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  • 99 DOTS- Envelopes

    Content

     

    The 99DOTS product consists of customised envelopes (see Figure 1) that fit around the tuberculosis medication blister pack distributed to patients. 

    Figure 1: 99DOTS Envelope

     

    Universal Envelopes (Figure 2): Each adult patient gets the same sleeve, regardless of their weight band.

    These are new envelopes that are currently being introduced by the program. Weight band wise envelopes will be used while the stock lasts, but new requirements by the state will be fulfilled by providing universal envelopes.

    There are 2 types of these envelopes: 1 envelope for IP: Intensive Phase, and 1 envelope for CP: Continuation Phase, for both Macleods and Lupin Fixed-dose Combinations (FDCs). These envelopes are only to be used for adult patients on anti-TB treatment using FDCs.

    Figure 3: Universal 99DOTS Envelopes

    Using the Universal Envelope

    • The counsellor/ pharmacist/ treatment supporter write the number of pills per day the patient should take on the envelope.
    • Every day, the patient will take the prescribed number of pills and reveal 1, 2, or 3 hidden phone numbers. The patient calls any one of the numbers they reveal that day.
    • The patient should start at pill 1 and move in sequence (1,2,3…28), completing each column, and starting from the top of each row.
    • The district should always have sufficient stock, which can be calculated as:
      • Number of IP strips = Number of IP envelopes + some buffer
      • Number of CP strips = Number of CP envelopes + some buffer

    Advantages of the Universal Envelopes

    • There is no need to estimate the requirements of weight band wise envelopes.
    • Less space is required to store the envelopes.
    • Stock-outs of envelopes for a particular weight band will not occur.
    • It is easy for patients to follow the top to down arrow mark pattern while dispensing and ingesting medicines.
    • Counselling time and dispensing time by pharmacists reduce per patient, thus increasing efficiency.

    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 of the following is correct about 99DOTS envelopes? The envelopes have medicine inside them. The envelopes have hidden numbers that can be called by the patient. There are weight-band wise envelopes. All of the above 4 99DOTS envelopes have anti-TB medicines with hidden toll-free numbers that patients call. These envelopes can be weight-band wise or universal envelopes.      
    For weight-band wise 99DOTS envelopes, background colours differ for each weight band. True False     1 For weight-band wise 99DOTS envelopes, background colours differ for each weight band.      

     

     

  • 99 DOTS- Envelope Dispensing Process

    Content

    The 99DOTS (Directly Observed Treatment, Short-course) universal envelope is developed to avoid the complexity of weight band wise 99DOTS envelope.

    The overall dispensing process is easy and can be divided into these steps:

    1. The patient consumes 2, 3, 4, or 5 pills per day, as per the doctor's prescription.
    2. One or more toll-free numbers can be seen behind the pill flap after taking out the pills every day.
    3. The patient takes the pill.
    4. The patient calls any one of the toll-free numbers seen on that day.

    This call will be recorded as a consumed dose for the day.

    The dispensing process is outlined in the figure below.

     

    Figure: 99DOTS Universal envelope dispensing process

     

    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 of the following is the 99DOTS universal envelope dispensing process?

    The patient calls the number on the envelope to ask for medicines.

    Pharmacist/ treatment supporter fills the number of pills to be taken – Patient opens the pill flap, takes the pills, and reveals the hidden number – Patient calls the toll-free number.

    The treatment supporter calls the medical officer to know how many pills to fill on the envelope – The pharmacist opens the pill flap to check that the medicine is in place.

    All of the above

    2

    The 99DOTS universal envelope dispensing process is: Pharmacist/ treatment supporter fills the number of pills to be taken – Patient opens the pill flap, takes the pills, and reveals the hidden number – Patient calls the toll-free number.

     

    		    

     

     

     

  • 99 DOTS- Initiating adherence monitoring of the patient

    Content

    Initiating adherence monitoring of the patient on 99DOTS (Directly Observed Treatment, Short-course) on Nikshay is done by the STS/ Health care provider initiating patient on treatment. 

    Registering a Patient

    It is the responsibility of the STS/ Health care provider initiating patient on treatment to register the patient on the Nikshay . S/he has to make sure to enter all the phone numbers of the patient and to keep them updated. They also add the complete address where the patient is currently residing, entering a landmark in the address field, if possible.

    Before adherence monitoring can be initiated on Nikshay, the patient’s status must show that they have positive test results and have started treatment on Nikshay. After entering a positive test result for a patient, treatment is started from the “Treatment Details” tab by clicking the “Start Treatment” button, as shown in Figure 1.

    Figure 1: Starting Treatment on Nikshay

     

    How to Select 99DOTS as the Adherence Technology?

    1. After entering the test details of the patient, click on the “Treatment Details” tab. 
    2. Under the “Adherence Monitoring” option, select “99DOTS” as the adherence technology and click “Start Treatment" (Figure 2).
    3. Once you click “Start Treatment” you will be able to see the adherence calendar of the patient under the “Adherence Tab”.

     

    Counselling Information to be given to the Patient when Initiating 99DOTS

    The counselling checklist to be followed by the National TB Elimination Programme (NTEP) staff when initiating patients on 99DOTS is shown in the table below.

     

    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​

    What is the correct sequence for initiating 99DOTS adherence for a patient on Nikshay?

    For 99DOTS, there is no need to register the patient on Nikshay.

    Register the patient – Select adherence details – Enter the test results – Enter treatment details.

    Register patient name, phone number and address – Add test details – Start treatment – Select 99DOTS as the adherence mechanism – Click ‘Start treatment’ to view the adherence calendar.

