TechNet-21 - Forum

This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.

Discussions tagged TB

CME workshop on Diagnostic role and the Rights to be observed in Tuberculin Skin Test (Mantoux test) at St John Medical College (SJMC), Bengaluru held on 04 Sep 2019.

Dear viewers KVG team wishes to share the following with the viewers and supporters of "End TB Programme" as tuberculin skin test [Mantoux test] is in practice since 1907 however there are many programmatic errors happening at the service delivery point which can be witnessed by anybody anywhere in the country administering tuberculin. Context: The Union Government has rolled out a programme for universal screening of an estimated 250 million children and adolescents below 18 years annually for Leprosy and Tuberculosis (TB) and put on treatment if required. TB kills an estimated 4.8 lakh Indians (sharing 31% of global TB deaths) every year [>1,400 every day]. India has the highest TB burden (27% of the world) with more than a million ‘missing’ cases every year that are not notified – either undiagnosed, unaccountable, inadequately diagnosed and treated in the private sector. (https://indianexpress.com/article/india/govt-rolls-out-scheme-to-screen-all-children-below-18-for-leprosy-tb-5943004/ accessed on 06-09-2019). In this regard Manotux test [TST] has a definite role. Tuberculin Skin Test (TST) is a simple and reasonably reliable method for the detection of infection by Mycobacterium tuberculosis. It is a diagnostic aid for corroborating with clinical findings though not a confirmatory test. Quote: It has to be approached “with respect, administered with care, read with deliberation and interpreted with sentient discrimination.”  Programmatic errors observed during opportunistic proactive supportive supervision: All the 8 rights to be observed before / while and after administering vaccines are applicable to Tuberculin also plus 2 more: a) Do’s and Don’ts for the patient during the reactogenic period of 0 to 48hrs; b) reading the test between 48 and 72 hours without fail. In almost all Medical Colleges visited in 4 states, tuberculin manufactured by “arkray” with different strengths is used: viz. 1TU, 2TU, 5TU and 10TU RT23 in 0.1mL, 5mL per vial providing 50 ID doses of 0.1mL each. Though the test is in practice since 1907, following programmatic errors in various permutation combinations were observed in different thematic areas of administering / reading TST: Cold chain: Stored in domestic refrigerator with vertical door opening horizontally. Often kept in the inner aspect of door abutting freezer compartment, tuberculin getting frequently frozen. Once brought from the main store, kept in the tray at the service point during working hours, often till the last dose in some institutions for couple of months. VVM: In India, tuberculin is not dressed with VVM and hence the potency of the reagent at any time is not known. Pediatric age: No uniformity, ranging from 0 – 5yrs to   0 – 18yrs.     About TU per 0.1mL and the units administered: “Testers” are not aware of number of TU per 0.1mL as a result in one college 10TU per 0.1mL is administered to children and 1TU in 0.1mL to adults. Different colleges are administering different strengths: 2 TU in 0.1mL for all, 5 TU in 0.1mL for all and 10 TU in 0.1mL for all. Quantity / volume: 0.05mL of 2TU in 0.1mL to children, 0.05mL of 5 TU in 0.1mL for children, 0.025mL (one digit from insulin syringe) of 10 TU in 0.1mL for children & or quantity made up to 0.1mL diluting with normal saline were administered. Volume < 0.1mL cannot yield wheal of required diameter of ≥7mm diameter; smaller diameter is like providing "badminton court for playing foot ball". Route: Often administered Sub Cutaneously. Multi dose vial policy: Once the vial is opened (opening date), same vial is used beyond the recommended 30 days till the last dose, with or without cold chain. Opening date and Beyond Useable Date (BUD) are not mentioned on the vial, not in compliance with guidelines. Trained staff: Testers are not “dedicatedly” trained for administering tuberculin, but many regular staff nurses & or lab technicians could administer intradermally correctly. In some institutions “testers” are not “dedicated”, anybody is allowed to administer from nursing students, interns, Post graduates. Wheal: The diameter of the wheal is not measured hence if the wheal is small (≤6mm); there is no repetition of the test immediately. AEFI Kit: Not available at many places. No display of standard operating procedure and job-aid at the service point. 2 step tests in needy circumstances are not in practice. Documentation: No standard documentation hence no indicators can be obtained required for performance review / operational research if any. Instructions to the patient / beneficiary: Explaining the procedure and giving Key messages to the patient are hardly adhered. Reading of the test: Test needs to be read between 48 and 72 hrs unlike many test doses in medical practice which is read ~30 minutes of administering the test dose. In substantial cases results were not read (~30%) defeating the purpose of the test. What we did: Charity should begin at home. We established nursing station for administering tuberculin skin test in the dedicated vaccination clinic in KVG Medical College by the dedicated staff. Developed a Supportive Supervision checklist as per CDC and RNTCP guidelines, used the same in the capacity building of testers and the officers in various Medical Colleges. Regularly shared the observations with DTF, STF, ZTF and NTF. We appraised the visitors to our college. As directed by the State Task Force, in collaboration with DTO, conducted training workshops to the Matron, testers of Medical Colleges of home district at the “Demo-site” of KVG Medical College. As directed by STF, experiences of training workshop presented in the STF meeting at State Institute of Health and Family Welfare on 7th June 2019. Way forward: Conducting similar CMEW in all the Medical Colleges of Karnataka for sensitization followed by intensive training of testers in small batches at the “Demo-site” in KVG Medical College in collaboration with government. Acknowledgement: We thank all the supporters of “End TB” programme.  With regards   

