The National Multisectoral Action Framework for TB-Free India, which aimed at building partnerships for convergent actions for a holistic response to TB epidemic, has identified ‘TB Free Workplace’ as one of the six strategic areas for multisector action. Engagement of workplace settings towards a ‘TB Free Workplace’ is an effort to complement government initiatives for ending TB among the working population engaged in various occupational settings (formal and informal) through strategic interventions at workplaces.  
A TB Free Workplace is defined as a workplace where systems are in place to protect the workforce from TB and sufferings due to TB and it includes provisions for -
-    Generating awareness about TB among all workers
-    Early & complete diagnosis of TB among the workers 
-    Supporting correct & complete treatment for all workers affected with TB
-    Linkage of workers affected with TB to welfare schemes and public health actions
-    Preventing transmission of TB in the workplace
-    Ensuring a stigma free environment for all workers affected with TB 
 

Figure 1: TB Free Workplace 
TB Free Workplace will have an environment and provisions where employees including contractual workers: (a) have easy access to information and services on TB and workers feel confident to utilize these services; (b)  have an environment conducive for prevention of TB; (c) undergo periodic screening for active TB; (d) workers having active TB are identified early and are put on treatment; (e) are supported during treatment and with employment protection and (f) are not discriminated either based on real or perceived TB status.

Objectives of establishing a TB Free Workplace

•    Promote awareness on TB prevention, early diagnosis, and treatment among the workers
•    Advocate for and facilitate an environment that minimizes and prevents TB transmission at workplaces
•    Support and ensure early and free diagnosis of TB among workers
•    Facilitate and ensure access to anti-TB drugs for the workers diagnosed with TB
•    Ensure care and support services for all workers affected with TB, during and after the completion of treatment
•    Advocate for a stigma free environment to access TB associated services at the workplace.
Key activities in a TB free workplace  
•    Adopting guidelines/policy for TB free workplace 
Employer need to assume an accountability to adopt and implement a TB Free Workplace intervention. Any workplace setting committed to become a TB free workplace will have a policy/guidelines present for awareness generation, early diagnosis, treatment initiation, support for completion of treatment and prevention of TB transmission. The policy/guidelines also need to ensure a stigma free environment for workers affected with TB, ensure public health actions, and continuation of employment relationship irrespective of the disease status. Draft workplace policy is attached as Annexure 7.1.
•    Setting up a Workplace committee for implementing the policy/guidelines and monitoring the progress. 
While the overall accountability of adopting and implementing the workplace policy rests with the management (Director Board/Chief Executive Officer/Managing Director), for day to day co-ordination and implementation of activities, it is desirable to have a workplace committee in place. TB free workplace committee needs to be established with clear terms of reference (Draft ToR Annexure 7.2).
The committee needs to: -
a)    Prepare annual action plan related to workplace intervention for ending TB.
b)    Mobilize resources, including identification of volunteers, for implementation of action plan.
c)    Implement the interventions as per the action plan
For smaller workplaces (Up to 100 workers), if it’s difficult to establish a committee, a nodal person from the organization may be nominated to oversee planning and implementation of workplace intervention on TB. (Customise the ToR for the nodal person based on Annexure 7.2) 
•    Identification and Training of Peer Educators
Peer educators are the selected workers  among the workforce who can influence their fellow workers. They are expected to provide awareness, screening and treatment support to the workers in need. Ideally one peer educator should be there for 50 workers.

 A Peer Educator should:
i)    be literate with formal education upto Eighth class (preferable)
ii)    have effective communication skills & leadership qualities
iii)    be accepted by their peers in the workplace
All peer educators need to undergo four hours of ‘Course for health volunteer and treatment supporters in NTEP’, endorsed by Central TB Division, and obtain their certificates. 
In a workplace with a health facility, the health staff can be further equipped to become trainers for training the peer educators. 
•    Branding and Awareness Generation among workers and their families regarding key messages on TB.
The entire workforce needs to be sensitized on the Organizations commitment to make the workplace TB Free and policy/guidelines related to it.

Awareness Messages need to focus on:
a)    Organization's commitment to End TB in the workplace
b)    Cough etiquettes and respiratory hygiene to be followed to prevent TB and other respiratory infections.
c)    Symptoms and diagnosis of TB 
d)    Facilities for diagnosis and treatment of TB 
e)    Government Schemes available for workers affected with TB
IEC activities for awareness generation could be done through posters on TB, health talks on TB, periodic health & wellness sessions, broadcasting messages on TB through internal Audio-Visual systems and propagating messages through social media groups.
Branding
Proper branding of workplace interventions for ending TB will have significant impact in mobilisation of workers towards adopting healthy behaviours. This can include adopting a slogan such as ‘End TB, Enable workplace prosperity!’ and propagating it.
•    Linkages with health facilities/NGOs or equipping own health facilities for providing TB services
The management needs to establish linkages with health facilities/NGOs or equip their own health facilities to provide the entire spectrum of TB services including testing and treatment. This could be done in partnership with the local NTEP networks also.
•    Conducting screening for TB at the time of induction of workers and at periodic intervals.
Screening can be conducted by asking the workers for symptoms suggestive of TB or by taking a Chest X-ray. Anyone having any of the TB symptoms or visible abnormalities in the Chest X-ray will be identified as workers with presumed TB. TB screening may be done at least twice a year for all workers. In case of occupations like mining, textile, construction, glass etc. TB screening may be done once in every quarter
Organizations can also promote self-screening among the workers through TB Arogya Sathi Application.(https://play.google.com/store/apps/details?id=com.tb.aarogya.sathi&pcam…)

•    Ensuring all workers with presumed TB are evaluated for TB
All workers with presumed TB need to be referred to the health facility of the workplace or the nearest peripheral health institute (PHI) for further investigations and evaluation.
•    Ensuring all workers diagnosed of TB are put on treatment
It has to be ensured that all workers diagnosed with TB avail treatment at the health facility of the workplace or the nearest PHI, as per the standards of TB care in India.
•    Facilitating treatment support to workers with TB 
Treatment support consists of counselling, adherence support, nutrition support, psychological support, welfare schemes for workers, and linking with other social protection schemes etc. Additional customised support for the workers such as support for transportation, support for air borne infection control kits etc. may also be provided by the management. This can be done with the support of National TB Elimination Programme also.
•    Protection from loss of job/protection of wages.
Management may take possible steps to protect the worker affected with TB from the loss of job/ protection of wages. Based on advice of the medical doctor, the worker may be encouraged to resume work once the person becomes non-infective of TB.
•    Ensuring that Air-borne Infection Control (AIC) measures are followed. 
Since TB is an air-borne disease, workplaces need to follow measures to control the transmission of TB among the workers. Risk assessment of workplaces may be conducted every year by a medical professional using the checklist for Air-borne Infection Control in workplaces in Annexure 7.6.  Compliance to the recommendations in the assessment report needs to be ensured by the committee.
•    Monitoring & Documentation
Monitoring of the activities against the plan need to be done routinely by the management. It has to be ensured that the information of workers diagnosed with TB is updated on a real time basis in Ni-kshay, the management information system of NTEP. It is also a good practice to publish a one-page annual report regarding the TB status and efforts to end TB in the workplace. 

Figure 2: Key Activities in a TB Free Workplace