services and there is no quality control.

Non-public health facilities There is a prison near Agraville Hospital holding 70 people (all adult males). Dr Karimi suspects that, if there were a thorough screening of all prison staff and prisoners, and testing of those with cough, one would likely detect one or two sputum smear-positive TB cases. These must be treated to prevent spreading in close prison quarters. There are two private clinics in Agraville, one with 5 and one with 4 physicians. There are also 6 physicians working alone in private practice (some of whom also work in the public health service). In total, there are about 27 physicians working in the district. Near Bella Health Centre, the physician working in the health centre has set up a private practice with convenient afternoon and evening hours of 16:00–20:00. Private practitioners treat some TB cases, but neither the number nor the standard of care is known. 4

HIV infection and HIV testing in the district The level of HIV infection in the district is not known, but people are aware that it is a threat because some AIDS cases are seen. There have been some HIV-related deaths in TB patients. In neighbouring Patanga district, there is a public HIV testing site that also provides voluntary counselling. This site is 120 km away from Agraville, and it takes 3 hours to get there by bus. There is a private clinic in Agraville that will do HIV tests, but they are expensive. In Agraville Hospital, blood is tested to keep the blood supply safe. There is a newly appointed HIV coordinator in Faba District. One of the HIV coordinator’s first priorities is to establish a public HIV testing site in the district. A TB/HIV coordinating committee has been formed, including the District TB Coordinator, the HIV coordinator, and the DMO. Some plans of this committee are included in the District TB Plan for 2004 (see below).

Plans for 2004 The District TB Plan for 2004 (shown at the end of this module) is currently being implemented. It is the first plan that has been carefully developed for the TB control programme in Faba District. To maintain and improve the programme and address problems, the plan for 2004 includes, along with other activities: • Sending selected staff from Agraville Hospital, Bella Health Centre, and 3 health posts currently providing TB control services for training in TB case detection and treatment (Management of Tuberculosis: Training for Health Facility Staff); Initiating and encouraging use of community TB treatment supporters; Investigating the possibility of Cara Health Centre giving directly observed treatment to TB patients who live nearby but were detected by another health facility; Training staff at Bella Health Centre and 3 health posts to ask all adults about cough; Initiating use of the Register of TB Suspects in health facilities providing TB control services; Providing larger, reliable supplies of sputum containers to health facilities; Providing more frequent and reliable transport for sputum samples and test results (transport needed at least once per week from each facility to the microscopy unit at Agraville Hospital); Conducting regular monthly supervisory visits to health facilities providing TB control services.

• • • • • •

•

There are no plans to expand TB control services to additional public health facilities in Faba District in 2004. The TB/HIV coordinating committee plans to visit the public HIV testing site in the neighbouring Patanga District together. The District TB Plan for 2004 also includes meetings

of the committee to learn about plans for the district HIV programme and to discuss ways to collaborate. Collaboration will include ensuring that all TB patients are offered HIV testing. Later in 2004, the District TB Coordinator hopes to involve private practitioners at the private clinics in Agraville in screening adults (including people living with HIV/AIDS) for cough lasting 2 weeks or more and referring them for testing for TB.

STOP The complete District TB Plan for Faba District in 2004 is shown on the next pages. Your facilitator will introduce the plan to the group.

2004 District Plan of Action for TB Control for ________

25 October 2003 Name of District TB Coordinator:__________________ Oke Karimi Faba Name of district: ___________________ Date plan prepared:______________

Background information (e.g. monitoring and evaluation results that influenced this plan):

In the first 3 quarters of 2003, the ratio of TB suspects tested to outpatients was low, 1–2%. Through supervisory visits, it was found that some staff (at Bella Health Centre and the 3 health posts) do not know to ask all adults about cough; others do not like the extra work of collecting and sending sputum samples; and there are not enough sputum containers or reliable transport for the samples. Outside the hospital, staff tend to ask only the sicker patients about cough. The overall positivity rate for the district was about 10%.

8% of TB cases were aged less than 15 years, which is in the expected range; 66% of TB cases were sputum smear-positive.

The sputum conversion rate for cases registered in the 2nd quarter of 2003 was 80% (increased from 75% for cases registered in the 1st quarter).

Treatment outcomes for cases registered in the 3rd quarter of 2002 were as follows: Cure: 54% Completion: 18% Treatment success (cure + completion): 72% Died: 5% Default: 17% Failure: 3% Transfer out: 3%

There is a need to decrease the number of defaults and increase follow-up sputum examinations to prove cures.

Target for maintaining and improving TB control services:

85 4 the quarterly sputum conversion rate in the district will reach at least ____%. By the end of 200____,

Target for expanding TB control services (if appropriate):

Target not set for 2004. Will improve existing services in 2004.

By the end of 200__, __ out of ____ public health facilities in the district will provide TB services.

