National Framework for Joint TB-Tobacco Collaborative Activities PDF

NATIONAL FRAMEWORK FOR JOINT TB-TOBACCO COLLABORATIVE ACTIVITIES National Framework for JOINT TB-TOBACCO COLLABORATIVE ACTIVITIES Revised National TB Control Programme National Tobacco Control Programme May 2017 Directorate General of Health Services Ministry of Health & Family Welfare Government of India Table of Contents Foreword i Preface ii Acknowledgements iii Acronyms iv 1. Introduction 1 1.1 Global Burden of TB and Tobacco 1 1.2 Burden of TB and Tobacco in India 1 2. Evidence of TB and Tobacco Co-morbidity 2 3. National Programmes for TB and Tobacco Control 3 3.1 Revised National TB Control Programme 3 3.2 National Tobacco Control Programme 6 4. Tuberculosis and Tobacco Collaborative Framework 9 4.1 Purpose 9 4.2 Objectives 9 4.3 Implementation Strategy 9 5. Coordination Mechanism between RNTCP and NTCP at National, State and District levels 10 5.1 National Level Coordination Mechanism 10 5.2 State Level Coordination Mechanisms 10 5.3 District Level Coordination Mechanisms 11 6. Activities for Coordination between RNTCP and NTCP 12 6.1 Integrating ‘Brief Advice’ for Tobacco Cessation in RNTCP 12 6.2 Involvement of NTCP in TB Case Finding 13 7. ‘Brief Advice’ for Tobacco Cessation: The 5 A’s and 5 R’s Approach 14 8. Linkages between TB and Tobacco Control Programme 16 8.1 Service Provision in RNTCP 16 8.2 Service Provision in NTCP 17 9. Sensitisation & Training of Health Staff for TB-Tobacco Collaborative Activities 19 10. Awareness and IEC 20 11. Recording and Reporting 22 11.1 Revised National TB Control Programme 22 11.2 National Tobacco Control Programme 23 12. Supervision, Monitoring and Evaluation 25 13. Roles and Responsibilities of Programme Staff for Collaborative Activities 26 13.1 Roles and Responsibilities of RNTCP Staff 26 13.2 Roles and Responsibilities of NTCP Staff 28 14. Implementation Plan 30 15. Tools for TB-Tobacco Collaborative Framework 32 Annexures 33 Annexures 1 Revised National Tuberculosis Control Programme 33 Annexures 2 TB ID card for referring registered TB patient to nearest Tobacco Cessation Centre 35 Annexures 3 Flow chart – 5As & 5 Rs model 38 Annexures 4 Tobacco Cessation Form 41 Annexures 5 Part B: Quarterly Reporting Template of National Tobacco Control Programme 43 Annexures 6 RNTCP Laboratory Request Form 46 Annexures 7 Infection Control Measures Guidelines 47 Annexures 8 National Tobacco Quitline Flyer 48 Annexures 9 National Framework for Joint TB-Tobacco Collaborative Activities 50 Annexures 10 National Tobacco Quitline Dashboard 54 References 55 Foreword Tuberculosis and tobacco use are major public health burdens that are largely preventable. In India, tobacco use and TB are common conditions.The vast numbers of tobacco users (nearly 275 million adults) according to Global Adult Tobacco Survey (GATS) contribute adversely to the sustainability of TB case management due to the strong association between tobacco use and TB treatment outcomes. The economic burden of tobacco use in India amounted to a staggering Rs.1,04,500 crore in 2011. Another study conducted in 2004 using health care data from National Sample Survey Organization (NSSO), estimated that the tobacco-attributable cost of TB was three times higher than the expenditure on overall TB control in the country.This grave scenario necessitates implementation of new approaches and interventions that have potential to curb the growing convergence of both, TB and tobacco epidemics. Patients with TB need and should receive counselling and assistance in stopping tobacco use. Recently, the World Health Organization (WHO) Tobacco Free Initiative, the WHO Stop TB Department, and the International Union against Tuberculosis and Lung Diseases (The Union) called for inclusion of brief tobacco cessation advice in standard TB case management. They advocated for a joint collaboration, wherein activities can be planned and carried out, within the framework of the existing health system. Against this background, the 'National Framework for Joint TB-Tobacco Collaborative Activities' has been developed by the Directorate General of Health Services with support from domain experts, WHO and The Union. The framework provides guidelines for programme managers of Revised National Tuberculosis Programme (RNTCP) and National Tobacco Control Programme (NTCP) on the implementation of tobacco cessation services as an integral part of TB case management. Further, screening of TB symptoms in tobacco users registered at the National Tobacco Quitline and Tobacco Cessation Centres will increase TB case detection and identify TB case relapse at early stages. The implementation of the 'National Framework for Joint TB-Tobacco Collaborative Activities' is a step in the right direction for addressing co-morbidities, as reduction in the prevalence of tobacco use is expected to bring about collateral beneﬁts in the control of TB in India. We are conﬁdent that the experience gained and lessons learnt from this intervention will further strengthen our approach towards addressing other co-morbidities. Dr Jagdish Prasad Director General Health Services Directorate General of Health Services Ministry of Health & Family Welfare Government of India, New Delhi i Preface Tuberculosis (TB) and tobacco use are two major public health challenges that independently cause considerable health and economic burden in the country, with serious socio-economic implications. India is the second largest consumer of tobacco products in the world with as many as 35% adults (15 years and above) consuming tobacco. India also has the highest burden of TB globally, with an estimated 2.8 million incident cases being registered per year. There is ample evidence, both globally and nationally, to demonstrate the adverse association between the TB and tobacco epidemics. Tobacco use has been found to be strongly associated with relapse of TB as well as mortality from TB. Therefore, in India, where both tobacco use and TB are common conditions at the population level, even a modest increase in relative risk of TB due to tobacco use, more speciﬁcally with respect to smoking, amounts to a signiﬁcant attributable risk of TB infection to the population. Since there is a direct relationship between the TB and tobacco epidemics, the RNTCP and NTCP share similar concerns and are inherently interdependent. Recognising this, a national workshop was organised in collaboration with WHO to deliberate on implementation strategies for enabling coordination between the two programmes.The evidence was discussed with stakeholders and experts and a decision was taken to develop and implement a collaborative framework to achieve projected national targets for both programmes. The collaboration between RNTCP and NTCP creates an opportunity within the health care system by providing cessation services to every TB patient who is a tobacco user to overcome the addiction. In addition, every TB patient who is not a tobacco user will be made aware of the consequences of being exposed to secondhand smoke. The collaboration through tobacco control efforts at the national and state level will contribute in increasing the TB case detection rates by screening of 'TB Symptoms Complex' in users who are accessing tobacco cessation services, either through Tobacco Cessation Centres or through the National Tobacco Quitline. It is a historical step for both programme divisions to come together to introduce the 'National Framework for Joint TB-Tobacco Collaborative Activities' which will guide programme managers and health care providers at various levels to coordinate integrated interventions for reducing prevalence of TB and tobacco use in the population.We commend the continued support and contribution of partners such as the National Institute of Tuberculosis and Respiratory Diseases, the National Institute of Mental Health and Neuro Sciences (NIMHANS), The International Union Against Tuberculosis and Lung Disease (The Union), WHO Country Ofﬁce for India, and other domain experts in outlining the framework. We are conﬁdent that the systematic implementation of the framework at various levels and settings in conjunction with routine TB treatment and tobacco cessation services will help in reducing the disease burden due to both conditions and alleviate human suffering and economic loss to the nation. Dr Mohammed Shaukat Dr Sunil D. Khaparde Advisor (NCD) Deputy Director General Dte. General of Health Services Central TB Division MoHFW/GoI, New Delhi Dte.General of Health Services MoHFW/GoI,New Delhi ii Acknowledgements The 'National Framework for Joint TB-Tobacco Collaborative Activities' provides guidelines for programme managers of the Revised National Tuberculosis Programme and the National Tobacco Control Programme to undertake coordinated and joint actions for addressing the co-morbidities of two diseases. It outlines a clear set of processes and procedures that need to adopted in order to implement tobacco cessation services, which are an integral part of TB case management. The framework is an outcome of series of deliberations with stakeholders, including a national consultation (Workshop on Collaborative Framework for National Programmes on Tuberculosis, Tobacco and Diabetes) held in June 2015 at New Delhi. Our sincere gratitude to the World Health Organization Country Ofﬁce for India (WCO-India) for providing technical expertise and guidance at every stage of its development. This document would have not been possible without the dedicated support and inputs received from partners, external agencies and state and district level programme managers. DOTS providers are also acknowledged for sharing their experience regarding implementation of 'Brief Advice'. We express our gratitude to Shri C. K. Mishra, Secretary (Health & Family Welfare), MoHFW, Government of India (GoI); Dr Jagdish Prasad, Director General Health Services, MoHFW, GoI; Dr A. K. Panda, Additional Secretary & Mission Director, National Health Mission, MoHFW, GoI; Shri Arun Kumar