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  • Flow of DS-TB Drugs in NTEP

    Content

    Drug-Susceptible Tuberculosis (DS-TB) drugs are available as Fixed Dose Combination. The treatment duration is generally 6-8 months. Weight-band-wise monthly strips are issued to the patient.

    There is a significant difference between the flow of DS-TB drugs and Drug-Resistant Tuberculosis (DR-TB) drugs under the National TB Elimination Program (NTEP).  The process of DS-TB drug flow in NTEP is explained below:

    • There is a centralised procurement mechanism under NTEP where the Central TB Division (CTD) procures drugs for all states at the central level and supplies the same to Central Medical Services Society (CMSS)/ Government Medical Stores Depots (GMSDs).
    • The GMSDs/ CMSS then dispatch the DS-TB drugs to State Drug Stores (SDSs) or districts based on the quarterly reports submitted to CTD through Ni-kshay Aushadhi.
    • The replenishment of DS-TB drugs from CTD to SDSs through Release Orders (RO) takes around 15-20 days.
    • The districts transfer the drugs to the Tuberculosis Units (TUs), which in turn supply them to the Peripheral Health Institutes (PHIs), who then issue them to the patients.

     

    Figure: Flowchart depicting the flow of DS-TB drugs

    DS-TB Drug Distribution Management

    • This whole process of drug distribution is carried out through a well-defined transportation mechanism/ Third-Party Logistics (3PL).
    • In case of critical situations, provision to issue the drugs directly to the districts is also available.
    • The SDS/ districts should follow up with the GMSDs/ CMSS in case of delay in receipt of drugs after receipt of the RO from the CTD.
    • The SDSs should have at least a reserve stock of 3 months of consumption of DS-TB drugs in the state at the beginning of the quarter.
    • To ensure sufficient stock of all drugs, as per stocking norms, at Peripheral Health Institution (PHI)/ Tuberculosis Unit (TU), District TB Centre (DTC) also need to have a reserve stock of three months of DS-TB drugs at the beginning of the quarter.
    • Once SDS receives the reports from DTCs through Ni-kshay Aushadhi, it takes around 10 days for SDS to process the requirement (from all districts).

     

    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    

    How many days does it take to replenish DS-TB drugs from CTD to SDSs through Release Orders?

    3-5 days

    5-7 days

    7-10 days

    15-20 days

    4

    The replenishment of drugs from CTD to SDSs through Release Orders takes around 15-20 days.

        

       Yes

     Yes

  • Flow of DR-TB Drugs in NTEP

    Content

    The DR-TB drugs are the Second Line Drugs (SLD) prescribed to the TB patients based on resistance pattern. The treatment duration varies from 9-20 months depending on the regimen being administered. These drugs are supplied as monthly Patient Wise Boxes (PWB) of Type A and Type B .The Type A boxes contains drugs that are common in Intensive Phase (IP) and Continuation Phase (CP) and Type B box contains drugs that are given only during the IP. 

    The Flow of DR-TB Drugs in NTEP

     

     

    Figure: Flow of DR-TB Drugs in NTEP

    • The centralized procurement agency supplies loose form of SLD to the Government Medical Store Depot (GMSD)/Central Medical Services Society (CMSS).
    • The GMSD/CMSS then transports the drugs to the various State Drug Stores (SDS) as loose drugs.
    • In some special situations the GMSD directly sends the DR TB drugs to the District Drug Stores (DDS).
    • At the SDS /DDS (as the case may be), the loose drugs are packed into standardized monthly PWBs of Type A ,Type B for various regimes and supplied to the Nodal/District DR TB Centre (N/DDR-TBC) ----> Tuberculosis Units(TUs) ---->  Health Facilities (HFs), each quarter.
    • The patients are issued 1 monthly PWBs which should be handed over by the Senior Treatment Supervisor (STS) to the treatment supporter who is identified in consultation with the patient and provider.
    • SDS shall also supply an additional loose quantity of SLD to the districts for special situations like modification of regimen/ extension of intensive phase etc.

    DR-TB Drug Distribution Management

    The whole process of drug distribution is carried out through a well-defined transportation mechanism/ Third-party Logistics (3PL). The SDS/ districts should follow up with the GMSDs/ CMSS in case of delay in receipt of drugs after receipt of the release order from the CTD. Once the reports are received by SDS from DTCs through Nikshay Aushadhi, it takes around 10 days for SDS to process the requirement (from all districts). All stocking points need to maintain a reserve stock of Type A and Type B PWBs except in case of HFs,  where in only those HF's  where patients are 'initiated' OR are 'on treatment'  for DR TB shall maintain a reserve stock of SLD.

    Resources

     

    Assessment

    Question    

    Answer 1    

    Answer 2    

    Answer 3    

    Answer 4    

    Correct answer    

    Correct explanation    

    Page id    

    Part of Pre-test    

    Part of Post-test    

    Which form of DR-TB drugs is supplied to the State/ SDS?

    Patient-wise box

    Loose

    Both of the above

    None of the above

    2

    The State/ SDS is supplied only the loose form of DR-TB drugs.

        

       Yes

     Yes

  • Flow of Bdq in NTEP

    Content

    Bedaquiline (Bdq) is a group A second line drug supplied as a jar containing 188 tablets having dosage strength of 100mg with 24 months of shelf life. The jar contains the dosages for entire 6 month of treatment duration.