A. Who and with whom When a) monthly Resources Available Needed Human Financial Human Financial

Activities to maintain and improve TB control services:

State activities in each category specifically (including what, where, and how many):

9 9 9 9 9 9 – 9 9 9 9 9 9 9 9 9 9 – 9 9 9 9 9 9 9 9

cost of motorcycle?

b) Feb visits c) by end Feb d) 1 April

A1. Supervision a) Conduct monthly visits to each of 5 health facilities: Agraville Hospital, Bella Health Centre, and Gadara, High Road, and Denali health posts. b) Investigate options for community TB treatment supporters; discuss at health facilities. c) Visit Cara Health Centre to see if the nurse there might serve as a treatment supporter (i.e. not detect cases but give directly observed treatment). d) Initiate use of Register of TB Suspects at all facilities offering TB services. a) TB coord b)TB coord, facility staff c)TB coord, facility staff d) Facility staff a) TB coord b) 2–6 Feb c & d) March visits e) April f) by 15 April g) 5–9 July b) 5 health workers c) TB coord d) TB coord e) TB coord f) TB coord g) 2 health workers a) 6 Jan

US$ 720

A2. Training a) Confirm arrangements for 5 health workers (one from each facility offering TB services) to take February course in Management of TB organized by province. b) Health workers attend training course in “a” above. c) Train staff at Bella Health Centre and 3 health posts to ask about cough. d) Train additional staff as needed in use of Register of TB Suspects. e) Assist health facility staff with initial training of community TB treatment supporters. f) Arrange for additional health workers (estimate 2) to take July course in Management of TB organized by the province. g) Health workers attend training course in “f” above.

US$ 300

A3. Drugs and supplies a) Order anti-TB drugs for the district. Increase orders of sputum containers.

b) Order supply of Register of TB Suspects. c) Distribute drugs to 5 health facilities.

a) TB coord b) TB coord c) district storeroom officer a-d) TB coord, District lab. supervisor

a)1st week of each quarter b) 5 Jan c) 1st week of each quarter a) monthly b) quarterly c) July d) July

A4. Laboratory support a) Visit TB microscopy unit at hospital; review Tuberculosis Laboratory Register. b) Obtain summary laboratory reports (for quarterly monitoring). c) Investigate costs of using private laboratories for microscopy. d) Investigate costs of microscopes and availability of training for microscopists.

9 9 9 9

Plans to obtain additional resources, if needed: Meet with local businesses to discuss transportation needs for supervision, drugs, sputum samples, etc.

Activities to expand TB control services: None planned for 2004

C. Who and with whom When a) TB coord b) TB coord, DMO a) 3–14Oct b) 21 Oct

Activities to plan, monitor, and evaluate TB control services: Resources Available Needed Human Financial Human Financial

State activities in each category specifically (including what, where, and how many):

C1. Planning a) Develop District TB Plan. b) Present District TB Plan to DMO.

9 9 9 9

C2. Monitoring a) Complete 3 quarterly reports and analyse 6 indicators. a)TB coord a) 1st week of each quarter b) monthly

9 9 9 9

b) Monitor number of sputum smears being examined at Agraville Hospital. b) Distr. Lab. Supervisor c) TB coord d) TB coord c) At sup. visits d) monthly a) Jan 2004 b) 3–14 Oct

c) Monitor use of community TB treatment supporters (discussion, checking TB Treatment Cards). d) Monitor other activities planned; update calendar. C3. Evaluation a) Evaluate achievement of district targets for 2003. b) Assess quality and extent of TB services in the district in 2004 (first 3 quarters). a) TB coord. b) TB coord.

9 9

C4. Special studies (if appropriate)

None planned for 2004.

–

Plans to obtain additional resources, if needed:

Collaborative TB/HIV activities and other activities:

Other activities could include advocacy, coordination with other districts or organizations, attending meetings or conferences, etc.

State activities specifically (including what, where, and how many):

Who and with whom When a–b) TB coord, a–b) Feb DMO, HIV coord.

Resources Available Needed Human Financial Human Financial

D1. Collaborative TB/HIV activities a) Meet with TB/HIV coordinating committee to discuss plans, possibilities for collaboration. b) Visit public HIV testing site in Patanga District.

9 9

c) Meet with private clinic that does HIV tests; discuss screening for cough to identify and refer TB suspects, and possibly provide directly observed treatment. c) TB coord. c) mid-June

D2. Other activities a) Meet with local business association to discuss resources needed for transportation for supervision etc. (possibly a motorcycle). a) TB coord, Bus. Ass’n a) mid-Jan b) 6–7 Dec b) TB coord.

9 9

b) Attend provincial TB conference.

Plans to obtain additional resources, if needed:

Planning Chart: Schedule of district-level TB control activities* Feb March _______ _______ _______ _______ _______ _______ _______ _______ _______

1st quarter April June July Sept Oct Dec ______ _______

Jan

2nd quarter May

3rd quarter Aug

4th quarter Nov

________

_____ __

A. Activities to maintain/improve TB control services A1. Supervision a) Conduct monthly visits to each of 5 health facilities. (Week 2,Agraville Hospital; Week 3, Bella Health Centre and High Road health post; Week 4, Gadara and Denali health posts) b) Investigate options for treatment supporters; discuss at health facilities. c) Visit Cara Health Centre to see if the nurse there might serve as a treatment supporter (i.e. not detect cases but give directly observed treatment). d) Initiate use of Register of TB Suspects at all facilities offering TB services.

•

• ____ _____ _____

____

as needed

• ____

A2. Training a) Confirm arrangements for 5 health workers (one from each facility offering TB services) to take February course in Management of TB organized by province. b) Health workers attend training course in“a” above. c) Train staff at Bella Health Centre and 3 health posts to ask about cough. d) Train additional staff as needed in use of Register of TB Suspects. e) Assist health facility staff with initial training of community TB treatment supporters. f) Arrange for additional health workers (estimate 2) to take July course in Management of TB organized by province. g) Health workers attend training course in “f” above. A3. Drugs and supplies a) Order anti-TB drugs for the district. Increase orders of sputum containers. b) Order Register of TB Suspects. c) Distribute drugs to 5 health facilities.

• • • •

•

• •

•

• •

•

• • ___ ___

•

• •

•

B. Activities to expand TB control services– None planned for 2004

_____

C. Activities to plan, monitor, and evaluate TB control services C1. Planning a) Develop District TB Plan. b) Present District TB Plan to DMO.