Jha, Economic Advisor, MoHFW, GoI; Shri Amal Pusp, Director, MoHFW, GoI; Dr Sunil D. Khaparde, Deputy Director General-TB, Central TB Division (CTD), GoI; Dr Mohammed Shaukat, Advisor, NCD, Directorate General of Health Services (Dte. GHS), GoI for providing constant leadership and encouragement. We are also grateful to Dr Henk Bekedam, WHO Representative to India; Dr Prakin Suchaxaya, Coordinator Health Programmes, WCO-India; and Dr Fikru Tullu, Team Leader-NCD, WCO-India for their support in this endeavour. We would like to acknowledge the efforts of the core team comprising of Dr Raghuram Rao, Dr L Swasticharan (Dte.GHS), Dr Malik Parmar, Dr Pradeep Joshi, Ms Vineet Gill Munish, Mr Praveen Sinha (WCO-India), Dr Bhavin Vadera, Dr Mahesh Gorla (CTD Consultant) who undertook extensive research and worked with multiple agencies to update the information. The guidance document was reviewed by Dr Rohit Sarin, Dr Pushpender K. Varma (National Institute of TB & Respiratory Diseases), Dr Chinmoyee Das (Dte.GHS), Dr Sadhana Bhagwat, Dr Ranjani Ramachandran (WCO-India), Dr Rana J. Singh, Mr Ashish Pandey (The Union), Dr Amar Shah (CTD), Dr Monika Arora (Public Health Foundation of India). They provided insightful comments to enrich the document and their contributions are acknowledged. We are also grateful to the communication team at WCO- India for editing and designing the framework. We now look forward to seeing the guidelines being used extensively, contributing to a better management of co-morbidities and beneﬁting the TB and Tobacco control strategies. We hope this framework will go a long way in helping the government achieve its ambitious target of eliminating TB by 2025. iii Acronyms ACSM Advocacy, Communication and Social Mobilisation ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist CHC Community Health Centre COTPA Cigarettes and Other Tobacco Products Act CTD Central Tuberculosis Division DDG TB Deputy Director General Tuberculosis DLCC District Level Coordination Committee DGHS Directorate General of Health Services DMC Designated Microscopy Centre DNO District Nodal Ofﬁcer DOTS Directly Observed Treatment Short course DTC District Tuberculosis Centre DTCC District Tobacco Control Cell DTO District Tuberculosis Ofﬁcer IEC Information, Education and Communication M&E Monitoring and Evaluation MoHFW Ministry of Health and Family Welfare MO-PHI Medical Ofﬁcer- Peripheral Health Institution NCC National Coordination Committee NCD Noncommunicable Disease NHM National Health Mission NRT Nicotine Replacement Therapy NTCP National Tobacco Control Programme OPD Out-Patient Department PHCs Primary Health Centres iv PHI Peripheral Health Institution RNTCP Revised National Tuberculosis Control Programme SLCC State Level Coordination Committee SNO State Nodal Ofﬁcer STCC State Tobacco Control Cell STDC State Training and Demonstration Centre STLS Senior Tuberculosis Laboratory Supervisor STO State Tuberculosis Ofﬁcer STS Senior Treatment Supervisor TCC Tobacco Cessation Centre TB Tuberculosis TCC Tobacco Cessation Centre TU Tuberculosis Unit WHO World Health Organization v 1 Introduction Tuberculosis (TB) is an infectious bacterial disease caused by Mycobacterium tuberculosis. It most commonly affects the lungs, as also other organs of the human body. It is transmitted from person-to-person via droplets from the throat and lungs of people with the active respiratory disease 1.1 Global Burden of TB and Tobacco In 2013, nine million people suffered from TB and 1.5 million died from the disease across the world. However, In 2010, an estimated six million people died globally over 95% of TB deaths occur in low- and middle-income from tobacco use with 72% of countries and the disease remains one of top ﬁve causes them hailing from low- and 1 of death for women aged 15 to 44 years. middle-income countries. Tobacco use is the leading preventable cause of disease and death in the world. Worldwide, tobacco use accounts for more than six million deaths (5.4 million deaths due to tobacco use and 0.6 million due to secondhand smoke) each year and is expected to cause more than 2 eight million deaths by the year 2030. According to The Tobacco Atlas, in 2010, tobacco was estimated to have killed six million people worldwide 72% of whom were in low- and middle-income countries.3 1.2 Burden of TB and Tobacco in India India is a country with nearly 1.23 billion people, representing 17.5% of the world population. It has the largest number of TB cases in the world (estimated at 2.8 million incident cases per annum) with an incidence rate of 217/100,000 per year for 2015. Treatment success for new and relapsed TB cases registered in 2014 was close to 74%.4,5 India is the third largest producer and second largest consumer of tobacco in the world.6 Nearly one million Indians die due to tobacco use every year, which is much more than the combined mortality resulting from HIV/AIDS, TB and Malaria. As per GATS 2010, there are 275 million adult tobacco users in India. Key ﬁndings from the GATS survey:7 More than one- third (35%) adults in India use tobacco in some form or the other; Use of smokeless tobacco is much more prevalent than smoking tobacco; Prevalence of smokeless tobacco use (26%) is almost twice that of smoking tobacco (14%); About 5% adults use both, smoking as well as smokeless tobacco; Prevalence of tobacco use is higher in rural areas as compared to urban areas; and Women use mainly the chewing forms of tobacco. 1 Evidence of TB and 2 Tobacco Co-morbidity Tobacco smoke contains toxic chemicals which cause disturbances in the bronchial surface of the lung. It weakens immunity of the patient to ﬁght with the TB bacteria.The following evidence emerges from several studies conducted to look at the association of TB and tobacco use in India and globally.8-13 Almost 38% of TB deaths are associated with the use of tobacco; Two critical ndings from a pilot carried out in Gujarat Prevalence of TB is three times higher among ever-smokers as compared to that of never- 1. High tobacco use found smokers; among TB patients Mortality from TB is three to four times higher 2. The intervention of 'Brief among ever-smokers as compared to never- Advice' helped 67.3% of smokers; t hese patients to quit tobacco use Smoking contributes to 50% of male deaths in the 25-69 age group from TB in India; Exposure to tobacco smoke has been found to affect TB by increasing risk of TB infection and risk of developing TB; affecting clinical manifestations and increasing risk of relapse among TB patients; affecting bacteriological conversion (sputum smear or culture) and outcome of treatment in TB patients; and increasing TB mortality and resistance to anti–tubercular drugs. Recent Efforts to Address TB and Tobacco Co-morbidity Moving forward from research-to-action, the Ministry of Health & Family Welfare (MoHFW), implemented ajoint pilot project within the existing Revised National Tuberculosis Control Programme (RNTCP) and National Tobacco Control Programme (NTCP) in 2010 in Vadodara, Gujarat. Tobacco cessation services were offered as 'Brief Advice'to TB patients registered for the Directly Observed Treatment Short course (DOTS) and among those who were using tobacco in any form,based on the model recommended by WHO and The Union. 'Brief Advice' for tobacco cessation based on the ﬁve A's (Annexure 3), was incorporated in the ongoing TB Control Programme in Vadodara District of Gujarat. Tools were developed for education, training and capturing data. All registered TB patients receiving DOTS who used tobacco in any form were offered 'Brief Advice' during routine interaction for treatment. The pilot showed that tobacco use was high among TB patients on treatment. At the end of the treatment, 67.3% patients who were offered 'Brief Advice' were able to quit tobacco use.8 A similar study was conducted under the coordination of the Central TB Division (CTD) in Jaipur District of Rajasthan with encouraging results. Around 75% TB patients had quit tobacco use after getting counselled by the DOTS provider. Studies proved that it is indeed feasible to introduce the 'Brief Advice' service as a cost-effective intervention for tobacco cessation among TB patients with careful monitoring. A logical conclusion that emerged was to make tobacco cessation an integral part of all TB control programmes. 2 National Programmes for 3 TB and Tobacco Control Since the mid 2000's, efforts to strengthen TB and tobacco control have been intensiﬁed with national policies and programmes delving deep into the root cause of prevention, control and treatment. The Revised National Tuberculosis Control Programme (RNTCP) was launched in 1993, in a phased manner and has over the last 25 years progressed steadily towards its goals. Meanwhile, the NTCP which was also a centrally sponsored scheme has strived to facilitate effective implementation of Tobacco Control Laws (COTPA 2003) and has since established State and District Tobacco Control Cells to ensure ground level implementation. 3.1 Revised National TB Control Programme The RNTCP was based on the internationally recommended DOTS strategy that was launched in Goal of RNTCP 1997. The programme later expanded across the To decrease mortality and morbidity country in a phased manner with support from the due to TB and reduce transmission World Bank and other development partners. A of infection until TB ceases to be a major milestone was achieved when nation-wide major public health problem in India. coverage of RNTCP was established by March 2006. In terms of treatment of patients, RNTCP has been acknowledged as the largest and fastest expanding TB control programme in the world. 3.1.1 Programme Structure A well-oiled organisational structure of RNTCP was constituted with clearly demarcated roles and responsibilities for those in-charges of overseeing the different functions, across the national, state, district, sub-district levels and the peripheral health institutions. A new sub-district level was created, namely the Tuberculosis Unit (TU) that was tasked with undertaking. Systematic monitoring and supervision of diagnostic and treatment aspects of the programme. 