    Flow of Bedaquiline (Bdq) drug in NTEP

    Figure: Flowchart depicting the drug flow of Bedaquiline

    • The Bdq drug is procured centrally and supplied to the Government Medical Store Depot (GMSD)/Central Medical Services Society (CMSS).
    • Based on  the report from the Ni-kshay Aushadhi, Central TB Division (CTD) prepares the Release Order (RO) following which the drugs are supplied to the respective State Drug Stores (SDS).
    • In case of Bedaquiline (Bdq), the drug is dispatched from the SDS to the Nodal/ District Drug-resistant TB Centre (N/DDR TBC) as the patients on Bdq are initiated on treatment at the N/DDR-TBC only.
    • Patients initiated on Bedaquiline (Bdq) treatment at the N/DDR-TBC are provided with the bottle containing Bdq during discharge which is then handed over to the treatment supporter under the supervision of the senior DR-TB/ TB-HIV supervisor.
    • Until the patient completes the Bdq treatment course, the bottle containing Bdq should be in the custody of the treatment supporter.
    • Once the bottle containing Bdq is issued to the patients/ treatment supporter at the N/DDR-TBC, their prescription should be uploaded on the Nikshay Aushadhi and the Senior DR-TB HIV supervisor should inform the storekeeper at the District Drug Store (DDS) about the same.
    • This information should also be entered into the stock register at the DDS, which will help the system to keep track of Bdq inventory.

     

    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    

    Bdq bottle is to be kept under the custody of the patient until the end of the course.

    True

    False

    		    

    2

    Bdq bottle is to be kept under the custody of the patient’s treatment supporter until the end of the course.

        

    Yes

    Yes

  • Flow of Dlm in NTEP

    Content
    • Delamanid (Dlm) is  a second line anti TB drug for Drug Resistant (DR) TB patients, supplied in the form of strips containing 8 tablets having dosage strength of 50mg with 60 months of shelf life. According to National TB Elimination Program (NTEP) guidelines, total 84 strips of Dlm tablets (672 tablets) are required to complete a full course for a patient (i.e, 100mg BD daily dosage) for 6 months of Intensive Phase (IP).
    • During the first 5 months, the patient will receive 120 tablets of Dlm each month (15 strips) and in the 6th month, the patient will receive only 72 tablets (9 strips) as Dlm is given only for 24 weeks.

    Flow of Delamanid under NTEP

     

    Figure: Flowchart depicting Drug-flow of Delamanid

    • The Dlm drug is procured centrally and supplied to the Government Medical Store Depot (GMSD)/Central Medical Services Society (CMSS).
    • Based on the reports from the Ni-kshay Aushadhi, Central TB Division (CTD) prepares the Release Order (RO) following which the drugs are supplied to the respective State Drug Stores (SDS).
    • In case of Dlm, the drug is dispatched from the SDS to the Nodal/ District Drug-resistant TB Centre (N/DDR TBC) as the patients should be initiated on Dlm,  preferably in an in-patient setting for a period of two weeks (15 days) in order to observe for tolerance of the patients to the regimen.
    • Upon discharge from the N/DDR TBC, patients initiated on Dlm are issued the Dlm strips for the rest of the first month which is handed over to the treatment supporter under the supervision of the senior DR-TB/ TB-HIV supervisor.
    • Post discharge, the Dlm drugs are directly supplied from the SDS to the respective DDS of the district where the patient will be continuing further 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    

    Where is the Dlm drug dispatched once the patient is discharged from the N/DDR TBC?

    Tuberculosis Unit (TU)

    Peripheral Health Institute (PHI)

    District Drug Stores (DDS)

    Nodal DR TB Centre (NDR-TBC)

    3

    Delamanid stock will be issued by the SDS directly to the respective DDS in the district from where the patient will be continuing further treatment.

        

       Yes

     Yes

  • Flow of CB-NAAT Cartridges/TrueNat chips in NTEP

    Content

    Cartridge-based Nucleic Acid Amplification Testing (CBNAAT) cartridges and Truenat chips are used in the molecular test for TB diagnosis.

    • It not only detects TB bacteria but also Rifampicin resistance.
    • These are procured at the central level and supplied to states/ districts/ Nucleic Acid Amplification Testing (NAAT) sites based on their requirements.
    • Recently, it has been decentralised and states are procuring through Government eMarketplace (GeM).  

    For procurement of diagnostics at the state level, the states are authorised to establish rate contracts at the beginning of each financial year for up to 25% of the annual requirement of CBNAAT/ Truenat machines and cartridges/ chips, using funds available through the “Free diagnostics” and “Free drugs” initiative.

     

    Flow of CBNAAT cartridges/ Truenat chips in National TB Elimination Programme (NTEP)

           

    Figure: Flowchart showing the Flow of CBNAAT Cartridges/ Truenat Chips in NTEP

     

    The procurement of cartridges and chips is based on

    • Stock availability
    • Consumption
    • Expected case load

     

    It should be recorded, reported and monitored through the Ni-kshay Aushadhi in real-time.

    The storekeeper of State Drug Stores (SDS)/ District Drug Store (DDS) is responsible for dispatching the cartridges/ chips to the NAAT site.

    The NAAT site in charge will send a monthly utilisation report to SDS/ DDS. The SDS will further share quarterly utilisation to the central level through Ni-kshay Aushadhi.        

     

    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    

    Who is responsible for dispatching the cartridges/ chips to the NAAT site?

    Storekeeper of SDS/ DDS

    PPM Co-ordinator

    Laboratory Technician

     DR-TB Counsellor

        1

    The storekeeper of State Drug Stores (SDS)/ District Drug Store (DDS) is responsible for dispatching the cartridges/ chips to the NAAT site.

        

       Yes

     Yes