•

____

•

C2. Monitoring ____ a) Complete 3 quarterly reports and analyse 6 indicators. b) Monitor number of sputum smears being • examined at Agraville Hospital. c) Monitor use of community TB treatment supporters (discussion, checking TB Treatment Cards). (Monitor at supervisory visits; see A1.a) d) Monitor other activities planned and update ____ calendar. ____ ____ ____ ____ ____ ____ ____ ____ ____

____

____ _____

C3. Evaluation a) Evaluate achievement of district targets for 2003. b) Assess quality and extent of TB services in the district in 2004 (first 3 quarters).

C4. Special studies (if appropriate)

None planned for 2004.

• • •

D. Collaborative TB/HIV activities and other activities D1. Collaborative TB/HIV activities a) Meet with TB/HIV coordinating committee to discuss plans, possibilities for collaboration. b) Visit HIV testing site in Patanga District. c) Meet with private clinic that does HIV tests; discuss screening for cough to identify and refer TB suspects, and possibly provide directly observed treatment.

D2. Other activities a) Meet with local business association to discuss resources needed (possibly a motorcycle). b) Attend provincial TB conference.

• __

*Numbers and letters of activities correspond

to those in the District Plan of Action for TB Control for 2004.

Jan March

Feb

April

May

June

July

Aug

Sept

Oct

Nov

Dec

WHO/HTM/TB/2005.347a

Management of Tuberculosis Training for District TB Coordinators

INTRODUCTION

World Health Organization Geneva 2005

Acknowledgements

Management of Tuberculosis Training for District TB Coordinators

Introduction Contents Page Importance of tuberculosis as a public health problem ..........................................................1 The DOTS strategy .................................................................................................................1 Role of the District TB Coordinator .......................................................................................2 Purpose of this training course................................................................................................3 Course methods and materials ................................................................................................4 Learning objectives.................................................................................................................5 How to work on a module.......................................................................................................7 Annex: TB forms used at health facilities...............................................................................9 Glossary ................................................................................................................................15 References.............................................................................................................................24

Introduction Importance of tuberculosis as a public health problem The World Health Organization (WHO) declared tuberculosis (TB) a global emergency in 1993 in recognition of the growing importance of TB as a public health problem. About one third of the world’s population is infected with Mycobacterium tuberculosis. Worldwide in 2002, there were about 8.8 million new cases of TB disease with 1.8 million deaths. M. tuberculosis kills more people than any other single infectious disease agent. Deaths from TB account for 25% of all avoidable deaths in developing countries. Some 95% of TB cases and 98% of TB deaths occur in developing countries. Of cases in developing countries, 75% are in the economically productive age group (15–50 years old). Once infected with M. tuberculosis, a person stays infected for life and may develop symptoms of TB disease at any time. However, among infected persons without human immunodeficiency virus (HIV), only 1 in 10 (10%) will develop TB; about 90% will remain healthy. The most important trigger for TB disease is weakening of the immune system. In this course, the terms “TB patients” and “TB cases” refer to patients in whom TB disease has been diagnosed. Without treatment, 50% of patients with pulmonary TB (and with no HIV infection) will die within 5 years, and 25% will remain sick with chronic, infectious TB. Another 25% will spontaneously recover and be healthy (because of strong immune defenses) but could become sick again at any time. Patients with weakened immune systems, such as those with HIV infection, are at greater risk of developing TB disease. Approximately one third of HIV-infected persons worldwide are also infected with M. tuberculosis. Of people infected with both HIV and M. tuberculosis, 50% will become sick with TB during their lifetime; 10% will become sick each year. Thus, the prevalence of HIV in a community has an important effect on the incidence of TB. TB can be cured in HIV-infected persons, although the chance of relapse or death is higher.

The DOTS strategy DOTS is the brand name of the internationally recommended strategy for TB control in response to the global TB emergency. DOTS has five key components:1 • • sustained political commitment to increase human and financial resources and make TB control a nationwide priority integral to the national health system; access to quality-assured TB sputum microscopy for case detection among persons presenting with, or found through screening to have, symptoms of TB (most importantly, prolonged cough);

An expanded description of these components is provided in the document titled An expanded DOTS framework for effective tuberculosis control. Geneva, World Health Organization, 2002 (WHO/CDS/TB/2002.297).

• • •

standardized short-course chemotherapy for all cases of TB under proper case management conditions, including direct observation of treatment; uninterrupted supply of quality-assured drugs; recording and reporting system enabling outcome assessment of all patients and assessment of overall programme performance.

This course will focus on aspects of the DOTS strategy that are carried out at the district level of a country’s TB control programme.