3 Figure 1: RNTCP's organisational structure National level (Central TB Division): The Central TB Division (CTD) is part of the Directorate General of Health Services, Ministry of Health and Family Welfare (MoHFW), and is responsible for TB control in the entire country. It is headed by a National Programme Manager, the Deputy Director General TB (DDG TB) and is implemented under the umbrella of the National Health Mission (NHM). 4 State level: At the State level, the State Tuberculosis Ofﬁcer (STO) is responsible for planning, training, supervising and monitoring the programme in their respective states, as per guidelines of the State health societies. Each of these technically follows instructions of the CTD for programme implementation. District level: The district is the key level for the management of primary health care services. The District Tuberculosis Centre (DTC) is the nodal point for TB control activities and the District TB Ofﬁcer (DTO) at the DTC has overall responsibility of physical and ﬁnancial management of RNTCP at the district level. It follows the guidelines that have been set by the District Health Society. Sub-district level (Tuberculosis Unit - TU): The TU is the nodal point for TB control activities in the sub-district. A team, comprising of a designated Medical Ofﬁcer – TB Control (MO-TC), Senior Treatment Supervisor (STS) and Senior Tuberculosis Laboratory Supervisor (STLS) at the TU have the overall responsibility of managing RNTCP at the sub- district level. Currently, there are 3644 TUs functioning in the programme. Under the current Five Year Plan (2012-2017) proposal, these TUs will be further aligned at the block level. Peripheral Health Institutions (PHIs): At this level you have the dispensaries, Primary Health Centres (PHCs), Community Health Centres (CHCs), referral hospitals, major hospitals, specialty clinics/ hospitals (including other health facilities) within the district. Some of these PHIs will also be DMCs. 3.1.2 Diagnostic Facilities for TB Detection and Treatment The RNTCP has a quality assured laboratory network for bacteriological examination of sputum that operates in a three-tier system that comprises of Designated Microscopy Centre (DMC), an Intermediate Reference laboratory (IRL) and a National Reference laboratory (NRL). The DMC is the most peripheral laboratory under RNTCP and it caters to a population of around 100,000 (50,000 in tribal and hilly areas). There are >13,000 Designated Microscopy Centres (DMCs) across the country. The programme provides free testing facilities for patients and suspects, including Drug Resistant TB (DR-TB), Paediatric TB and HIV-TB, Extra-Pulmonary TB. The RNTCP laboratory services include state-of-the-art testing facilities that provide rapid testing methods such as Line Probe Assay (LPA) and Cartridge Based Nucleic Acid Ampliﬁcation Tests (CB-NAAT), in addition to a range of conventional diagnostic modalities such as Direct Smear Microscopy, LED-Florescence Microscopy (LED-FM) and solid and liquid culture. Under the current strategy, the programme is rapidly expanding the laboratory and newer technology platform capacity to achieve universal access to quality assured diagnosis. As of March, 2017, there were 65 culture and Drug Susceptibility Testing labs, 51 LPA and 628 CB-NAAT labs functional in the country. All TB patients, including those with co-morbidities such as TB-HIV or TB- diabetes, registered under the programme are provided free quality assured treatment services through a network of providers. These include the entire gamut ranging from community volunteers to tertiary care dedicated institutions specialising in TB treatment and care. 5 3.2 National Tobacco Control Programme (NTCP) The NTCP was launched in the year 2007-08 with the primary objectives of creating awareness about the harmful effects of tobacco consumption; reducing production and supply of tobacco products; ensuring effective implementation of provisions under “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” (COTPA); and helping people quit tobacco use through Tobacco Cessation Centres. The NTCP is being implemented through a three-tiered structure comprising of a National Tobacco Control Cell (NTCC), State Tobacco Control Cell (STCC) and District Tobacco Control Cell (DTCC). NTCP's Roll-out Strategy: 3-Tier Organisational Structure National Tobacco Control Cell State Tobacco Control Cell (STCC) State Nodal Ofﬁcer State Consultant (NTCP) Legal Consultant District Tobacco Control Progranmme District Nodal Ofﬁcer District Consultant (NTCP) Social Worker + Psychologist/Counselor Figure 2: NTCP’s Roll-out Strategy: 3-Tier Organisational Structure National Tobacco Control Cell (NTCC): The NTCC has been set up under the Ministry of Health & Family Welfare to undertake overall policy formulation, planning and monitoring and evaluation of different activities envisaged under the programme. Some of its major components and activities include: Conducting public awareness/mass media campaigns for awareness building and behavioural change; Establishing tobacco product testing laboratories; 6 Setting up a National Tobacco Regulatory Authority (NTRA); Conducting advocacy establishing and intersectoral linkages; Carrying out research including the Global Adult Tobacco Survey (GATS) and the Global Youth Tobacco Survey (GYTS); Ensuring monitoring and evaluation; Expanding tobacco cessation facilities; Setting up a National Tobacco Quitline and helpline; and Organising review meetings and monitoring visits for implementing NTCP. State Tobacco Control Cell (STCC): The STCC is headed by a State Nodal Ofﬁcer, who is a Senior Ofﬁcer from the State Department of Health, preferably on a full-time basis. His/her chief mandate is to look after all the NCD programmes. The STCC is envisaged to be established as a sub-set of the State NCD Cell for optimum resource utilisation. Under the STCC is the State Level Coordination Committee (SLCC) that is headed by the Chief Secretary or his nominee and Principal Secretary/Secretary (Health) as Member Secretary. Every state is supposed to have this coordination committee that is responsible for overall implementation of the NTCP and COTPA. States may form a small working group with representatives from key departments to monitor activities under NTCP on a day-to-day basis. In order to review progress, the working group may meet on a monthly basis, while the SLCC must meet every quarter. Some of the major activities carried out by the STCC include: Training of multiple stakeholders for tobacco control through state level advocacy, workshops/sensitisation programmes; Integrating tobacco control with other health programmes/activities; Incorporating tobacco control in the state level IEC campaign; and Strengthening monitoring and enforcement of COTPA. District Tobacco Control Cell (DTCC): Every identiﬁed district is mandated with having a DTCC that is established as a sub-set of the District NCD unit for optimum resource mobilisation. It is responsible for overall planning, implementation, and monitoring of different Intensifying efforts activities. Additionally, it is assigned the task of By March 2016: achieving the physical and ﬁnancial targets that - State Tobacco Control Cells were have been set under the programme at the district established in all 35 States/UTs; level. Under the DTCC is the District Level - District Tobacco Control Cells Coordination Committee (DLCC) which is were established in more than constituted in each district. It is chaired by the 400 districts. Collector or District Magistrate and has the District Nest on the anvil: Nodal Ofﬁcer as its Member Secretary, who is - Tobacco Cessation Centres to be expected to convene meetings of the Committee. established in all NTCP destricts. Some of the major activities of the DTCC include: Conducting training and capacity building of relevant stakeholders; Carrying out school awareness programmes; Setting up and expanding tobacco cessation facilities, including support for pharmacological treatment of tobacco dependence; and Launching an Information Education Communication (IEC) media campaign. 7 Each District has also been provided support for establishing a Tobacco Cessation Centre (TCC) at the District hospital. The TCC is supported by a Counsellor who is supposed to provide brief and intensive counselling for tobacco addiction. At the district level, efforts are to be made to provide regular tobacco cessation services at the out-patient department (OPD) of the district hospital, where those who want to quit tobacco use can be referred and counselled as per a set protocol. Box 1: Two successful initiatives with scope for scale-up 1. National Tobacco Quitline: Counselling via toll-free number The MoHFW has set up a toll-free National Tobacco Quitline, under the NTCP on a pilot basis. It aims to provide telephonic counselling to those desirous to quit tobacco. The toll-free number 1800-11-2356 is a national number and can be accessed from all tele-service providers. The services are currently provided in two languages i.e. English and Hindi, from 8.00 am to 8.00 pm six days a week, except on Mondays. Once a tobacco user gets registered with the Quitline, a Quit Tobacco pack is sent by mail or post to him/her. A minimum of four proactive calls are placed by the Counsellor after the tobacco user is registered with the Quitline. As of March 2017, more than 46,000 tobacco users were counselled through this Quitline. 