[Draft] Course on TB Free workplace interventions

Tuberculosis (TB) is a communicable disease* that is a major cause of ill health, one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent (ranking above HIV/ AIDS).

TB is caused by the bacillus Mycobacterium tuberculosis, which is spread when people who are sick with TB expel bacteria into the air; for example, by coughing.

TB is a disease of poverty. Economic distress, vulnerability, marginalization, stigma and discrimination are often faced by people affected by TB.

TB is curable and preventable. About 85% of people who develop TB disease can be successfully treated with a 6-month drug regimen.

*Communicable diseases are diseases that can be spread from one person to another and cause a large number of people to get sick

Resources:

• Key facts on Tuberculosis: https://www.who.int/news-room/fact-sheets/detail/tuberculosis

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

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

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

Assessment

Resources:

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

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

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

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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

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

Figure: Transmission of TB bacteria through air via droplet

Resources:

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

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

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

Increased exposure of TB due to where they live or work

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

Limited access to Quality TB services

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

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

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

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

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

Figure: Flow chart for TB disease progression

Resources:

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

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

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

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

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

Resources:

• Latent Tuberculosis Infection Guideline

• Guideline for Programmatic Management of Tuberculosis Preventive Treatment in India

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

What is Drug-Sensitive Tuberculosis (DS-TB)?

• DSTB is a case where a person is infected with TB bacteria that are susceptible to all first line anti-TB drugs. It means that all of the first line TB drugs will be effective as long as they are taken properly and regularly.

• This type of TB has the best prognosis and the shortest treatment duration.

• Patients diagnosed with TB are considered to be DS-TB case, till such time s/he detected with resistance to any anti-TB drugs.

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What is Drug-Resistant Tuberculosis?

• Drug-Resistant TB occurs when bacteria become resistant to the drugs used to treat TB. This means that the drug can no longer kill the TB bacteria.

• Multidrug-resistant TB (MDR TB) is a type of DR-TB where TB bacteria is resistant to both Isoniazid and Rifampicin, the two most potent anti-TB drugs.

                               Figure: High Risk for Drug-Resistant Tuberculosis (DRTB)

Resources:

• Guidelines for Programmatic Management of Drug-Resistant Tuberculosis in India, March 2021 
• WHO Consolidated Guidelines on Tuberculosis: Module 4-Treatment: Drug resistant TB Treatment, 2020

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

Figure: Patient Flow

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

Nikshay provides-

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

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

Figure: Nikshay Login Pages

TB Aarogya Sathi empowers Citizens (including TB Patients under NTEP) and to serve as a Direct interface with the national TB program.

Citizen: The App is aimed at  increasing awareness among the citizens. It is available for all Citizens using the App (no login required to access this content)

• Information on TB (Symptoms, Side Effects)
• Health Facility Search
• BMI Assessment
• Nikshay Sampark Helpline
• Nutritional Advice

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

• Patients registered under Nikshay get access to their TB health record additional information (after login)
  • Adherence Details
  • Treatment Progress Details
  • DBT Details

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

Figure: TB Aarogya Sathi Application snapshot

Resources:

• Nikshay Training Material

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

Figure: Signs and Symptoms of TB

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

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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

 Presumptive TB can be categorized into

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

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

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

Resources:

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

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

Figure: Signs and Symptoms of active TB

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

• History of close contact with known active TB case 

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

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

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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

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

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

  

  Figure: Genxpert Machine for CBNAAT

  

  Figure:  Truenat Machine

• Line Probe Assay

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

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

Extra Pulmonary TB:

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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People who have been exposed to patients with infectious TB are known as TB contacts; they constitute a high-risk group for TB. Case finding investigation contributes to the early detection of TB cases, and results in identifying a significant number of additional patients.

Figure: Approaches to Tuberculosis Case Finding

Active case-finding requires systematic screening and clinical evaluation of populations who are at high risk of developing TB, such as people living in slums, tribal areas, congregate settings, persons who are household contacts of TB cases

Resources:

• Assessing TB Case-Finding

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

Figure: Measures for control and prevention of tuberculosis

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

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

First line drugs are the least toxic and most effective drugs that are used in first line of therapy.

The first-line antituberculosis drugs that form the core of treatment regimens are

Resources:

• Tuberculosis: Multidrug-resistant tuberculosis (MDR-TB)

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Standard TB Treatment is divided into two phases

• Intensive Phase(IP): In this phase,
  • Kills most of the TB bacteria during the first 8 weeks of treatment, but some bacteria can survive longer
  • Therefore, more drugs are administered to kill the bacteria and reduce the severity of disease.
  • Treatment in this phase usually is of short duration(2 to 6 Months or more) in comparison to Continuation Phase(CP)

• Continuation Phase(CP): In this phase,
  • All the remaining TB bacteria are in the dormant stage i.e., stage when growth and development of bacteria are temporarily stopped.
  • Therefore, fewer but powerful antibiotics are administered to kill those bacteria. 
  • Treatment in this phase usually lasts longer than Intensive Phase(IP)(4 to 18 Months or more)

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To know the TB treatment response and to determine that if patient is cured, TB patients are clinically evaluated at the end of every four weeks of treatment, and they are also followed up by performing sputum test at end of each treatment phase (i.e. Intensive phase and Continuation phase)

TB patients during clinical evaluations are assessed to

• Identify possible adverse reactions to medications;
• Check for any comorbid conditions;
• Weight change;
• monitor adherence; and determine treatment efficacy by observing their symptoms

Although each patient responds to treatment at a different pace, all TB symptoms should gradually improve and eventually go away.