Role of the District TB Coordinator While the work of detecting and treating TB cases occurs at the health facility level, the District TB Coordinator is responsible for many activities that allow the health facilities to do their work, for example, supplying anti-TB drugs, training health workers, and ensuring laboratory support. The District TB Coordinator is responsible for planning, organizing, implementing, and evaluating activities of a district TB control programme. A district usually serves a population of 100 000 or more. TB control may be the individual’s primary responsibility, or TB may be just one of several areas of responsibility for disease control. Depending on the size of the district and the number of staff available, the District TB Coordinator may be one person or a team of people. If a district is large, one full-time person solely responsible for TB control, or a team approach, may be justified. In a small district, it may be a part-time responsibility to coordinate the TB control programme. For the purposes of this course, the person (or team) responsible for TB control at the district level is called the District TB Coordinator. The District TB Coordinator is usually a physician or a nurse. He or she works at the district health office and may also have clinical duties at the hospital. The job of District TB Coordinator is primarily administrative and managerial. Although the District TB Coordinator must be thoroughly familiar with clinical guidelines of the national TB control programme, he or she is primarily responsible for enabling and monitoring the implementation of these guidelines, rather than actually treating patients. The District TB Coordinator usually reports to the District Medical Officer (DMO) and is supervised by the Provincial TB Coordinator. The District TB Coordinator has no direct supervisory authority over health facility staff, but is responsible for overseeing their performance of tasks related to TB case detection and treatment. For example, the District TB Coordinator visits health facilities to observe performance, record cases in a District TB Register, make suggestions, solve problems, and provide training and support. Health facilities providing TB control services in a district may include public or non-public health centres, hospitals, dispensaries, or health posts. Throughout this course, the term “health facility” is used to include all types of health services that deliver outpatient care. In most countries TB control is part of general health-care delivery, and TB patients are received along with other types of patients. Improving TB case management is part of improving health care in general. 2

Purpose of this training course This course has been designed for District TB Coordinators. It teaches the skills and knowledge needed to plan, supervise, implement, monitor and evaluate the activities of a district TB control programme. The specific learning objectives of the course are listed on pages 5–6 of this module. This course does not teach the skills and knowledge needed to detect and treat cases of pulmonary TB at the health facility level. Those skills and knowledge are taught in another course, titled Management of Tuberculosis: Training for Health Facility Staff (WHO/CDS/TB/2003.314), available through WHO. This course for District TB Coordinators is designed to be entirely consistent with the course for health facility staff. In fact, District TB Coordinators may use Management of Tuberculosis: Training for Health Facility Staff as a resource for providing training in their districts. (See module D: Provide Training for TB Control.) This course will not teach medical procedures used by clinicians to diagnose TB, manage severe side-effects, treat TB patients who have defaulted, or treat patients with chronic or multidrug-resistant TB (MDR-TB). For information on these procedures, physicians and other clinicians should refer to WHO treatment guidelines and other appropriate references.1 It is expected that participants in this course will implement the managerial, supervisory, and administrative procedures taught. In order to implement these procedures, District TB Coordinators will need: • • • • • • a thorough understanding of the national TB control guidelines, microscopy support for examining sputum samples for TB, training support from the provincial level, a reliable source of anti-TB drugs and related supplies, standard TB forms such as the District TB Register and Quarterly Reports as required by the national TB control programme, resources for transportation (e.g. time, vehicle, fuel, per diem) to conduct supervisory visits to health facilities in the district.

TB treatment regimens vary from country to country. Each district should, of course, implement the standard regimens recommended in the national guidelines. The general managerial principles and practices taught in this course are applicable anywhere.

Course methods and materials This course uses a variety of instructional methods, including reading, written exercises, discussions, demonstrations, and observations in a real health facility. Practice, whether in written exercises or discussion, is considered a critical element of instruction. Many of the exercises in this course are related to an imaginary district, called Faba District, for which you will make decisions as though you were the District TB Coordinator. The complete training course includes the following modules (booklets). Modules C–J are instructional units that contain exercises; the other modules contain support materials such as a glossary, background information needed for exercises, and answer sheets. Depending on the structure of your course, you may have been given some or all of these modules: A: Introduction (includes a glossary with definitions of terms) B: Faba District C: Conduct Supervisory Visits for TB Control D: Provide Training for TB Control E: Manage Drugs and Supplies for TB Control F: Ensure Laboratory Support for TB Control G: Monitor and Evaluate TB Control H: Advocacy and Collaboration for TB Control I: Develop the District Plan of Action for TB Control J: Field Exercise – Supervisory Visit K: District Tuberculosis Register L: Tuberculosis Laboratory Register M: Answer Sheets

This course is designed for small groups of participants who are led and assisted by “facilitators” as they work through the course modules. The facilitators are not lecturers as in a traditional classroom. Their role is to answer questions, provide individual feedback on exercises, lead discussions, etc. For the most part, participants work at their own pace through the modules, although in some activities the small group works together. The modules may be used in several different ways: • • • • • • All of the modules may be completed in sequence without interruption, for example, in a 5-day training session. Selected modules may be used in a series of short training sessions, for example, one or two modules per month. Selected modules may be used in a training session to teach specific needed skills. Motivated individuals may work through modules on their own to teach themselves. Modules may be used as a reference.

Learning objectives Each module will provide information and examples and allow you to practise certain skills needed by a District TB Coordinator. Exercises are provided at the end of each module. The skills and information presented in the instructional modules (C–J) will prepare you to do the following tasks: C: Conduct Supervisory Visits for TB Control

• Make a schedule for supervisory visits to health facilities • Maintain the District TB Register: register patients who were detected recently at the health facility; at later supervisory visits, record their follow-up sputum examination results and finally their treatment outcomes • Determine whether smear-positive patients are converting by the end of the initial phase, and try to solve any problems with treatment • Review the Register of TB Suspects to identify any problems with case detection • Assess performance of TB case detection and treatment to identify problems; analyse causes and possible solutions • Promote the DOTS strategy and the TB control programme at health facilities • Identify training needs of health workers responsible for TB case detection and treatment • Write a brief report of a supervisory visit D: Provide Training for TB Control

• Recognize good training • Provide training for health facility staff to prepare them to identify TB suspects • Resolve problems due to lack of skill and knowledge through training E: Manage Drugs and Supplies for TB Control