2. mCessation Programme: Health information via mobile text messages The programme is part of the Digital India Initiative and provides evidence-based behavioural change (short) text messages on mobile phones, which include health information on tobacco use hazards, tips on quitting, and encouragement for those attempting to do so. The unique feature of the programme is that tobacco users who want to quit, can register by giving a missed call to 011-22901701, or by registering at: http://www.nhp.gov.in/quit-tobacco. After getting registered, the user gets regular mobile text messages based on his/her type of tobacco usage. The content library consists of messages for smokeless users, smokers, and for those who consume tobacco in both ways. The programme is currently available in English and Hindi and will be expanded to other regional languages in a phased manner. As of March 2017, about 21,00,000 users registered themselves for mCessation services. 8 Tuberculosis and 4 Tobacco Collaborative Framework The framework for TB and tobacco collaboration has been developed after establishing a clear understanding of what it will achieve and how it will be implemented. 4.1. Purpose The national framework for TB-tobacco collaborative activities between the two national programmes, namely RNTCP and NTCP, aims to reduce the burden of co-morbidity due to TB and tobacco use. 4.2. Objectives To establish mechanisms of collaboration between RNTCP and NTCP for addressing TB and tobacco use co-morbidity; To identify tobacco users among registered TB patients and provide ‘Brief Advice’ for tobacco cessation to motivate them to quit tobacco use; To screen for active TB symptoms in tobacco users registered at Tobacco Cessation Centres (TCC), NCD clinics and National Tobacco Quitline/mCessation initiatives; To strengthen long-term outcomes among cured TB patients (who use tobacco in any form) through initiatives planned under NTCP (Quitline, m- cessation initiatives, etc); and To enhance effectiveness of tobacco cessation services by expanding the outreach to susceptible population. 4.3. Implementation Strategy A 5-step implementation strategy has been adopted to ensure smooth coordination between RNTCP and NTCP. Establish joint coordination mechanisms at national, state, district & sub-district levels Implement “Brief Advice” for Implementation tobacco cessation in RNTCP Strategy for RNTCP- Screen active ‘TB Symptoms Comples’ among NTCP Collaboration registered tobacco users in NTCP & train programme/ﬁeld staff in TB/tobacco activities Develop collaborative awareness campaigns and IEC activities & conduct joint supervision and M&E Figure 3: Implementation strategy for RNTCP-NTCP collaboration 9 Coordination Mechanism between 5 RNTCP and NTCP at National, State and District levels To ensure success of the initiative and achievement of objectives, there has to be smooth coordination and convergence across levels with respect to both RNTCP and NTCP programmes. 5.1. National Level Coordination Mechanism Suitable existing mechanisms at the national level under both RNTCP and NTCP will be used for providing overall guidance and necessary coordination. The coordinating body will comprise Deputy Director Generals of CTD and NTCP, Dte.GHS; Additional/Deputy Additional Director Generals of CTD and NTCP, Dte. GHS; Director NTCP and RNTCP, MoHFW, representatives from academia; civil society organisations, WHO and other domain experts. The key functions of the coordinating body are to: Strengthen coordination mechanisms between RNTCP and NTCP at the national, state and district level for addressing TB and tobacco co-morbidity; Provide guidance to states for implementing the TB- tobacco collaborative activities; Suggest strategies for roll-out and scale-up of activities aimed at minimising mortality and morbidity associated with TB -tobacco co-morbidity; Review, optimise and plan for future TB-tobacco collaborative activities based on reports shared by the states; and Regularly review normative tools and training materials based on feedback from the ﬁeld. 5.2. State Level Coordination Mechanisms The State can use existing mechanisms for coordinating the TB-tobacco collaborative activities. The State TB Committee can be pressed into service with participation of the State Nodal Ofﬁcer. Alternately, under NTCP, in the SLCC framework, the State TB Ofﬁcer and the Director of State Training and Demonstration Centre (STDC) of the TB programme should be included in the SLCC for collaboration between the two programmes at the state level. States may also use an existing Committee, other than SLCC and include state ofﬁcials of RNTCP and NTCP in the same. The key functions of the Coordination Committee are to: Ensure implementation of joint collaborative activities implemented at state level; Review status of trainings conducted at district level for DOTS care providers on ‘Brief Advice’; Ensure timeliness of reporting from district level; Review performance indicators agreed under a collaborative framework; Review outcomes of the joint monitoring of the collaborative activity; 10 Ensure availability of manpower and supplies of Nicotine Replacement Therapy (NRT) for tobacco cessation interventions; and Support and provide measures for involvement of other stakeholders for implementing ‘Brief Advice’. 5.3. District Level Coordination Mechanisms At the district level, a mechanism similar to state level can be replicated. District TB Committee to include District Nodal Ofﬁcer from NTCP as Committee member. Alternatively, District TB Ofﬁcer (DTO) to be included as Committee member in the existing District Level Coordination Committee (DLCC) of NTCP. This will facilitate coordination of activities at district and sub-district levels. The key functions of the Coordination Committee at the district level are to: Strengthen coordination between RNTCP and NTCP staff in the district; Address issues related to training of key programme staff and general health staff; Promote participation of NGOs/CBOs and other private practitioners in implementing‘ Brief Advice’; Review availability of NRT at the Tobacco Cessation Centre; Ensure timeliness of reports from peripheral health institutions; and Review outcomes of joint monitoring of the collaborative activity. 11 Activities for Coordination between 6 RNTCP and NTCP There is ample evidence showing that tobacco use in TB patients causes high rates of relapse, morbidity and mortality. This clearly points to the need for TB patients to be drawn into tobacco cessation activities, especially given the fact that they will be in regular contact with health workers and may be more motivated than healthy persons to quit tobacco use. A system has been already established in TB programmes, wherein the status of tobacco use is being recorded (Figure 4). Addiction related information Current Tobacco user Yes No If yes, Smoking Smokeless Linked for cessation Yes No If tobacco user, status of tobacco use at end of treatment Quit Not quit Figure 4: Portion of TB treatment card The introduction of select interventions in the form of ‘Brief Advice’ will be easy and will hold promise of better outcomes. On the other hand, the Tobacco Cessation Centre and other cessation platforms will help to screen and identify latent TB infection and TB relapse cases in the community and support early initiation of TB management. 6.1. Integrating ‘Brief Advice’ for Tobacco Cessation in RNTCP All healthcare professionals who are responsible for implementing DOTS must be trained and counselled on the different processes and steps that need to be followed with respect to helping patients quit tobacco use and be tested for TB in a timely and efﬁcient manner. Some of these steps include: Enquiring status of tobacco use with every patient who gets registered as a TB case; Recording information about tobacco use in the revised TB treatment card (Annexure 1); Offer to the patient ‘Brief Advice’ on how to quit tobacco use based on 5 As and 5 Rs model; Follow-up with the patient by providing ‘Brief Advice’ at least twice a week and check on his/her quitting status; Observe patients and note if s/he is showing signs of quitting tobacco use after completion of intensive phase (two months of regularly providing ‘Brief Advice’). If not, encourage him/her to avail cessation services at the TCC or National Tobacco Quitline. Meanwhile, ensure that the Treatment Supporter (DOTS Provider) continues to provide ‘Brief Advice’ and record the ﬁnal status of quitting at the completion of TB treatment; 12 Make sure that the Treatment Supporter ﬁlls up and maintains the TB treatment Card and makes it available at the District TB Centre for future reference and follow-up. The District TB Centre must ensure that information related to tobacco use is duly ﬁlled in the TB Treatment card; Send the information recorded in the TB treatment card as feedback through the existing HMIS (NIKSHAY) under RNTCP; Enhance the skill of Treatment Supporter regarding the process of providing ‘Brief Advice’ to tobacco users; try and motivate registered TB patients to avail National Tobacco Quitline/ mCessation SMS services for getting regular tips and SMS for quitting the tobacco habit. Both the services are user friendly and available for free. Registration for mCessation can be done by giving a missed call on 011–22901701; and Explore the mechanism for introducing a follow-up column regarding ‘Brief Advice’ in the digital TB treatment card. 6.2. Involvement of NTCP in TB Case Finding For enhanced case ﬁnding of TB patients through NTCP, the following process has been indicated: Screening four symptoms of active TB- ‘TB Symptoms Complex’ among tobacco users registered at the District Tobacco Cessation Centre (TCC), National Tobacco Quitline/mCessation. ‘TB Symptoms Complex’ comprises of cough that has persisted for more than two weeks, fever of more than two weeks and experiencing of signiﬁcant weight loss and night sweat and referring for further conﬁrmation and management; Training modules for NTCP Programme Staff and Training modules for National Tobacco Quitline to include chapter on ‘TB-Symptoms Complex’ to identify active TB cases among persons registered for tobacco cessation; mCessation algorithm to include SMS on ‘TB-Symptoms Complex’; TB infection control guidelines to be implemented in TCC; Teachers’ training modules prepared for tobacco control to include information on ‘TB-Symptoms Complex’ for increasing awareness among children and young adults; and TCC and National Tobacco Quitline to support in identifying TB relapse cases, as there is increased risk of relapse of TB among tobacco users. 