Continued Medical Education Workshop for sensitizing on Tuberculin Skin Test

Dear viewers in view of the following context we [KVG team] wish share the attached. Context: The Union Government has rolled out a programme for universal screening of an estimated 250 million children and adolescents below 18 years annually for Leprosy and Tuberculosis (TB) and put on treatment if required. TB kills an estimated 4.8 lakh Indians (sharing 31% of global TB deaths) every year [>1,400 every day]. India has highest TB burden (27% of the world) with more than a million ‘missing’ cases every year that are not notified – either undiagnosed, unaccountable, inadequately diagnosed and treated in the private sector. (https://indianexpress.com/article/india/govt-rolls-out-scheme-to-screen-all-children-below-18-for-leprosy-tb-5943004/ accessed on 06-09-2019). In this regard Manotux test [TST] has a definite role. Tuberculin Skin Test (TST) is a simple and reasonably reliable method for the detection of infection by Mycobacterium tuberculosis. It is a diagnostic aid for corroborating with clinical findings though not a confirmatory test. Quote: It has to be approached “with respect, administered with care, read with deliberation and interpreted with sentient discrimination.” All the 8 rights to be observed before / while and after administering vaccines are applicable to Tuberculin also plus 2 more: a) Do’s and Don’ts for the patient during the reactogenic period; b) reading the test between 48 and 72 hours without fail. In almost all Medical Colleges visited in 4 states, tuberculin manufactured by “arkray” with different strengths is used: viz. 1TU, 2TU, 5TU and 10TU RT23 in 0.1mL, 5mL per vial providing 50 ID doses of 0.1mL each. Though the test is in practice since 1907, many programmatic errors in various permutation combinations were observed in different thematic areas of administering / reading TST.  What we did: Charity should begin at home. We established nursing station for administering tuberculin skin test in he dedicated vaccination clinic in KVG Medical College. Developed a Supportive Supervision checklist as per CDC and RNTCP guidelines, used the same in the capacity building of testers and the officers in various Medical Colleges. Regularly shared the observations with DTF, STF, ZTF and NTF. We appraised the visitors to our college. As directed by the State Task Force, in collaboration with DTO, conducted training workshops to the Matron, testers of Medical Colleges of home district at the “Demo-site” of KVG Medical College. As directed by STF, experiences of training workshop presented in the STF meeting at State Institute of Health and Family Welfare on 7th June 2019. Way forward: Conducting similar CMEW in all the Medical Colleges of Karnataka for sensitization followed by intensive training of testers in small batches at the “Demo-site” in KVG Medical College. Acknowledgement: Thanks to the supporters of End TB programme. Please find the attached for additional inputs from the viewers. with regards Holla n team      

Enlightening the CUSTODIANS of Mantoux Test [Tuberculin Skin Test – TST]

Dear viewers  we feel proud to share the following. Though the decision making is with the professionals, many skilled procedures like parenteral administration of medicines through ID / SC / IM / IV, insertion of nasogastric tube, IV canula proper use of AMBU (artificial manual breathing unit) bags with or without oxygen for resuscitating asphyxiated newborn, preparing slides, proper staining and reading slides under microscope to look for Malaria parasites, mycobacteria etc. are with the nursing staff / lab technicians. Hence, adequate training, retraining, periodic supportive supervision on a regular basis, supporting peer education for rapid expansion & sustenance of capacity building certainly strengthens implementation of national health programmes. Legacy from the polio eradication programme, president success stories are very much useful in timely elimination of Tuberculosis. Coming to the point: As shared on 01st June, proper administration of tuberculin as per the “Rights” in all thematic areas by the staff nurses / lab technicians [TST testers] decides the outcome of the test: induration or no induration which influences the decision of treating doctor and the fate of the patients who adore doctor’s decision; the foundation of programme success. On observing and sharing innumerable lapses in administering TST in the last two years, author was asked to conduct a CME to the “TST testers” of medical colleges of Dakshina Kannada district which was held on 01 June and to share the experiences as feedback in the State Task Force (STF) meeting held on 07 June for way forward. We wish to share the feedback presented on 7th June with the viewers of techNet-21. Way forward: The ZTF chair / STF chair / JD and DD tuberculosis of Karnataka state on the spot expressed that one day training has to be conducted for the “TST testers” of all Medical Colleges in batches of 18-21 at the Demosite established in KVG Medical College, functioning since April 2016. We trained 144 Staff Nurses of Mobile Medical Units (MMU’s) of 27 districts of Karnataka in Extended Immunogram between 11-03-2017 & 10-06-2017. Management of KVG Medical College gracefully provided free accommodation to the participants. We are now ready to train the TST “Testers” of all Medical Colleges of Karnataka. Acknowledgement: India is committed, Karnataka is more committed. KVG team is heartily indebted to the ZTF / STF chairs, JD / DD-TB Karnataka, WHO consultants, all the RNTCP nodal officers of all the Medical Colleges of Karnataka & DTO Dakshina Kannada. Attached is the feedback presented in the STF meeting at Bangalore on 7th June 2019. with best wishes Holla n Team    