• Calculate the quantity of anti-TB drugs to order for the district for a quarter • Calculate the quantity of sputum containers to order for the district for a quarter • Calculate quantities of anti-TB drugs to distribute to each health facility for a quarter • Calculate quantities of forms and registers needed for a year F: Ensure Laboratory Support for TB Control

• Assess health facilities’ access to a TB microscopy unit • Assess the TB microscopy workload and how it is distributed in the district • Determine whether there is a need to increase the capacity of the TB laboratory services • Review the Tuberculosis Laboratory Register and verify that all smear-positive cases are registered accurately in the District TB Register • Review the Tuberculosis Laboratory Register to identify problems • Check whether microscopists keep slides for quality assurance, have sufficient equipment, supplies and training 5

G: Monitor and Evaluate TB Control

• Monitor implementation of the District Plan of Action for TB Control • Complete the Quarterly Report on TB Case Registration • Complete the Quarterly Report on Sputum Conversion • Complete the Quarterly Report on Treatment Outcomes • Understand and apply principles of cohort analysis • Calculate and analyse five recommended district-level indicators • Identify causes and solutions of problems identified through monitoring • Evaluate achievement of annual targets for sputum conversion and expansion of TB control services H: Advocacy and Collaboration for TB Control

• Promote the DOTS strategy to non-public health facilities, and collaborate with them in TB control efforts • Promote the DOTS strategy to private physicians, physicians’ associations, and medical and nursing associations • Promote the DOTS strategy and TB control services to community organizations and their leaders • Collaborate with the HIV programme I: Develop the District Plan of Action for TB Control

• Assess the extent and quality of current TB control services • Plan to maintain and improve current TB control services • Set a sputum conversion target for the coming year • Determine whether to expand TB control services to more health facilities in the district • Set a target for expanding TB control services in the district • Specify activities in a District TB Plan J: Field Exercise – Supervisory Visit

• Complete the Checklist for Supervisory Visits while visiting a real health facility • Complete the chart, Training Needs for TB Control, for this health facility • Analyse a performance problem observed at the health facility The order of modules in the course has been carefully planned. You may wonder why module I, which teaches how to develop a District TB Plan, is presented towards the end of the course. One reason is that it is helpful to learn about the different activities described in earlier modules (supervision, training, managing drugs and supplies, etc.) before being asked to describe them in a plan. Another reason is that monitoring and evaluation provide the basis for a good plan; therefore, the module on monitoring and evaluation needs to precede the module on planning. An example of a District TB Plan is also presented early in the course, in module B: Faba District. 6

How to work on a module You will begin each module by reading it to yourself. When you come to a stop sign, such as the one below, follow the instructions given.

STOP Usually the instructions are to turn to an exercise in the back of the module and complete it. There may be several types of exercises in a module. The following pictures appear before exercises to show the type of work to be done:

This picture of a pencil indicates a written exercise. Write your answers directly in the module.

This picture of faces indicates a group discussion. Some questions are given to help you prepare for the discussion.

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GO BACK to page __, section __, and continue reading until the next stop sign.

At the end of each module you will find a summary of important points, followed by selfassessment questions that will allow you to check what you have learned from the module. The answers to self-assessment questions are given in the module so that you can check your own work.

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Annex: TB forms used at health facilities The forms in this annex are commonly used at the health facility level. These forms are mentioned occasionally in this course and so are presented here for your convenient reference. How to complete and use these forms is explained in detail in the course Management of Tuberculosis: Training for Health Facility Staff (WHO/CDS/TB/2003.314). The purpose of each form is described below: Request for Sputum Examination – This form is sent with sputum samples to the TB microscopy unit to request sputum examination. The results of microscopy are recorded on the form, which is then sent back to the health facility. Register of TB Suspects – This register (sometimes called a “cough register”) is used to record the name, age, sex, and address of every TB suspect identified at a health facility. When sputum samples are sent to the microscopy unit, and when results of sputum examinations are received, this information is also entered in the register. If a TB suspect is identified as a case, a TB Treatment Card is opened and the date recorded in the register. All subsequent information for that case is recorded on the TB Treatment Card. TB Treatment Card – This card is kept by the health facility (or treatment supporter) for every TB patient. It is used to record contact information, sputum examination results, diagnosis, treatment regimen, and administration of drugs throughout the initial and continuation phases of treatment. At the end of treatment a treatment outcome is recorded. Tuberculosis Referral/Transfer Form – This form is used to ensure continuation of appropriate treatment when a TB patient moves or is referred to a different health facility. One copy of this form is sent with a copy of the TB Treatment Card to the receiving health facility. Another copy is kept at the original health facility, and a third copy is given to the District TB Coordinator.

TB LABORATORY FORM REQUEST FOR SPUTUM EXAMINATION Name of health facility ____________________________ Name of patient ________________________________ Date _________________ Age ______ Sex: M F

Pulmonary

RESULTS (to be completed by Laboratory) Lab. Serial No. ____________________________ (a) Visual appearance of sputum: Mucopurulent (b) Microscopy: DATE SPECIMEN 1 2 3 RESULTS +++

Blood-stained

Saliva

POSITIVE (GRADING) ++ + scanty (1–9)

Date _______

Examined by (Signature) __________________________________

The completed form (with results) should be sent to the health facility and to the District Tuberculosis Unit.