13 'Brief Advice' for Tobacco Cessation: 7 The 5 A's and 5 R's Approach Health workers should ask everyone in the community if they smoke and/or chew tobacco and urge every tobacco user to quit by providing clear, strong and personalised advice. ‘Brief Advice (5 A and 5 R)’ approach is one of the programmatic approaches which advice against stopping smoking/tobacco chewing based on the individual’s preferences, needs and circumstances. People who smoke/chew should be asked how interested they are in quitting and if so, assistance should be provided. People who are not ready to quit should also be asked to consider the possibility and encouraged to seek help in the future. The Treatment Supporter (DOTS Provider) must try to motivate the tobacco-user to think about quitting. This is important because there are so many other forces acting that are difﬁcult to control: physiological compulsions to use tobacco, learned habits, social pressures and accessibility, amongst others. Engaging the mind of the tobacco-user, bolstering it with new knowledge and a sense of caring by the health professional can help motivate the patient to change. Follow-up will be important to help keep the tobacco-user on track, until s/he is conﬁdent about remaining tobacco-free and is sure of preventing relapse. This simple intervention by a healthcare professional/Treatment Supporter can help motivate patients to change their behaviour. This is important even for patients who have adequate knowledge about why they should quit using tobacco, because of the nature of addiction, and is even more important for those who do not have such knowledge. The intervention helps them to think about the importance of quitting tobacco use because of the respect the healthcare professionals enjoy in society. Box 2: 5 A’s approach of ‘Brief Advice for Tobacco Cessation 5A's Approach of 'Brief Advice' for Tobacco Cessation 'Brief Advice' for quitting tobacco use consists of 5 'A's 1. ASK the patient if s/he is a tobacco user, during the course of every visit. 2. Brieﬂy ADVISE against continuing tobacco use and link the current condition/ailment to continued tobacco use, where possible. e. g, “Quitting smoking/tobacco use would improve your health and aid in early recovery from illness.” 3. ASSESS readiness to quit by asking the patient whether s/he is ready to quit tobacco use at this time. e.g, “How recently have you thought about quitting tobacco?” 4. ASSIST the tobacco user in making a quit plan. 5. ARRANGE for follow-up by setting the next contact date. 14 Box 3: 5 R’s approach of ‘Brief Advice for Tobacco Cessation 5R’s Approach of ‘Brief Advice’ for Tobacco Cessation Relevance of quitting: If the tobacco user is not yet thinking about quitting tobacco use, the doctor/counsellor/ Treatment Supporter (DOTS provider) will promote greater awareness to the patient regarding the relevance of quitting. Risks of continuing: Risks of continuing use of tobacco should be pointed out to a TB patient. The risk of relapse, especially within the ﬁrst six months after treatment has been completed; risks of disease among household contacts who are already infected, especially children; long-term risk of heart disease, asthma, bronchitis etc are aspects related to tobacco use that must be understood. Rewards of quitting: Ask the patient to mention potential beneﬁts of stopping tobacco use beyond the beneﬁts related to his/her TB disease. Underscore the most relevant ones and feel better with the knowledge that TB is being cured and that s/he will be able to perform better in physical activities. The person will also be able to save money and live a better life. S/he will once again be able to relish food and ﬁnd sense of smell and taste getting restored, Roadblocks to quitting: Many tobacco users are largely unaware of the potential harm that continued tobacco use can do to them. If the patient is not ready to quit, the doctor/counsellor/Treatment Supporter (DOTS provider) must not push the patient. People usually need time to change the mindset. If the patient is at least thinking about quitting, the doctor/counsellor/Treatment Supporter (DOTS provider) can ﬁnd out the roadblocks which the patient is experiencing with respect to quitting and help him/her to overcome these. This process will assist the patient to get ready for quitting tobacco use, in a sensitive yet ﬁrm manner. Repetition: The assessment of readiness to quit tobacco use at every visit to DOTS centre. If not ready to quit, repeat intervention at a later stage. 15 Linkages between TB and 8 Tobacco Control Programme A systematic step-wise plan that strengthens service provision both for RNTCP and NTCP will ensure strong linkages between the two progammes. This will help programme managers to stay on track and reach maximum number of tobacco users and TB patients, bringing them under the ambit of treatment. 8.1 Service Provision in RNTCP Service provision under RNTCP relates to mostly the ‘Brief Advice’ that is given to TB patients and the feedback that is sought on TB diagnosis of tobacco user clients. ‘Brief Advice’ for improving TB treatment outcomes: All TB patients who have been diagnosed and registered under RNTCP will be screened for tobacco use. The Medical Ofﬁcer at Peripheral Health Institution (MO-PHI) will be responsible for capturing the tobacco use information from the TB patient on the treatment card. The referral of TB patients to the nearest Tobacco Cessation Clinic will be done after the completion of Intensive Phase by MO-PHI after inputs have been received from the Treatment Supporter (patient not able to quit after giving repeated ‘Brief Advice’). Tobacco Quit status can be said to be achieved when a person has abstained and has not used any tobacco products in the last 12 weeks, 6 months and 1 year. Since the DOTS treatment spans over 6 months, the milestone for tobacco quitting under TB programme can be 12 weeks and further follow-up can be done with respect to tobacco quit status in case the TB patient is being followed up for at 1 year. The same deﬁnition will be used in the TB treatment card for indicating quit status. The information about quit status will be recorded at the end of TB treatment considering the possibility that the patient might relapse and re- initiate tobacco use. In the districts where NTCP is not being implemented or is functional, TB patients can be referred to the National Tobacco Quitline (toll free number-1800-11-2356) for further counselling. Information on tobacco use, type of tobacco use and quitting status at the completion of treatment will be captured by the Senior Treatment Supervisor (STS) from the treatment card of the respective TB units and transferred thereafter in the NIKSHAY platform. 16 Box 4: Key steps in the ‘Brief Advice’ Intervention The MO-PHI will provide ‘Brief Advice’ for tobacco cessation at his/her ﬁrst contact. The patient will be provided with an information ﬂyer about the quitting beneﬁt with the TB treatment card. The information ﬂyer can be obtained from the District Tobacco Control Cell (DTCC). Treatment Supporter (ANM/ASHA/teacher etc.) as stipulated in RNTCP will provide subsequent ‘Brief Advice’ to the registered TB patient and do follow-up at least twice in a week with the patient, as s/he comes to collect TB drugs. A job-aid card will be given to each Treatment Supporter which will contain step-by-step counselling technique to implement ‘Brief Advice (Annexure 3)’. The ﬁnal status of tobacco quitting will be recorded in the treatment card after completion of TB treatment. The STS will ensure completeness of treatment card and motivate. Medical ofﬁcer-Incharge of the health facility will make sure that the patient is regularly receiving ‘Brief Advice’, if the patient is taking TB treatment from institutes (public and private health facilities). The Treatment Supporter will advise and assess the quitting status of the TB patient on every visit. If the patient does not quit after the completion of Intensive Phase (IP), s/he will be referred to the nearest Tobacco Cessation Centre (TCC). The patient can also be referred earlier to the TCC if s/he has withdrawal symptoms. The patient will be referred to the nearest TCC using the treatment ID card mentioned at Annexure 2. As the RNTCP migrates to Daily Regime treatment and involves family members as Treatment Supporter, Brief Advice will be provided/ reinforced by frontline workers or trained health care professionals on regular basis. Feedback on TB diagnosis of tobacco user clients referred to DMC: The DTO will share the quarterly feedback report about the ﬁnal diagnosis of the TCC clients who were referred from the TCC to the nearest DMC, based on suspected TB symptoms. The feedback report can be generated from the NIKSHAY ‘Case Finding’ output report and feedback information subsequently updated in the ‘Tobacco Cessation Form’ at point number 25 (signiﬁcant current co-morbidity disorder) provided at Annexure 4. 8.2 Service Provision in NTCP Service provision under NTCP entails identifying of suspected TB cases from among tobacco users and referring the TB patient from the DOTS centre for counselling. Identiﬁcation of suspected TB cases among tobacco users: Intensiﬁed TB case ﬁnding will be conducted among clients at the Tobacco Cessation Centre (TCC)/National Tobacco Quitline/mCessation through screening of four symptoms of active ‘TB Symptoms Complex’. The ‘TB Symptoms Complex’ comprises cough of more than two weeks, fever more than two weeks, night sweat and signiﬁcant weight loss. The TCC will be responsible for implementing Infection Control Measure Guidelines to reduce exposure of TB infection among TCC clients. The Guidelines are placed at Annexure 7. The National Tobacco Quitline will screen the four symptoms of suspected TB in their registered clients. The Directory of TB health institutes will be provided to the counsellors of the ‘National Tobacco Quitline’ from which they can guide the patient to the nearest centre. 