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  • TB Treatment Adherence

    Content

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

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

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


     

  • Importance of Treatment adherence

    Content

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

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

     

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


     

  • Recording and Monitoring Adherence

    Content

    Recording of Treatment Adherence can be done as

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

     

    Monitoring Treatment Adherence:

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

     

    Figure: Sample Nikshay Adherence Calendar in web and Mobile App

     

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

    Figure: DSTB Treatment Card (Paper)
     

  • Digital Adherence Monitoring Technologies

    Content

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

    Figure: 99 DOTS Envelope

     

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

     

    Figure: MERM Box

     


     

  • Directly Observed Treatment

    Content

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

     

  • Treatment Support

    Content

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

     

    Figure: Key Components of Treatment Support

     

    Resources

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

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

     

    Assessment

    Question​ 

    Answer 1​ 

    Answer 2​ 

    Answer 3​ 

    Answer 4​ 

    Correct answer​ 

    Correct explanation​ 

    DOT is the only treatment support provided to TB patients.

    True

    False

     

     

    2

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

     

  • Treatment supporter to TB Patient

    Content

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

     

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

     

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


     

  • Assigning a TS

    Content

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

    How to identify a Treatment supporter for a patient 

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

    Assigning a Treatment Supporter to a Patient 

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

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

    NOTE:

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

     

    Steps to assign a Treatment Supporter

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

    AssignTrSuppNi-kshay

    Figure: Screenshot Assigning a Treatment Supporter in Ni-kshay

     

    Resources

     

    Assessment

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

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

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

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

  • Recording manual doses in Nikshay

    Content

    Manual recording of Adherence in Nikshay:

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

    Figure: Steps to record manual dose in Nikshay

     

    Recording in Patient Treatment Card:

     

    Figure: Filled Treatment card for TB Patient

     


     

  • Adherence Summary Dashboard

    Content

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

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

    879 (1)

     

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

     

    879 (2)

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

    879 (3)

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

    879 (4)

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

    This dashboard provides a summary of the following:

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

    Resources

    Assessment

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