Year _______________

Facility ________________________

Date

TB Suspect Number

Name of TB Suspect

Date Sputum Sent to Lab TB Treatment Card Opened? (record date)

Results of Sputum Examinations 1 2 3

Observations/ Clinician’s Diagnosis

TUBERCULOSIS REFERRAL/TRANSFER FORM (Complete top part in triplicate) Tick and comment to indicate the reason for this referral or transfer: Referral to register and begin TB treatment

Referral for __________ ____________________ ____________________

Transfer (registered patient is moving)

Name/address of referring/transferring facility_________________________________

Address (if moving, future address) _______________________________________

_________________________________________________________________ Name and address of contact person for patient _________________________________ ________________________________________________________________________ Diagnosis*_______________________________________________________ District TB No* __________________ Date treatment started*____________________ Category of treatment:* ❒ CAT I New case, smear-positive ❒ CAT II Re-treatment ❒ CAT III New case, smear-negative or extrapulmonary ❒ CAT IV Chronic or MDR-TB Drugs patient is receiving ______________________________________________ ___________________________________________________________________ Remarks (e.g. side-effects observed) _____________________________________ ____________________________________________________________________

For use by facility to which patient has been referred or transferred: Name of facility ______________________________________________ District __________________________ Date ____________________ Name of patient __________________________District TB No. _______________ The above patient reported at this facility on ____________________(date) Signature ___________________________Position________________________ Send this part back to referring/transferring facility as soon as patient has reported.

Glossary The definitions provided here refer to the use of terms in the content of this course and are not necessarily valid in other contexts. acid-fast bacilli (AFB) ....................................rod-shaped bacteria that hold stain colour even after washing with acid. Tubercle bacilli are acid-fast bacilli. adverse reaction ...................undesirable side-effect of a drug. advocacy ................................winning the support of key constituencies in order to influence policies and spending, and bring about social change. As used in this course, advocacy involves promoting and gaining support for the DOTS strategy and the TB control programme. Gaining support includes seeking political commitment and resources. AIDS ......................................acquired immunodeficiency syndrome. antiretroviral therapy (ART) ....................................treatment for HIV with a combination of drugs to improve the quality and duration of life for people living with HIV/AIDS. BCG .......................................bacille Calmette–Guérin, vaccine against tuberculosis that reduces risk of disease by 50–80% when given before infection. blister pack ...........................a special package in which tablets and/or capsules are sealed between a plastic layer and a paper or foil layer. Usually tablets/capsules for a certain time period (such as a day or a week) are sealed together in one package with directions for taking them printed on the paper or foil back. The tablets or capsules can be pushed out of the package one at a time, as needed. case of tuberculosis ..............a patient in whom tuberculosis has been bacteriologically confirmed or diagnosed by a clinician. checking question .................a question asked after giving instruction, intended to check the learner’s understanding, so that more information can be given if needed. chronic case ..........................a patient who is sputum-positive at the end of a re-treatment regimen. cohort ....................................a group of individuals considered together for the purposes of reporting, monitoring, or evaluation. As used in this course, a cohort is a group of TB cases who were registered in the District TB Register during the same quarter. collaboration .........................working together towards a common purpose. 15

compliance ............................following a rule or procedure as directed. For example, for a TB patient, compliance means taking anti-TB drugs as scheduled. contact ...................................see household contact. continuation phase ...............the phase of TB treatment after the initial phase. The continuation phase usually lasts 4–6 months, during which the TB patient takes fewer drugs either daily or intermittently. The continuation-phase regimen is intended to eliminate remaining tubercle bacilli and prevent relapse. conversion .............................changing from sputum smear-positive to sputum smearnegative. Sputum conversion is the best indicator that initialphase TB treatment has been effective. conversion rate .....................the proportion of new sputum smear-positive cases that are shown to be sputum smear-negative after 2 or 3 months of treatment. convert...................................to change from sputum smear-positive to sputum smear-negative. culture ...................................a method of diagnosis involving growing bacteria in a special medium conducive to their growth. cure (treatment outcome) ....a sputum smear-positive patient who is sputum smear-negative in the last month of treatment and on at least one previous occasion. daily treatment .....................as used in this course, treatment that is taken every day, or 6 days per week with a specific day off. default ..................................to stop TB treatment for 2 consecutive months or more. default (treatment outcome) ............a patient whose treatment was interrupted for 2 consecutive months or more. denominator .........................in a fraction, the number below the line. diagnostic sputum smear examination ..........................sputum smear examination done by microscope to diagnose pulmonary TB. died (treatment outcome) ............a patient who dies for any reason during the course of treatment. directly observed treatment...............................treatment observed by a health worker or a community TB treatment supporter. The health worker or community TB treatment supporter actually watches the TB patient swallow the drugs at every time that a dose is scheduled.

district storeroom .................site of storage of drugs and other supplies at the district level. The district storeroom receives supplies from the next higher level (such as the regional warehouse) and provides supplies for health facilities in the district. DMO ......................................district medical officer, the coordinator of public health activities in the district. DOTS.....................................the internationally recommended strategy for TB control. drug kit..................................a pre-packaged box or bag that contains all the anti-TB drugs for an entire treatment regimen for one TB patient. drug presentation .................the form in which a drug is made and its strength. For example, one presentation of HR is a tablet containing H 100 mg and R 150 mg. One drug presentation made for children is a tablet containing H 100 mg. drug resistance .....................adaptation of microorganisms so that they are not killed by a particular drug concentration that used to be effective. evaluate .................................to review a programme’s efforts and results at the end of a designated time period (such as a year), compare what was achieved with what was planned or expected, assess the current extent and quality of services, and identify the causes of any problems as well as reasons for success. expired...................................(in reference to a drug) past the date at which safety and effectiveness of the drug can be assured. Expired drugs may be unsafe or ineffective and should be destroyed or returned to the district level storeroom, or higher levels as appropriate. expiry date ............................the date on which a drug expires, or becomes possibly less safe and effective. extrapulmonary TB ............tuberculosis affecting organs other than the lungs, for example, lymph nodes, bones and joints, genitourinary tract, meninges, pleura, or intestines. fixed-dose combination (FDC) .....................................two or more drugs combined in one tablet, in specific dosages, to facilitate correct drug intake. follow-up sputum smear examination ..........................sputum smear examination done by microscope to assess progress of TB treatment or prove cure (also called “control”). genitourinary tract ...............genital and urinary organs. haemoptysis ..........................coughing up blood.