17 Box 5:Critical role of counseling in TB control Critical role of counseling in TB control The clients at TCC suspected with TB shall be referred to the nearest DMC facility for TB diagnosis with the RNTCP Laboratory Request Form (Annexure 6). The Psychologist/Counsellor posted at the TCC will be responsible for referring the suspected TB patient with Laboratory Request Form. S/he will also record the screening of TB symptoms in the ‘Tobacco Cessation Form’ at point no.16 (positive for any TB symptoms). The Psychologist/Counsellor will obtain the RNTCP Laboratory Request Form from the nearest DMC. Following which, the information compiled in the ‘Tobacco Cessation Form’ will be shared with the DTCC on a regular basis along with other reports. The DTCC will then share the information with the STCC accordingly. The clients referred from the TCC will be transferred back to the TCC after getting the TB services. In the National Tobacco Quitline, If the client is found positive for any of the ‘TB Symptom Complex’ symptoms, s/he will be encouraged to visit the nearest health centre for detailed check-up and the essential details (name, age, sex, address) will be recorded in the online software. Linking the suspected TB patient through digital initiative: The Quitline software will have provision to generate the report on a real-time basis. The dashboard part of the software will provide information about the proﬁle of suspected TB clients. Administrative link of the dashboard will be shared with the CTD division to extract information for further necessary action. A mechanism will be explored to link the ‘National Tobacco Quitline’ dashboard report with the ‘TB Missed Call’ initiative of the RNTCP programme. The ‘TB Missed Call’ will ensure that the suspected TB patient has visited the health facility for the diagnosis of TB. Further, the counsellors at the Quitline services will be trained for identifying TB symptoms and recording information. By conducting screening of TB symptoms, TCC/Quitline will also support to retrieve interrupters. They will identify relapse of TB in their regular clients who have completed TB treatment as there is increased risk of relapse of TB disease among tobacco user/s. TB patient referred from the DOTS centre for counseling: The TB patients referred to the Tobacco Cessation Centre (TCC) from the nearest PHI shall be followed up with intensive counselling services. Based on results of the ‘Fagerstrom Test for Nicotine Dependence’, patients will be managed as per the treatment protocol stipulated under the Tobacco Dependence Treatment Guideline. Medication available for tobacco cessation can be broadly divided into the following two groups: Nicotine Replacement Therapy (NRT) Non Nicotine Replacement Therapy In the 12thFive Year Plan, there is a provision of Rs. 200,000 per annum under the DTCC budget for providing Pharmacological Treatment of Tobacco Dependence at the district level. In this context, procurement and storage of NRT drugs should be strictly guided by the extant NHM Guidelines/ State NHM Guidelines, whichever is more applicable. The TCC will update the information about the referral in the ‘Tobacco Cessation Form (Intake and Follow Up)’ at point number 9 (Annexure 4). The DTCC after compiling information from TCC will share quarterly feedback with DTO on the quitting status of the referred TB patient. 18 Sensitisation & Training of 9 Health Staff for TB–Tobacco Collaborative Activities States will conduct Training of Trainers (ToT) at the state level to train all district TB ofﬁcers and district NTCP ofﬁcers for implementing the collaborative framework. Experts from the Tobacco Cessation Centre at the state level will also be utilised as resource persons for training. An e- Learning training capsule will be developed to sensitise both Treatment Supporter and counsellors posted at Tobacco Cessation Centre/ National Tobacco Quitline about the 'Brief Advice' and Screening of 'TB Symptom Complex' respectively. Job-aid for Treatment Supporter will also be prepared on similar lines. The National Tobacco Control Cell may be contacted for resource persons for trainings which will be conducted as part of routine RNTCP trainings. To optimally utilise the existing platform for training, the DOTS care provider/ Treatment Supporter will be trained in conducting regular ongoing trainings at the district level. Here, the District TB Ofﬁcer, NTCP District Nodal Ofﬁcers and NTCP counsellors may be requested to serve as resource persons. Under the NTCP programme, a dedicated chapter on TB screening will be included in the NTCP programme managers' manual. The programme staff of the NTCP will be trained for screening TB complex during their regular NTCP training. Further options will be explored to revise and include the TB screening chapter in the existing training module for doctors, health workers and the Accredited Social Health Activists (ASHA), to be used under the NTCP programme. Sensitisation of stakeholders, administrators and partners at the state/local level will be the joint responsibility of RNTCP staff and NTCP at the state and district levels. 19 10 Awareness and IEC The activities pertaining to Information, Education and Communication (IEC) aim to favourably change knowledge, attitudes, and practices among various stakeholders. They play a very critical role in bringing about awareness on TB symptoms and treatment, as also highlighting the harmful effects of tobacco use, with a view to induce health seeking behaviour. The IEC campaign must therefore inform, educate and persuade people to realise their roles and responsibilities and the beneﬁts that will accrue to them if they invest in the right practices. Sensitisation about the collaborative activity is required to generate awareness, both at the staff and community levels. The programme and hospital staff needs to be aware about the purpose and mechanism of the collaboration. The community needs to be informed regarding inter- linkages between the two diseases and the associated increased risks that they are likely to face. Key messages that must then be included in the various IEC materials will be developed and shared with States for further adaptation in local languages. Some of the efforts that can be made to increase awareness are: Develop and display/air IEC materials/public service announcements (PSA) on co-morbidities; Develop TB-tobacco posters under NTCP and share these with RNTCP Division and vice versa for further updating, if needed; Strive to make all the DOTS centres/clinics tobacco-free; ▪ Display IEC materials at TUs, DMCs and Tobacco Cessation Clinics; ▪ Display IEC materials at DMCs and TUs with clear mention of the hazards of tobacco use, along with ‘Brief Advice’; Prominently put up materials related to hygiene and TB awareness at the Tobacco Cessation Centres; Step up awareness building efforts at both units for patients and staff members; Sensitise all stakeholders (partners, policymakers and administrators) on a regularly basis; Programme divisions to make every effort to sensitise the community about the ill effects of TB and tobacco use; and Make available Quitline brochures to all registered TB patients who are using tobacco in any form. 20 Figure 5: TB-Tobacco Posters 21 11 Recording and Reporting Recording and reporting is an important component to guide and monitor the progress for any initiative in the programme. The existing mechanism of both programmes will be utilised for reporting and recording, with necessary revision in existing formats. The formats will be used by various facilities as prescribed in both programmes. The information collected in the reporting and recording formats will then be utilised in the review meetings. 11.1Revised National Tuberculosis Control Programme A number of the indicators and reporting formats under RNTCP have in recent times undergone changes and modiﬁcations. Indicators under RNTCP Proportion of Proportion of Proportion of Proportion of TB registered TB screened TB screened TB patients who have patients screened patients identiﬁed patients linked to successfully quit for tobacco use as tobacco user tobacco cessation tobacco use services Numerator= No. of Numerator= No. of Numerator=No. of Numerator=No. of TB patients screened TB Screened TB TB patients provided screened for patients identiﬁed as patients identiﬁed as 'Brief Advice' for tobacco use tobacco users tobacco users linked tobacco cessation to tobacco cessation and who have Denominator=No. of Denominator=No. of services at the end successfully quit TB patients TB patients of Intensive Phase tobacco use on registered in the screened for (Tobacco Cessation completion of TB reporting quarter tobacco use Centre/National treatment Tobacco Quitline/ mCessation) Denominator=No. of TB patients Denominator=No. of screened as positive screened TB tobacco users patients identiﬁed as tobacco users The information for all the above will be recorded in the TB treatment card and the indicators will be recorded in NIKSHAY/Quarterly Report on Programme Management and Logistics (QRPML). Reporting Formats: Reporting template of TB Treatment Card is being captured in the NIKSHAY platform. The report can be made available and generated through NIKSHAY at TU level and above under the 'Case Finding' output report. NIKSHAY can generate reports on a monthly/quarterly basis on the following: 22 Number of registered TB patients who use tobacco products and the type of tobacco (smoke/smokeless); Number of registered TB patients linked to cessation services at the completion of intensive phase after regularly providing 'Brief Advice'; and Number of registered TB patients who were tobacco users and have quit tobacco use at the end of TB treatment. 