Tuberculin Skin Test Test / Mantoux test: Adminstration practices in a local medical college, India

Quote from IAPSM BEST PRACTICES COMPEDIUM “Knowledge is of no value unless you put in to practice. Practice till you are the best, Practice to remain the best”  On 24th April, I had the opportunity to visit a Medical College in Dakshina Kannada. As hobby / passion / proactive social service, along with a post graduate from the department of Community Medicine, interacted with those who provide Mantoux test services in that College for mutual learning / capacity building to minimize programmatic errors if any. Current observations are attached with a few photos for illustrations. In this institution pediatric age for TST is ≤16 yrs, adults are ≥17 yrs. Pediatric age group grossly varied 6 / 10 / 12 / 14 / 16 & 18 yrs in different Medical Colleges. Similarly number of PPD units for children are also varied from 2 to 5 TUs; volume varied from 0.025mL to 0.1mL. We wish to share this with the global experts so that many who are senior consultants / policy makers in this field can advice / guide the service providers technically to minimize the errors to which the beneficiaries are subjected. Another apprehension is that, if “we” are making these many errors in a simple skin test practiced for more than several decades, are “we” not making errors in the recent and more sophisticated procedures / investigations which may affect the treating doctors in decision making?? Kindly give very valuable input for strengthening the programme to eliminate TB by 2025 in India.   Following were the errors found earlier in various institutions. 1.    Tuberculin vials were kept in the inner aspect of door of the domestic fridge, often abutting the freezer compartment, causing repeated thawing. 2.    Vial brought to the nursing station / lab in the morning at about 9 AM and returned in the evening at about 5 PM. Till such time it is kept in a tray at room temperature. 3.    Multi dose vial policy not adhered to; no opening date, no Beyond Useable Date & used for more than 2 months, even beyond 5 months till the last dose was spent. 4.    Inadequate skill of ID administration, weal size not routinely measured hence if the diameter is 0.1mL. 6.    TU PPD-IP units - - 10 / 5 & 2 per 0.1mL, 50 doses per vial are available. In the absence of 5TU/2TU preparations, 0.05 or ~0.025 mL were drawn from 10TU PPD-IP per 0.1mL preparation and administered. 7.    Yet times volume made up to 0.1mL by drawing normal saline and administered. 8.    Confusion with regard to pediatric age: 9.    Confusion with regard to PPD Units for children: 5 TU PPD-IP for all age group in some colleges and 2 TU PPD-IP or 0.05mL of 5 TU PPD-IP preparation being placed in a few other colleges. 10. No standardized documentation – entered in the general injection register in the OPD / general lab investigation register in the central lab etc hence, on request, >95% testing centers could not provide data when attempted through Google survey from, some could not share due to operational dilemma.   11. Results (reading) were not found entered in the case sheet in IP cases. 12.  Loss to follow up: test administered but not read by one who prescribed the test and or by the tester as some were discharged before 48hrs of test / inadequate address. 13. As of now, no VVM on the vials in India.   With best regards Holla n Team

Activities to inactivate TB

Dear viewers World TB day theme 2018- Wanted: Leaders for a TB free world and the corollary:  Quickly and adequately involve the active leaders. In view of the above we wish to share the attached highlighting the activities to inactivate TB. Two related activities – BCG vaccination and Mantoux test [TST] are routinely practiced for several decades with number of errors. Regular Supportive Supervision is an integral part of any disease control / elimination / eradication programme. Polio eradication, Measles elimination, introduction of JE, Pentavalent, IPV and the like improved the quality of vaccination service along with increase in coverage. However BCG vaccination has escaped this SS radar. Administering 0.05mL of reconstituted BCG vaccine to a newborn needs super skill which is more difficult than administering 0.1mL of tuberculin as many are more than 3 months old. NTI recommends trained person to administer TST [1500 times administered with

Prevailing TST practices: rapid identification and concurrent rectification through Supportive Supervision Approach of RAPID.