HIV ........................................human immunodeficiency virus. household contact ................someone who lives in the same dwelling with the TB patient (sleeps and eats at least one meal there per day). incidence ...............................the number of new cases of a disease occurring in a defined population during a given time period. indicator ................................a measurable number, proportion, percentage, ratio, or rate that suggests, or indicates, the extent of a programme’s achievement or the level of some condition among the population. initial phase ...........................the first phase of TB treatment, usually lasting 2–3 months, during which the TB patient takes an intensive drug regimen (4–5 drugs daily). During this phase, sputum conversion usually occurs and clinical symptoms improve. intermittently ........................as used in this course, 3 times per week. When treatment is taken intermittently, WHO recommends 3 times a week. Some countries use 2 times a week. interruption ..........................missing scheduled treatment for any length of time. If treatment is interrupted, health workers should make home visits to find the patient. If interruption lasts 2 months or longer, the patient is considered to have defaulted. job aid....................................a reference such as a checklist, chart, or poster that is used on the job to help a person do work correctly. kit ...........................................see drug kit. MDR-TB ...............................multidrug-resistant TB. Active tuberculosis with bacilli resistant to at least rifampicin and isoniazid. meninges ...............................the membranes that envelope the brain and spinal cord. microscopy ............................examination by means of a microscope. microscopy unit ....................as used in this course, a TB microscopy unit is a site with at least one microscope suitable for doing sputum smear examination for TB and at least one trained microscopist. monitor ..................................to watch closely or check on a regular basis. Mycobacterium tuberculosis ...........................tubercle bacillus, that is, the bacillus that causes tuberculosis. new (type of patient) ............a patient who has never had treatment for TB or who has taken anti-TB drugs for less than 1 month.

NGO ......................................nongovernmental organization. non-public health facilities ..all health-care facilities that are not managed by the government (e.g. private clinics), or that are managed by the government but not open to all of the public (e.g. prison or military health facilities). numerator .............................in a fraction, the number above the line. on-the-job training ...............training conducted in the workplace using real examples and carefully supervised practice in real work situations. other (type of patient) ..........all cases that do not meet the definitions of new, relapse, treatment after failure, treatment after default, or transfer in. percentage .............................a part of a whole expressed in hundredths. If 50% of a population is female, it means that 50 out of 100 people are female. The following examples show different ways of expressing the same meaning: 50% = 0.50 = 50/100; 4% = 0.04 = 4/100. performance-based training ..................................training that teaches skills and knowledge needed to perform specific tasks of a job. performance problem ..........a task that is performed incorrectly or not at all. A performance problem exists when there is difference between what should be done and what is actually done. A performance problem may be stated in terms of who is not doing what. pleura ....................................the membrane covering the lung and the wall of the chest cavity containing the lungs. PLWHA ................................people living with HIV/AIDS. positivity, positivity rate ........................the proportion of TB suspects tested who were sputum smearpositive. prevalence .............................the number of all cases of a disease existing in a defined population at a specific point in time or during a given time period. proportion .............................the relationship of a part to a whole, often written as a decimal fraction or percentage (for example, 0.17 or 17%). public health facilities ..........health care facilities that are managed by the government and open to all of the public. pulmonary TB ......................tuberculosis affecting the lungs.

pulmonary tuberculosis– sputum smear-positive (PTB+) ...................................1. two or more initial sputum smear examinations positive for acid-fast bacilli (AFB), or 2. one sputum smear examination positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis as determined by a clinician, or 3. one sputum smear examination positive for AFB plus sputum culture positive for Mycobacterium tuberculosis. pulmonary tuberculosis– sputum smear-negative (PTB–) ...................................a case of tuberculosis that does not meet the above definition for smear-positive tuberculosis. radiographic abnormalities ........................abnormalities that appear in X-rays. regional warehouse ..............site of storage of drugs and other supplies at the regional level. The regional warehouse receives supplies from the next higher level (such as the national warehouse) and sends supplies to storage sites at the next lower level of the public health system (the district storeroom). quarter ..................................a 3-month period of the year. For example, the 1st quarter of the year includes January, February, and March. quarterly ...............................once during every 3-month period. Monitoring of district level indicators is done quarterly. rate.........................................a measure of the frequency of some event in a defined population during a given time period, expressed, for example, as 1.5 per 100 000. Rates may also be expressed as decimal fractions (for example, 0.25) or as percentages (for example, 25%). ratio .......................................the relationship of one number to another, sometimes expressed with a colon between the numbers. For example, the ratio of TB suspects tested to adult outpatients could be expressed as 3:100. This ratio could also be expressed as 0.3 or 3%. In a ratio, the individuals to the left of the colon are not necessarily part of the group to the right of the colon. For example, the ratio of teachers to students at a school might be 1:15. referral ..................................sending a patient to another health facility or to a clinician. TB patients may be referred for diagnosis, initiation of treatment, or special care/hospitalization for complications, toxicity, etc. refresher training .................training intended to review skills or knowledge previously learned, but which have deteriorated over time.