Patients whose symptoms do not improve during the first 2 months of treatment, or whose symptoms worsen after improving initially, should be re-evaluated for adherence issues and development of drug resistance.

After completion of TB treatment, all patients should be followed up at the end of

• 6 months,
• 12 months,
• 18 months &
• 24 months

TB patients at the follow up should be screened for any clinical symptoms and/or cough. If found positive on screening, then sputum microscopy and/or culture should be considered. This is important in detecting the recurrence of TB at the earliest.

After completion of TB treatment, if the patient has not developed any clinical symptoms and/or cough and also if the microscopy remains negative during their follow up, then the patient is considered as “Relapse Free Cure from TB.”

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.

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 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

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Figure: DSTB Treatment Card (Paper)
 

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

Figure: Various activities under Public Health Action

Contact tracing is a process to identify people who are  at a high risk of developing TB due to their contact with a known TB case.

The aim of contact tracing is to find other people with TB disease and those infected with TB

All close contacts, especially household contacts of a Pulmonary TB patient, should be screened for TB. 

In paediatric TB patients, reverse contact tracing for the search of any active TB case in the child's household must be undertaken.

Particular attention should be paid to contacts with the highest susceptibility to TB infection.

Figure: Contacts to be Prioritized for contact TB screening

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

Aspects to be considered during a Home visit:

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

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

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

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

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

Stigma is when someone sees you in a negative way.

Discrimination is when someone treats you in a negative way.

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

Figure: Stigma towards TB Patients in the community

At Individual Level

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

At Family and Community Levels

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

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

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

Why Community Engagement?

Figure: Importance of Community Engagement

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

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

Figure: Importance of Community Engagement

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

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

Figure: Roles of TB Champion

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

Figure: Help to TB Patients by Community Health Volunteers

Direct Benefit Transfer (DBT) is a major initiative of Government of India (GoI) whereby any government subsidy or benefit is to be transferred directly into the beneficiary's bank accounts. Intermediary government agencies only manage the process of payments, without handling actutal money.

NTEP is one of the first health programmes in India to use a fully adopt DBT. It uses an end to end electronic system, to digitise beneficiary information and transfer monetary benefits. In NTEP to process benefits, two electronic systems are used, Ni-kshay (operated by NTEP) and PFMS (Public Finance Management System, operated by the Ministry of Finance). Ni-kshay enables Direct Benefit Transfer by digitizing the beneficiaries(bank account details of patients, treatment supporters and providers) and calculates of incentives/ benefits (eligible payment) and processes them for payment through PFMS under various schemes. The various schemes operational under NTEP are:

• Nikshay Poshan Yojana(NPY)
• Tribal Support Scheme
• Treatment supporter’s Honorarium
• Incentive for Notification and Outcome

What’s inside:

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

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

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

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Source:

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

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

What’s inside:

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

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

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

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

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

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

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

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

What’s inside:

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

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

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

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

• Loss of employment
• Lower Income

Added to the social consequences such as:

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

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

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

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

Four principles to prevent or reduce consequences of stigma:

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

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

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

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

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

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

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Recommendations for the employer:

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

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TB transmission in Workplaces

What’s inside:

Read this page to learn how TB spreads inside your workplace 

Introduction:

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

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

Dynamics of TB Spread:

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

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

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

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Why TB & Workplace ?:

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

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

What’s inside:

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

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

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

1. Administrative Control
2. Environmental Control

Administrative Control Strategies:

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

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

Following, are the activities recommended under administrative control strategies:

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Environmental Control:

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

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

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Types of ventilation: 

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

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

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

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

What’s inside:

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

Page: 1 What is a TB Free Workplace?

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

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

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

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

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

Key activities for implementing TB Free workplace:

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

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

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Read this page to know about the TB Free workplace commitee

Forming a TB Free workplace committee

TB Free workplace committee (Recommendations):

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

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

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

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

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

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

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

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

Page 3: Checklist for a TB Free Work Place

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

TB work place policy by the Corporate Organizations:

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

Key principles for developing a workplace policy:

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

Benefit of an ideal TB Free workplace policy:

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

Models of TB Free Workplace policies:

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 Policies and Guidelines related to TB in Workplace:

From the Government and the ILO :

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

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

Supporting an employee diagnosed with TB

What’s inside:

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

Expressing Solidarity with the TB diagnosed employee

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

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Ensuring a safe workplace:

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

Sick leave and flexible workhours:

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

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

Support for continuity of Treatment:

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

Return to work:

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

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

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

What’s inside:

Read this page to learn how nutrition is linked to TB

TB Nutrition and workplace :

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

Evidence suggests that nutritional interventions are associated with:

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

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

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

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

Composition of Nutrition Kits:

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

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Supports for TB patient from the Government

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

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

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

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