11.2National Tobacco Control Programme The list of indicators and reporting formats have been developed and shared with concerned ofﬁcials across levels. Indicators under NTCP Proportion of registered Proportion of attendees at Proportion of identiﬁed TB clients at Tobacco TCC found positive for TB patients referred by Cessation Centre and symptoms and diagnosed RNTCP to avail TCC screened for 'TB with TB services after completion Symptom Complex' of Intensive Phase Numerator=No. of Numerator=No. of Numerator=No. of TB attendees/clients at TCC attendees suspected for patients referred by screened for four TB among attendees at RNTCP after giving regular symptoms of TB TCC (found positive for TB 'Brief Advice' symptoms) Denominator=No. of clients Denominator=No. of total registered at TCC in Denominator=Total no. of attendees at TCC reporting quarter attendees at TCC screened for TB symptoms This information will be This information will be This information will be recorded in point no. 16 of recorded in point no. 25 of recorded in point no. 9 of 'Tobacco Cessation Form' 'Tobacco Cessation Form' 'Tobacco Cessation Form' provided at Annexure 4 provided at Annexure 4 provided at Annexure 4 and indicator shall be and indicator shall be and indicator shall be reported in Quarterly reported in Quarterly reported in Quarterly Report of DLCC Report of DLCC Report Reporting Formats: Quarterly reporting template by the National Tobacco Control Programme (Part B) is provided at Annexure 5. Part B will capture the following additional information. 23 Part B: Quarterly Reporting Template of National Tobacco Control Programme S.No. Activities During Up to the the quarter quarter in the Financial Year 15. a. Number of persons screened for the TB symptoms complex referred to DOTS Centre b. Number of persons found positive for the TB symptoms complex and referred to nearest Designated Microscopic Centre c. Number of registered TB patients referred to TCC for tobacco cessation counselling after giving ‘‘Brief Advice’’ State may provide details of any other outstanding/important initiative/activity undertaken 16. during the quarter at the State or district levels (including in non-NTCP districts of the States) Figure6: Portion of Part B of Quarterly Reporting Format of NTCP Number of registered clients at TCC screened for TB symptoms; Number of registered clients at TCC found positive for TB symptoms; and Number of registered clients diagnosed as TB patients. The information from the ‘Tobacco Cessation Form’ from the TCC will be compiled at the district level and will be reported in Part B of the Quarterly Reporting Format at the District Tobacco Control Cell (DTCC). Next, the DTCC will on a quarterly basis share the report with the State Tobacco Control Cell (STCC). The National Tobacco Quitline will be linked to the online dashboard which provides real time information on programme performance. A provision will be made in the dashboard software to provide real time information that includes details like name, age, address and mobile number of the clients who are suspected to be positive for TB symptoms. The administrative link to such information will be provided to the Central TB Division (CTD) which will then generate the report on an excel ﬁle, sharing the information with States for needful action. The provisional Dashboard report is provided at the Annexure 10 and will provide the following information: Number of registered clients at Quitline screened for TB symptoms; Number of registered clients at Quitline found positive for TB symptoms; and Number of registered clients at Quitline referred to the nearest DMC. 24 Supervision, Monitoring and 12 Evaluation The District Nodal Ofﬁcers (DNO) of NTCP and District TB Ofﬁcer (DTO) of RNTCP will participate in the quarterly review meetings of both programmes along with district level supervisors and coordinators of both programmes. In the meeting, the DTO will compile and share the information that has been captured in the 'Case Finding' as part of NIKSHAY. This will have information about the quitting status of registered TB patients using tobacco products. The DNO will share the information about the TCC clients who were suspected for TB and were referred to the Designated Microscopic Centre, from the reports complied from the TCC. Any gap in the reporting and recording will be discussed and resolved in the review meeting. The DTO and DNO will also plan the joint monitoring visit, at least on a quarterly basis to TCC/DOTS centre based on the analysis of indicators in the quarterly reports. The State Nodal Ofﬁcers (NTCP) and State TB Ofﬁcer (RNTCP) will conduct joint monitoring visits to districts and prioritise them based on performance indicators and programme needs. The STO and SNO will also participate in the monthly/quarterly review meetings of both the programmes along with state level supervisors/coordinators/consultants of both the programmes. The STO and SNO ofﬁcers shall be responsible for collation and compilation of reports from the districts and will do the quarterly reporting to national level authorities. Regular supervision will be undertaken to ensure that the DOTS care-providers, including health workers are implementing skills imparted in training courses. Supervision of joint TB and tobacco control activities therefore should be included in the checklist for STLS and STS. The District TB Ofﬁcer and District Nodal Ofﬁcer-NTCP will jointly plan monthly supportive supervision to assess implementation of Brief Tobacco Advice in the treatment card. 25 Roles and Responsibilities of 13 Programme Staff for Collaborative Activities As per the hierarchy followed in the NTCP, the programme staff includes a state level consultant, a DNO consultant, a, counsellor and a data entry operator. Their roles and responsibilities are clearly assigned and are summarised below: 13.1 Roles and Responsibilities of RNTCP Staff The RNTCP staff is assigned at the state and district level as also at the TB unit level and the DMC/PHC level. Each of these are assigned speciﬁc tasks which are summarised below: State level District level TB Unit level DMC/PHI level (STO, STDC (DTO, District (MO-TC/BMO, (MO, LT, ANM, Staff Director, APO, Programme STS, STLS) Nurse, Health DEO) Coordinator, MO- worker) DTC, DEO) Invite State Nodal Collaborate with Ensure screening of Give ﬁrst 'Brief Ofﬁcer of NTCP in DLCC/TCCs for tobacco use at TB Advice' to registered State TB Committee implementation of diagnosis centre TB patient meeting and actively TB- tobacco and its report participate and activities sharing with District contribute in SLCC TB ofﬁcer to discuss TB- tobacco collaborative issues on quarterly basis Review district level Actively participate Train/motivate Ensure components of TB- and contribute in Treatment completeness of tobacco DLCC outlined for Supporter on 'Brief records e.g. collaborative TB-Tobacco Advice' information related activities on collaborative to tobacco use in TB quarterly basis activities treatment card 26 Align Assist in training of Ensure that Ensure that patient implementation of sub-district staff and Treatment is referred from TB-tobacco other staff involved Supporter is giving PHI/TU/Treatment collaborative in management of regular 'Brief Advice' Supporter for activities in relation TB-Tobacco to registered patient intensive to expansion of co-morbidities and patient has counselling for NTCP programme in been linked to tobacco cessation districts cessation services and share feedback at end of Intensive phase (Tobacco Cessation Centre/National Tobacco Quitline/ mCessation) Provide funds for Conduct joint Ensure information Responsibility for relevant training supervision of about tobacco use collecting pertaining to TB- collaborative and quitting status information and tobacco activities with from treatment card updating treatment collaborative District Nodal Ofﬁcer is captured by card will rest with activities (NTCP) Senior Treatment institutional Supervisor of Treatment respective TB unit in Supporter of PHI/ NIKSHAY Health worker Involve in joint Ensure submission supervision of of accurate and collaborative timely reporting of activities with State TB-tobacco formats Nodal Ofﬁcer to state ofﬁcial along (NTCP) with feedback about progress of TB- tobacco collaborative activity Collaborate with relevant stakeholders to strengthen TB- tobacco activity in the district 27 13.2 Roles and Responsibilities of NTCP Staff State level DNO/Consultant Counsellor Data Entry (SNO/State Operator Consultant Convene and Collaborate with Conduct screening Compile accurate coordinate SLCC District TB Unit for of 'TB Symptom report of TB-tobacco meeting; invite STO implementation of Complex' in clients collaborative activity to the meeting; and TB-tobacco activity attending NCD in formats participate in the clinic/ mentioned in the State TB Committee TCC/registering at collaborative meeting National Tobacco framework Quitline/ mCessation initiative and provide tobacco cessation counselling to TB patients referred from the DOTS centre Review components Convene DLCC Ensure proper Provide feedback to of TB-tobacco meetings and invite display of IEC SNO/ collaborative District TB Ofﬁcials materials related to DNO/Consultant on activities on to attend meetings TB-tobacco any discrepancy for quarterly basis from as outlined in the collaborative the indicator all districts TB-tobacco activities at TCC analysed collaborative and at all other framework/ events/activities participate in District TB Committee meeting Align Assist/organise Actively participate Collaborate with implementation of training of TCC in training of TB- data entry operator TB-tobacco involved in providing tobacco of District TB unit to collaborative cessation services collaborative activity exchange reports of activities in relation to ensure screening TB-tobacco to expansion of of 'TB Symptom collaborative activity NTCP programme in Complex' Tobacco prepared from Form the districts Cessation Clinic and B of Quarterly its report sharing Reporting Template with District TB and 'Tobacco ofﬁcer Cessation Form' of TCC 28 Ensure that training Conduct joint Assist Maintain records of on TB-tobacco