regimen .................................a plan of treatment specifying which drugs are to be given and the dose, frequency, and duration of treatment with each drug. relapse (type of patient) .......a patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) tuberculosis. reserve stock .........................extra stock kept to ensure adequate supplies even if there is increased use or a delay in drug delivery. Reserve stock is kept at each health facility, district storeroom, regional warehouse, and national warehouse. safe injection .........................an injection that does not harm the recipient, does not expose the provider to any avoidable risk, and does not result in any waste that is dangerous for other people. safe injection practices.........practices that prevent the spread of infection by injection, such as use of a sterile needle and syringe for every injection. If disposable syringes and needles are used, safe injection practices include correct disposal of used needles and syringes. If reusable needles and syringes are used, they must be correctly sterilized. scanty.....................................result of examination of a sputum sample when fewer than 10 acid-fast bacilli are found while observing at least 100 microscopy fields. The absolute number of bacilli seen should be reported. side-effect ..............................a secondary and usually adverse effect of a treatment or drug. specimen ................................sample, a small amount (e.g. urine, sputum) to be tested. sputum...................................matter ejected from the lungs through the mouth. sputum smear microscopy ...........................examination of sputum with a microscope to determine whether acid-fast bacilli are present. sputum smear-negative cases .......................................pulmonary TB patients whose sputum does not contain enough tubercle bacilli to be detectable by microscopy. In consolidated data from TB control programmes, these also include cases with no information on smear results (i.e. all non smearpositive cases). sputum smear-positive cases .......................................pulmonary TB patients whose sputum contains tubercle bacilli that are detectable by microscopy.

standard regimen (for TB) .................................drug regimen selected by a country for treatment of a TB patient based on efficacy, cost, prevalence of drug resistance, state of development of the health services, and coverage of the population. The regimen specifies the anti-TB drugs, dosages of each anti-TB drug, frequency of intake, and duration of the regimen for each diagnostic category (that is, treatment category I, II, or III). The standard regimen should be given to all TB patients in the category unless there is a specific reason to change it, such as adverse reaction to one of the drugs. stock card ..............................a card kept with each drug and drug strength in the storeroom. The stock card is updated whenever drugs are received or dispensed, so that it always shows the actual balance in stock. target .....................................a specific goal to work towards, expressed as a number, proportion, percentage, or rate. A target should include a date, location (e.g. the district), and measurable level to be achieved. TB suspect .............................any person who presents with symptoms or signs suggestive of tuberculosis, in particular, cough of long duration (2 weeks or more). transfer ..................................as used in this course, to change a TB patient’s treatment facility when that patient moves. A patient may transfer to another health facility within the district or to another district (see transfer in below). transfer in (type of patient) ....................a patient who has been transferred from another TB register to continue treatment. In the District TB Register, this is a patient transferred from another district to continue treatment. In records kept at the health facility level, a “transfer in” may come from another facility within the district or from outside the district. transfer out (treatment outcome) ............a patient who has been transferred to another recording and reporting unit and for whom the treatment outcome is not known. treatment after default (type of patient) ....................a patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more. treatment after failure (type of patient) ....................a patient who is started on a re-treatment regimen after having failed previous treatment.

treatment completed (treatment outcome) ............a patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure. treatment failure (treatment outcome) ............a patient who is sputum smear-positive at 5 months or later during treatment. Also an initially sputum smear-negative patient who becomes sputum smear-positive at 2 months. treatment success .................an indicator calculated by adding the number or proportion of patients cured to those who completed treatment. treatment supporter .............a trained and supervised community member who directly observes a TB patient’s treatment. When it is not convenient for a patient to visit the health facility during regular hours, a community TB treatment supporter may be selected and trained to directly observe a patient’s treatment at a more convenient place and time. tubercle bacilli ......................rod-shaped bacteria that cause tuberculosis (Mycobacterium tuberculosis). tuberculin test .......................Mantoux test, that is, intradermal injection of 0.1 ml of tuberculin (protein extracted from TB bacilli). The test indicates TB infection but not disease. In an individual infected with TB, a thickening (induration) of the skin can be observed at the injection site in 48–72 hours. tuberculosis (TB) ..................a disease caused by the organism Mycobacterium tuberculosis. Not everyone infected with M. tuberculosis develops symptoms of TB disease, which may include cough, haemoptysis, chest pain, weight loss, and tiredness (in pulmonary TB). In this course, TB refers to TB disease rather than the infection without disease. VCT .......................................voluntary counselling and testing for HIV infection.

References The following documents are referred to in this course: An expanded DOTS framework for effective tuberculosis control. Geneva, World Health Organization, 2002 (WHO/CDS/TB/2002.297). Crofton J, Horne N, Miller F. Clinical tuberculosis, 2nd ed. London, Macmillan Education Limited, 1999. Frieden T, ed. Toman’s tuberculosis. Case detection, treatment, and monitoring: questions and answers, 2nd ed. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.334). How to organize training for health facility staff on TB control. Geneva, World Health Organization, 2004 (WHO/CDS/TB/2004.332). Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization, 2004 (WHO/HTM/TB/2004.330; WHO/HTM/HIV/2004.1). Management of tuberculosis: training for health facility staff. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.314). Public-private mix for DOTS, practical tools to help with implementation. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.325). TB Advocacy–A Practical Guide. Geneva, World Health Organization, 1999 (WHO/TB/98.239). Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.313). Web sites that may be useful to course participants include: www.who.int/tb/en www.stoptb.org www.iuatld.org

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 31 décembre 2005

Source Organisation mondiale de la santé