This document provides guidance on tuberculosis (TB) treatment initiation and follow up. It outlines key actions including counseling patients, initiating appropriate treatment regimens based on drug sensitivity and testing for HIV/diabetes, assessing socioeconomic status, opening treatment cards, ensuring treatment adherence, arranging drug and supply availability, and maintaining patient follow up and records. It also describes the Nikshay Mitra program which aims to improve TB treatment outcomes through community support such as nutritional assistance. Health staff are tasked with enrolling donors to this program.

1. CME
on
Tuberculosis
1st/ 2nd Saturday Block MIES meeting
National TB Elimination Programme
August 2022
State TB Cell
Swasthya Bhawan
Directorate of Health Services
West Bengal

2. Treatment initiation after
Diagnosis of Tuberculosis

3. Key actions for treatment initiation
1. Counselling
2. Initiation of appropriate regimen
3. Clinical evaluation including nutritional assessment
4. HIV & Diabetes Testing
5. Assess the socioeconomic status
6. Open a treatment card
7. Plan appropriate treatment adherence and monitoring mechanisms
8. Ensure availability of Drugs
9. Arrange for follow up during treatment and long term follow up of TB cases
10. Arrangement to maintain records
11. Arrange for Public Health Action for all notified TB patients

4. 1. Counselling
• Counselling all TB patients by MO-PHI before initiating treatment
• Involve close family members during the counselling
• Counselling should include
• Education of patient and family members
– About type of disease
– Mode of spread of disease
– Dosage schedule, duration,
– Common side-effects of treatment & methods to prevent them
– Counselling regarding importance of need for regular treatment
– Consequences of irregular treatment or premature cessation of treatment
• Treatment adherence monitoring methods explained
– DOT manually
– ICT methods
• Cough etiquette and proper disposal of sputum for prevention of transmission of
disease
• Encourage him / her to get all his close contacts (especially household contacts)
screened at the earliest
• Assure the patients that s/he will be supported during the entire course of
treatment by the MO and peripheral health workers

5. 2. Initiation of appropriate regimen
• Decision on type of patient and treatment regimen
– Based on drug sensitivity pattern, i.e., DSTB or H-mono/ poly
resistance, history of ADR to ATT
– Initiation of appropriate regimen and ensures completion of
treatment
• All diagnosed patient should be initiated on treatment at the
diagnosing PHI as soon as possible after the diagnosis

6. 3.Clinical evaluation
• Record weight and height of the patient
– To assess Body Mass Index (BMI)
– Initiating treatment regimen based on weight bands
• Assess nutritional status of patient and link the patient for additional nutritional support
• Assess general condition to identify patients who may need hospitalization
• Assess for co morbidities like HIV, diabetes, liver or renal diseases, neurological disorders etc so
that appropriate management measures can be taken
• Assess for substance abuse especially tobacco (in any form) & alcohol and link him/her to
respective TCC (Tobacco Cessation Clinic)/ de-addiction centre
• Clinical examination of all TB cases should be done by MO
• Clinically follow up the patient once in a month to early identify any adverse drug reaction
• Clinically follow up to assess clinical improvement
• Follow up should be supported by laboratory investigations whenever necessary

7. 4. HIV Testing
• MO should make efforts to get HIV testing
– All presumptive TB patients
– All diagnosed TB patients if not done earlier
• All HIV positive TB patients must be referred to ART Centre
– Initiation of ART
– Initiation of CPT

8. 5. Assess the socioeconomic status
• Link the patient with appropriate social support schemes
• Nutritional support scheme- under Nikshay Poshan Yojana
• Locally managed additional nutritional support

9. 6. Treatment card issuance
• At the time of initiation of treatment a set of treatment card
(Annexure 5) to be issued
– For each patient ( one at PHI, one at TU, one at sub centre)
– If required more cards may be issued ( in case of treatment supporter)
• Each patient must be given TB Identity Card (Annexure 6)

10. 7. Plan for Treatment adherence
• Plan appropriate treatment adherence
• Plan appropriate monitoring mechanisms
– To be done consultation with the patient
– To be done consultation with his/her family members
– To be done consultation with peripheral health worker who is
responsible for monitoring treatment adherence

11. 8. Availability of Drugs & logistics
• Drugs should be available at the treatment support centre
along with the TB treatment card
• 99 dots envelopes , wherever available , should be given with
the strips of FDCs
• Arrange for sputum containers for collection of early morning
samples for follow-up examinations
• Annexure 15A form should be made available at all the
treatment support centres (SC/SSK/PHC/UPHC/UHC/HAU)

12. 9. Arrange for follow up
Follow up for Pulmonary patient
• Arrange for follow up
– During treatment (end of IP & end of CP for DSTB , as per guideline for
DRTB)
– Long term follow up of TB cases
• A due list to be maintained by all the treatment supporters
(ASHAs/HHWs) to ensure timely follow-up
• Long term follow-up:
– After completion of treatment, the patients should be followed up
clinically at the end of 6, 12, 18 & 24 months
– In the presence of any clinical symptom, (e.g., cough) sputum microscopy
and/or culture of the biological specimen should be considered. This is
important in detecting recurrence of TB at the earliest

13. 9. Arrange for follow up
Follow up for extra pulmonary patient
a. Clinical Follow up: it is the most important criteria for the follow up
of patients with Extra-pulmonary TB. The follow up is mainly based
on following clinical parameters. -
– Weight Gain
– Decrease or increase in symptoms (e.g. healing of ulcer /
scrofuloderma)
– Increase or Regression in size of nodes
– Appearance of new nodes
– If chest symptomatic, monthly sputum for AFB and chest X-ray (to rule
out pulmonary involvement)
– Other Extra-pulmonary sites should be monitored
– Monitoring for drug adverse reactions
• b. Bacteriological Follow up: it should be done as per schedule,
whenevr specimen is available.

14. 10. Maintain records
• MO & CHO should maintain TB Notification register at the
PHI level (Annexure 7) for patients
– Diagnosed in PHI
– Transferred in PHI
• Ensures updating of Notification register and NIKSHAY

15. 11. Arrange for Public Health Action
• Arrange for Public Health Action for all notified TB patients
• Including those notified from private sector

16. Community Support to Tuberculosis
Patients :
Nikshay Mitra

17. 1. To improve treatment outcome of TB patients.
2. To augment community involvement in meeting commitment to end TB by 2025
3. To leverage the avenues for Corporate Social Responsibility (CSR) opportunities.
SCOPE OF THE PROGRAM
• Smallest unit – Districts /Blocks/ Urban Wards/ Individual or Group of TB
patients
• Type of assistance –
• Nutritional supports (Mandatory)
• Vocational support (additional)
• Support in accessing the diagnostic services (Additional) as mutually agreed by the
donor, district administration and other stakeholders.
• Minimum Period of Commitment – One year/ Two Year/ Three Year
Objective of Nikshay Mitra

18. MAIN TASK and PROGRESS UPDATE
• Consent collection from on Treatment TB Patients
– Mobile OTP based
– Physical consent form
• Finding potential donor & Enrollment of NIKSHAY MITRA (
Donor Registration)
• Who can be DONOR
– Co-operative, Corporate, Institutions, Individuals, Elected
representatives, NGOs

19. Roll of Health Staff for NIKSHAY MITRA enrollment
–Encourage potential donors across the State to register themselves as
Nikshay Mitra to contribute to the initiative
–Districts authorities and Blocks to identify and motivate potential
donors (Nikshay Mitra)
–Encourage all line departments in the State/UT to support the
initiative
–Monitoring and periodic review of the initiative
–Felicitation of Nikshay Mitra in public forums