Tuberculosis Case Management
Full Review

Reviewed by: Dr. L. S. Chauhan, Deputy Director General – Tuberculosis, Directorate General of Health Services, Ministry of Health & Family Welfare; Government of India
Review posted 18 April 2006
Review No. 76

CD-ROM Information

Content: This CD-ROM is a useful training tool to sensitize medical practitioners who are unable to allocate time for modular training. The content emphasizes a standardized anti-tuberculosis (TB) treatment in accordance with the Directly Observed Therapy Short-course, or DOTS strategy.
Publication Date: 6 June 2004
Audience: Medical officers and treatment supervisors or paramedical staff involved in TB case management such as identifying suspects, monitoring treatment, and administering counseling.
Producer: United States Agency for International Development USAID, Quality Assurance Project (QAP)
Size: 593 MB
Price: Free to developing countries / US$20 for developed countries
Manual needed: No manual is provided. It would be very helpful to include one to support the CD-ROM.
How to order:

Order by e-mail:
E-mail: qapdissem@urc-chs.com

Order by fax:
Fax: +1 301-941-8427

Download order form.*

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Full Review

Content

A CD-ROM training tool on tuberculosis case management is a welcome innovation and apparently among the first of its kind. The content aims to convey the basic guidelines of TB case identifications and case management according to the internationally recommended Directly Observed Therapy Short-course, or DOTS strategy. This strategy has five components:

1. Political commitment
2. Good quality diagnosis
3. Good quality drugs
4. Direct supervision of drug therapy
5. Systematic monitoring and accountability.

One of the dominant features of the DOTS program is the direct supervision of drug therapy which requires a patient to swallow medicine in front of a healthcare worker.

The content presents seven topics that are featured as part of the "learning room" section. These sections give an introduction to pulmonary TB and describe transmission and pathogenesis of TB, as well as the relationship between TB and HIV/AIDS.  The sections also cover TB case management, diagnosis, treatment and monitoring, recording, and counseling.    

Each chapter is divided into sub-topics that are presented through a series of audio-visual slide presentations. At the end of each slide presentation is a series of review questions that reinforce the key points of the learning exercise. The presentation text highlights key vocabulary and terms. Clicking on a highlighted word brings users to an easy-to-use glossary. When users successfully complete each section, they may take a post-test to check their progress and comprehension. All questions and answers can be reviewed at the end of the test, and users are encouraged to revisit the learning room to review the material.

Included are five case studies to help identify TB suspects and prescribe appropriate treatment. The content of these case studies is technically sound and clearly highlights the basic principles of DOTS strategy for treatment regimes of pulmonary tuberculosis. The course content helps the learners review their progress at every step by presenting well-framed questions. The case studies are supported by pre-tests and post-tests to evaluate their understanding of the principles of tuberculosis management.

The CD-ROM is not accompanied by any manual or statement identifying the specific learning objectives. This is an oversight because the objectives of such tools need to be clearly identified at the outset of study in order to best assess the learning outcomes at the end. Also, such scientific training tools need to be supported with manuals that can be used for reference.

Overall, the CD-ROM is well designed to cover all of the major topics for sensitization of health staff on epidemiology of TB and TB control activities under the DOTS strategy. The first line drugs recommended for TB management are readily available in developing countries. The drugs are also available in the market in generic form.

However, the diagnostic, treatment, and follow up activities stated in the CD-ROM need modification to comply with national guidelines in each country. These modifications would include case definitions of smear negative TB, guidelines for follow-up sputum microscopy, drug dosage and standardize treatment regimens, FCD/blister packs in patient-wise boxed, and TB recording formats. Since these tools are to be used by health staff in different countries, any deviation from local practices may raise queries and create confusion. These tools need to be adapted to country specific programs, with links to an up-to-date library on specific national program policies and guidelines.

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User-friendliness and Navigability

The CD-ROM has introductory remarks on the program guide and a tutorial with general instructions on navigation. The tutorial is available at every stage of the course, either in the form of instructions or via clickable highlighted icons. These instructions are simple and can be followed by individuals with minimal computer literacy. It is possible to move across sections and track the status on sections covered. The user long-in tool allows users to resume work in the section where they were last working.  This ensures an orderly and thorough progression through the material.

However, the CD-ROM installation package is complicated and does not automatically create a shortcut on the desktop after the program is installed. This could be simplified, perhaps through an auto-run program system.

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Interactivity

The interactive facilities are somewhat limited, though the question and answer sections of the tutorial are well thought out and useful.

The interactive case studies on drug therapy recommendations were useful as they summarize the topics and help in categorization and prescription of treatment. However, the drug dosages recommended are not as per the recommended combinations used under DOTS in all countries. (In India for example: a thrice weekly regimen under the programme - INH is used @600mg/dose (against 450mg); Pyrazinamide @1500mg (against 1200mg) and Ethambutol @1200mg/dose(against 1600mg). One of the drug regimens containing Thiacetazone is currently not recommended under the program, thus may be deleted from the section.

Likewise there are countries using a daily regimen and/or drugs in fixed dose combinations. Hence, any alternate dosing schedule other the one practiced in a specific country may lead to confusion. For example, the program in India trains all levels of staff including medical doctors and health workers using standardized modules to ensure standardized quality training.

The CD-ROM introduces question and answer sections, tutorials, and diagnostic procedural checklists to make the learning tool interactive. However, there may be several questions (say benefit of intermittent regimen; 3 sputum smears, etc.) which would require additional referencing and discussion. This will always be a limitation for any audio-visual learning tool that attempts to impart technical knowledge or skill. Detailed manuals and guidelines on TB case management would help to overcome this limitation, as would using this CD-ROM in a blended learning environment with a facilitator.

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Sustainability

In general CD-ROM delivered training is useful to medical practitioners who cannot attend courses because of time demands. While this particular version of the CD-ROM supports current TB case management practices, there needs to be a system for updating the content regularly in order to stay abreast of new initiatives in treatment, changes in program guidelines, and management practices.

Even with updating, the CD-ROM could benefit from supplementary manuals and study materials to give additional value and better mirror a live training session. These training materials could also be localized to specific areas and languages in order to achieve maximum benefit in the field.

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Distribution

Quality Assurance Project provides CD-ROM publications free of charge to non-sponsored individuals in Africa, Southeast Asia, the Caribbean, Eastern Europe, and Latin America. CD-ROMs can be ordered from North America, Australia, and Western Europe for US$20, shipping and handling included. Individuals or organizations in developing countries with headquarters in North America, Australia, and Western Europe must pay for CD-ROMs. 

The CD-ROM content is not available online. 

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Comment(s)

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1. VIKASH RANA
   (posted 03 May 2006 / 01:56:09 PM)
   
   The topic on "Tuberculosis Case Management" is a very important one. There are a lot of cases in Assam (India) where I come from. In my own family we had cases. But now we have a lot of information regarding this.
   
   If any one is seen with the symptoms of TB, we immediately contact the Health services and take a lot of precautionary measures.
   
   A little bit of information is revolutionizing the whole theater of TB and your topic regarding this gives us more inputs & motivates us to fight against this.
   
   I am very thankful to every one who brought this topic into the limelight.
   
   With regards
   
   Vikash Rana