supervision of DNO/Consultant in TB-Tobacco collaborative collaborative preparing TB- collaborative activity activities are activities with tobacco with other NTCP mainstreamed in District TB Ofﬁcer collaborative activity records ongoing training action plan under NTCP at state and district level Conduct joint Ensure submission supervision of of accurate &timely collaborative reporting of activities with State Quarterly Reporting TB ofﬁcials Template that contains information on TB-tobacco collaboration Collaborate with relevant stakeholders to strengthen TB- tobacco activity in the district 29 14 Implementation Plan In 2014, programme managers of ﬁve states, namely Kerala, Gujarat, Himachal Pradesh, Chhattisgarh and Tripura were trained to implement the TB-tobacco collaboration activity. The implementation status of collaborative activities will be assessed and learning from the evaluation report used to expand the collaborative framework in other states and districts. In the second stage, the programme will be implemented in districts where both programmes have a well developed infrastructure in terms of manpower, implementation of activities and utilisation of funds. While the ‘Brief Advice’ will be provided to every registered TB patient who is a tobacco user, screening of TB symptoms will be done in Tobacco Cessation Centres which are functional under the NTCP programme. In the third stage, the National Tobacco Quitline will be linked for screening TB symptoms in registered clients. States will be encouraged to setup similar Tobacco Quitline services with the help of medical colleges/NGOs at the state level to cater to the increased utilisation of cessation services. The National Tobacco Quitline will share the patient proﬁle of suspect TB to ‘TB Missed Call’ initiative for ensuring that s/he utilises health services. The mCessation services for screening TB Symptom Complex will also be explored in the third phase of services. A mechanism will be explored to introduce a follow-up column regarding ‘Brief Advice’ in the digital TB treatment card. Referral for intensive counselling or National Tobacco Quitline will be made based on the patient’s status of quitting tobacco use, at the end of the treatment. The collaborative framework will be implemented in the following manner in selected districts: Activities Responsibility CTD and NTCP to send appropriate directives to state CTD/NTCP Division focal points to prepare action plan for implementation of TB–tobacco collaborative activities States to start implementing TB–tobacco collaborative SNO (NTCP) and STO activities as per state implementation plans RNTCP consultants to support Training of district and sub-district staff at State Nodal Ofﬁcer (NTCP) state/regional level and for district level staff on Brief and STO Tobacco Advice RNTCP consultants to support Sensitisation of ﬁeld level staff as part of regular DTO/DNO (NTCP) ongoing training Sensitisation of stakeholders (administrators, State Nodal Ofﬁcer (NTCP) partners) at state and district levels and STO RNTCP consultants to support 30 Initiation of implementation and reporting State Nodal Ofﬁcer (NTCP) and STO RNTCP consultants to support Joint visits by STO/SNO – State level ofﬁcials to district and sub-district level – National teams to states CTD/NTCP Linkage with National Tobacco Quitline/ CTD/NTCP mCessation/TB Missed Call services 31 Tools for TB-Tobacco Collaborative 15 Framework The following sets of tools are available for implementing the TB-tobacco collaborative framework: TB Treatment Card and TB ID card; Job Aid for 'Brief Advice' - 5A’s and 5R’s approach for tobacco cessation; RNTCP Laboratory Request Form; Infection Control Measure Guidelines; Tobacco Cessation Form of the TCC; Quarterly Reporting Format of State and District Tobacco Control Cell; Flyer for the TB Patients- Tobacco Quitline Brochure; 32 Annexures 1 33 34 TB ID card for referring registered TB patient to nearest Tobacco Cessation Centre 35 Annexures 2 36 TB Site: □ Pulmonary □ Extra Pulmonary If extra pulmonary, pleasc specif ----------------------------- Druge H R E Z mK mA mC xfL xfM sC atE SAP zld zfC xmA vlc rlC QDB Treatment regimen □ Regimen for INH mono/poly resistant TB □ Regimen for MDR/RR TB □ Modiﬁed Regimen for MDR/RR- TB + FQ/SLI resistance □Regimen for XDR TB □ Modiﬁed Regimen for mixed Dose pattem resistance □ Regimen with Bedaquiline (mg) for MDR-TB Regimen + FQ/SLI resistance □ Regimen with Bedaquiline for XDR-TB □ Regimen with Bedaquiline for failures fo regimen for MDR-TB □ Regimen with Bedaquiline for failures of regimen for XDR-TB □ Regimen for mixed pattern resistance Initiation Date: ------------------------------------------- Registration Date: -------------------------------------- 37 Annexures 3 Flow chart – 5As & 5 Rs model Tobacco user accesses a healthcare/ Treatment Supporter (DOTS provider) 38 Tobacco user accesses a healthcare/ Treatment Supporter (DOTS provider) *Quitting means a person who has not used any sort of tobacco product for the 'last 12 weeks' 39 5 As and 5 Rs Models 5A’s for patients who are ready to quit 5R’s for patients not ready to quit Ask- Ask about tobacco use Relevance- How is quitting most personally relevant you? Advise- Advise to quit Risks- What do you know about the risk fo smoking in that regard? Assess- Assess ‘readiness’ to make a Rewards- What would be the beneﬁts of quitting quit attempt in that regard? Assist- Assist in quit attempt Roadblocks- What would be difﬁcult about quitting for you? Arrange- Arrange follow up Repetition- Repeat assessment of readiness to quit-if still not ready to quit repeat intervention a later date. How to implement 5A’s and 5R’s? Ask Relevance Risks Rewards Advise Roadblocks Repetition Not Ready to Quit Assess Five R’s Ready to Quit Not Ready to Quit Assist End positively Arrange 40 Annexures 4 Tobacco Cessation Form Average numbers of cigarette/sachers Age at Starting Tobacco use Smokeless 1. 2. 3. Smoking 1. 2. 3. 41 42 Annexures 5 Part B: Quarterly Reporting Template of National Tobacco Control Programme S.No. Activities During Up to the the quarter quarter in the Financial Year No. of meetings of the SLCC with dates 1. No. of meetings of the Working Group with dates Whether State Level Advocacy Workshops held 2. If yes, attach reports/minutes No. of participants in the Advocacy Workshops Training of Trainers programmes held 3. If yes, attach reports Trainings on tobacco cessation for Health care providers If yes, attach reports 4. No. of Participants in the Trainings on tobacco cessation for Health care providers Types of IEC materials adapted /developed (e.g. posters/stickers/handouts/wall paintings/hoardings etc.) 5. Examples of different IEC materials disseminated Examples of instances of integration of tobacco control messages in other health / development campaigns Details of meetings held with other relevant State Govt. departments 6. Details of training programmes of other departments in which STCC participated and made presentations on tobacco control Details of meetings held with civil society organizations 7. and professional bodies (e.g. NGOs, NSS, NCC, IDA, IMA etc.) DTCCs set up in the State 8. Staff recruited by the DTCCs Districts where District Level Co-ordination Committees have been set up Districts where meetings of the District Level Co-ordination 9. Committees have taken place Total Meetings of the District Level Co-ordination Committees Districts where enforcement squads have been set up to monitor compliance of COTPA 10. Visits conducted by the enforcement squads Persons challaned and amount collected (information to be given month-wise in the format as annexed) 43 Details of complaints received through National Violations helpline Details of such complaints where action has been taken Trainings/sensitisation programmes for different stakeholders organised by district cells 11. Participants in the trainings/sensitization programmes at district level Types of IEC materials adapted/ developed by DTCCs 12. (e.g. posters/stickers/handouts/wall paintings/hoardings etc.) PHCs, CHCs, Govt buildings, schools and other public places covered with these IEC materials Schools covered in the School Programmes by the district cells (i) Public Schools (ii) Private Schools (iii) Coaching 13 Institutes Details of children covered in these School Programmes Details of School Programmes conducted Number and names of districts where Tobacco Cessation Centres (TCCs) have been set up Details of TCCs set up in the districts (indicate separately details of TCCs set up in the district hospitals, other government set-ups, NGOs, private set-ups etc.) 1. Whether staff is in place in these TCCs 2. Whether counsellors working in these TCCs are formally trained in cessation activities (indicate separately the total number of counsellors in place and the number of counsellors who have received formal training) 3. Have the TCCs arranged for any cessation trainings 14. for healthcare providers/workers? If yes, indicate the number of trainings undertaken with details 4. Whether pharmacological treatment of tobacco dependence is available 5. Whether equipments such as Carbon Monoxide monitor and Spirometer have been procured 6. No. of persons who availed services at the TCCs a. Number of persons who received counselling b. Number of persons who received pharmacotherapy c. Number of persons who received both d. Number of persons who received counselling / pharmacotherapy and quit tobacco use 44 15. a. Number of persons screened for the TB symptoms complex referred to DOTS Centre b. Number of persons found positive for the TB symptoms complex and referred to nearest Designated Microscopic Centre c. Number of registered TB patients referred to TCC for tobacco cessation counselling after giving ‘‘Brief Advice’’ State may provide details of any other outstanding/important initiative/activity undertaken 16. during the quarter at the State or district levels (including in non-NTCP districts of the States)

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