Dear viewers World TB day is fast approching for which we wish to share the attached through which any high risk practice in any field of public health can be rapidly, effectively and sustainably closed through proactive approach blended with support from professional colleagues in the authorized posts. This usually needs zero budget or minimal budget but needs proactive positive reciprocation from the implementing authorities with empathy towards the local innovators, beneficiaries and the service providers.   Please do review the attached only a few major observations are shared for warfoot action. Best wishes Holla and the team  

Sharing the PPT on establishing dedicated vaccination clinic & nursing station for administering tuberculin

In response to the demand by HODs of Department of Community Medicine of a few Medical Colleges, KVG team is proud to share 7 slides PPT on the above subject.  We wish replication of the same in all Medical Colleges, especially private to promote quality vaccination and Mantoux test [Tuberculin Skin Test –TST] services to strengthen National programmes of Routine Immunization and Revised National Tuberculosis Control Programme [RNTCP]. Several high risk practices were observed by the author with regard to the “RIGHTS TO BE OBSERVED BEFORE ADMINISTERING THE VACCINES AND TUBERCULIN” – a few high risk practices are to be addressed as a public health emergency – like non-freezing of the antigens, correct intra-dermal route producimg≥7mm weal in the private sector since decades resulting in non-immunization of the vaccinated / no induration in Mtb infected person following improper TST. These decadal problems can be rapidly set right within a maximum of 4 months in all the centre’s of a State by establishing “DEDICATED VACCINATION CLINIC & NURSING STATION” for administering Multi dose Tberculin through “RAPID” team of our College.   This centre is already visited by independent observers from the Block / District / State / Nation and representative of international Organization and other Medical Colleges. Best wishes Dr Holla n Team 

Role of BCG in attaining “END TB” by 2030

Dear viewers. We the KVG team wish a happy new year and wish to share the post on BCG vaccination. As a question of justice, world wants to end TB by 2030 – the major killer among infectious diseases often hand in glove with HIV / AIDS. India aims to achieve the same by 2025. Specific vaccination with BCG vaccine – one of the oldest vaccine is iterated as the first strategy and more and more evidences are proving the efficacy of the vaccine in preventing the infection for about 20 years, which was underestimated. Being live attenuated, can protect against other mycobacteria helping in preventing leprosy and Buruli ulcer. Nonspecifically, BCG has a role in the treatment of warts, bladder cancer. BCG vaccine is known to complement other live attenuated vaccines like OPV, Measles, in lowering the overall child mortality rate, more so on administering at birth. In view of this we wish to share the post with the viewers. Best wishes Holla n Team  

Questions & answers regarding "TST" + Job-Aid for display

Dear TechNet viewers Greetings Like many chronic diseases, whether communicable or non communicable, Tuberculosis is also an inadequately understood Vaccine Preventable Disease with frequent change in definition and treatment protocol. In the recent RNTCP quarterly review meeting, substantial gap in the operational knowledge and differences of opinion were found regarding the Tuberculin Skin Test (TST) - a traditional, simple and reasonably reliable test as a diagnostic aid for the detection of infection by Mycobacterium tuberculosis. The results of TST are not confirmatory but reliable and corroborative in making diagnostic decision. Hence an attempt is made to present the same in the form of Questions and Answers and a one page job-aid for the TST provider as ready reckoner to be displayed at the nursing station for testing and maintaining Multi Dose Vial Policy [MDVP]. Any error in the whole process from referring the patient to the reading and interpretation of the result and decision making can make a difference of "HANG HIM NOT; LET HIM GO or HANG HIM, NOT LET HIM GO". Hope a few of the viewers will revert with +ve suggestions Regards Holla
Admin

BCG World Atlas

Claude Letarte reminds us that 24 March 2011 was World Tuberculosis Day and shares with us links to the free BCG World Atlas published by McGill University and partners in Montreal. The Atlas is: "a first-of-its-kind, easy-to-use, searchable website that provides free detailed information on current and past TB vaccination policies and practices for more than 180 countries." ... and is "designed to be a useful resource for clinicians, policymakers and researchers alike," ...

BCG Atlas Video: http://www.youtube.com/mcgilluniversity#p/c/44/0aey63bbtdi
World Atlas: http://www.bcgatlas.org/
Press preview link: www.plos.org/press/plme-08-03-pai.pdf
Post-embargo link to article : http://www.plosmedicine.org/article/info%3adoi%2f10.1371%2fjournal.pmed.1001012

Thank you Claude!
  • Page :
  • 1