    None of the above

    3

    The correct sequence for initiating 99DOTS adherence for a patient on Nikshay is: Register patient name, phone number and address – Add test details – Start treatment – Select 99DOTS as the adherence mechanism – Click ‘Start treatment’ to view the adherence calendar.

    ​

    Yes

    Yes

     

     

  • 99 DOTS- Self Reporting Adherence

    Content

     

     

    Self-reporting adherence by dispensing pills and calling toll-free numbers

    When patients dispense pills, they break through perforated flaps on the back of the envelope, revealing a hidden, unpredictable phone number.

    Patients use an ordinary phone (usually their own or a relative’s) to place a free call to this number, which a computer answers, says “Thank You”, and hangs up.

    Important information to tell patients about calling the toll-free number:

    • Make a free call (from a mobile or landline phone) on any one of the toll-free numbers revealed every day.
    • Don’t add ‘0’ or ’91’ before the toll-free number.
    • The call can be made with no balance and from any city and anytime (no roaming charges).
    • A call for a day’s medication must be made on the same day.
    • Make calls only from the phone (mobile/ landline) numbers given to the centre (and registered on Nikshay).
    • Do not cut the call till you hear “Thank You”.

    From this simple interaction — the combination of the patient’s registered caller ID on Nikshay and the sequence of unpredictable numbers that they call over time — healthcare workers can monitor when pills were dispensed and likely taken.

    In addition to this mechanism for self-reporting adherence, 99DOTS also supplies supporting Information, Communication and Technology (ICT) tools (Nikshay, 99DOTS platform) for health workers, enabling them to efficiently monitor and respond to any missed doses.

    If a patient does not call 99DOTS on any given day, they receive an escalating series of dosage reminders. First, an automated SMS message is sent. If additional doses are missed, the patient can expect a personal outreach from a health worker, either via a phone call or a home visit.

     

    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​

    99DOTS is a digital adherence technology that allows for self-reporting adherence by the patient.

    True

    False

     

     

    1

    99DOTS is a digital adherence technology that allows for self-reporting adherence by the patient.

     

    		    

     

     

     

  • 99 DOTS- Troubleshooting

    Content

    Whenever a patient calls a toll-free line on the 99DOTS (Directly Observed Treatment, Short Course) envelope, they should have the following experience:

    • The call is answered immediately.
    • A brief "thank you" message is played.
    • The call hangs up automatically.

    In total, the call is less than two seconds long. After this sequence, the Nikshay adherence dashboard will be updated with the adherence details.

    Patients may sometimes face issues with the toll-free lines. In such cases, the healthcare worker must try to understand the challenge and help the patient to resolve the issue. The table below shows common issues with the toll-free lines and their solutions.

    Issues

    Solutions

    The patient dials the toll-free number and hears “Thank You”, but the Nikshay dashboard is still showing red.
    • Ask the patient to give a missed call to your phone. Check that it is the same number that is registered in Nikshay. If there is a data entry error in the registered phone number, correct the number in Nikshay.
    • The patient might also have a dual SIM phone or another alternative phone number. If another number is being used by the patient, add the number in Nikshay.

    The patient dials the toll-free number but hears an out-of-service voice message.
    • Visit the patient and check the balance in the pre-paid phone connection.
    • If it is negative, the call cannot be made.
    • The call can be made with zero or more balance in pre-paid connections.
    • In post-paid connections, if the bill is not paid, the patient cannot dial the toll-free number.

    The patient dials the toll-free number but hears “Please check the number”, “Invalid number”, or “Number not in use” voice messages.
    • Ask the patient to dial the number.
    • Check that they are dialling the entire number, without adding ‘0’, ‘91’, or ‘+91’ and they should not cut the call till they hear “Thank You”.

    The patient says that their pre-paid balance is deducted after dialling the toll-free number.
    • Ask the patient to make a toll-free call.
    • Check the balance SMS they receive. The last call charge will show as Rs.0.00 and the total balance will also be shown.

    The patient has very little or zero balance, dials the toll-free number and hears a long message regarding less or zero balance.

     
    • When the balance in the pre-paid connection is very little or zero, the patient might hear a long message from the telecom service provider.
    • Request the patient to wait for that voice message to end. On completion of this voice message, the toll-free number will be dialled, and the patient will hear “Thank You”.

    The patient dials the toll-free number but cannot hear anything or “Thank You” is not heard.
    • Request the patient to try multiple times.
    • At times, due to network congestion, the call may not go through, just like any other mobile number.
    • You can also try dialling the same toll-free number from your phone, to check that the toll-free line is working.

    The patient says that they are not able to connect to the toll-free lines after 1:00 PM or 3:00 PM.

     
    • The toll-free calls can be made till 11:59 PM for the current day’s dose. The timing restriction is only for the SMS alerts.
    • Educate the patient that if they do not call by 1:00 PM they will get an SMS reminder.
    • Even after that, if they do not call till 3:00 PM the staff will get an SMS alert.
    • They can still call after 3:00 PM till 11:59 PM. The moment they call, the dashboard will turn green.
    • It is only at 12:00 AM (midnight) that the dashboard turns red.

     

    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​

    What should be done if a patient dials the 99DOTS toll-free number and hears “Thank You”, but the Nikshay dashboard is still showing red?

    Tell the patient that they lied as they did not take their medication.

    Check that there are no errors in the patient’s phone number on Nikshay.

    Check if the patient used an alternative number to call the toll-free line and register this dual line on Nikshay.

    Options 2 and 3

    4

    If a patient dials the 99DOTS toll-free number and hears “Thank You”, but the Nikshay dashboard is still showing red, then: Check that there are no errors in the patient’s phone number on Nikshay, also check if the patient used an alternative number to call the toll-free line and register this number on Nikshay.