8 Tuberculosis Guidelines 2011

DISCLAIMER
The authors do not warrant the accuracy of the information contained in the
TB Technical Guideline and do not take responsibility for any death, loss,
damage or injury caused by using the information in this document.
While every effort has been made to ensure that this document is correct and
in accordance with current evidence based and clinical practices, the dynamic
nature requires that users exercises in all cases independent professional
judgement and understand the individual clinical scenario.
Fiji National Tuberculosis Programme

Ministry of Health. Tamavua-Twomey Hospital
Princess Road, Suva
Republic of Fiji.
Tel (679) 368 4333 or (679) 332 1066
www.health.gov.fj
© Copyright Ministry of Health, 2011. All rights reserved. This material may be freely
reproduced for education and not-for- profit purposes within the Ministry of Health. No
reproduction by or for commercial organisations is allowed without express written
permission of the Ministry of Health-Fiji.
TB Guideline - Fiji 2

ACKNOWLEDGEMENT
_______________________________________________________________________________

ACKNOWLEDGEMENT
This Guideline was prepared by the Fiji National Tuberculosis Programme with the
_______________________________________________________________________________
technical and funding support from the Australian Respiratory Council (ARC) and the
Global Fund to fight AIDS, TB and Malaria respectively.
Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for
their valuable contributions to the key technical concepts of this Guide.
The indispensible comments and suggestions by Dr Linh Nguyen of WHO office in Suva
must not go unrecognized.
Last but not the least, the contributions and support of the following personnel and
institutions is acknowledged:
Dr Josefa Koroivueta
Dr Iobi Batio
Dr Sakiusa Mainawalala
Dr Frank Underwood
Dr Apisalome Nakolinivalu
Fiji Red Cross Society
Dr Iobi Batio
Fiji Nursing Association
Grant Management Unit of Fiji MOH and
Dr Frank Underwood
Public health officials

CONTENTS
_______________________________________________________________
ACKNOWLEDGEMENT
Preface ......................................................................... 5
_______________________________________________________________________________
Foreword ......................................................................... 6
Acronyms ......................................................................... 7
This Guideline was.........................................................................

Introduction prepared by the Fiji National Tuberculosis 8-10 Programme with the
Global TB Programme
Fund to fight AIDS, ElementsTB and Malaria respectively.
Detecting & diagnosing people with TB .....................11-22
Treatment
Particular forispeople
gratitude accorded withtoTBProfessor........................................22-29
Guy Marks and Ms Kerry Shaw of the ARC for
Preventing TB ......................................................................
their valuable contributions to the key technical concepts 30-32
of this Guide.
Monitoring & evaluation ....................................................33-35
Programme supervision
The indispensible comments and .....................................................36-37
suggestions by Dr Linh Nguyen of WHO office in Suva
References ................................................................................38
Appendices ...............................................................................39
Last butTubnot
1 the least, Referral/transfer
the contributions forms and support of the following personnel and
Tub 2 Laboratory
institutions is acknowledged: Register
TubKoroivueta
Dr Josefa 3 Laboratory (AFB microscopy) request form
Dr IobiTub 4
Batio AFB Microscopy Register
Tub 5
Dr Sakiusa Mainawalala TB Register
Dr Frank UnderwoodTB Patient ID Card
Tub 6
Tub 7 Nakolinivalu
Dr Apisalome TB Contact Register
Fiji RedTub 8 SocietyTB Treatment Card
Cross
Fiji Nursing9 Association
Tub HIV testing Consent form
Tub 10
Grant Management Unit Pharmacyof Fiji MOH form and
Public Tub 11 officialsDomicilliary Treatment Supervision form
health
Tub 12 Treatment Completion form
Tub 13 Quarterly Report on Sputum Conversion
Tub 14 Quarterly Report on TB case registration
Tub 15 Quarterly Report on Treatment Outcome
3

PREFACE
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
ACKNOWLEDGEMENT
This is the third edition of the technical guide for tuberculosis control in Fiji. The first
edition was printed in 1996 and the second in 2004. This edition updates previous
_______________________________________________________________________________
editions to current data, health system and practice, as well as treatment and programme
recommendations.
The contents of this guide have been developed with reference to the World Health
ǯ
This Guideline
was ,
prepared by theAustralian Respiratory
Fiji National Council
Tuberculosis and the with
Programme IUATLD
the
recommendations.
Global
The Fund
main to fight of
objectives AIDS,
thisTB and Malaria
guideline are: respectively.
x To describe global, regional and local TB burden and the strategy for effective TB
control;
x valuable
their contributions
To describe to the
standardized key technical
treatment concepts
regimens of thistoGuide.
according TB case definitions;
x To demonstrate monitoring and evaluation principles for individual patients and the
Programme; comments and suggestions by Dr Linh Nguyen of WHO office in Suva
The indispensible
x To go
must not provide information on special and emerging situations in TB control
unrecognized.
This guideline is aimed primarily at TB clinicians, medical physicians, paediatricians, civil
Last but
society not the least,
organizations, butthe contributions
clinical and publicand support
health of the
teachers, and following personnel
students in and
medical and
nursing will also find it helpful.
Dr Iobi Batio
Dr Frank Underwood
3

FOREWORD
_______________________________________________________________
ACKNOWLEDGEMENT
_______________________________________________________________________________
This Guideline
There was welcome
will be a warm preparedto by
thisthe Fijiedition
third National
of theTuberculosis
TB guidelines.Programme
The first andwith the
second
editions were
technical printed
and in 1996
funding and 2004
support fromrespectively, and have
the Australian been most Council
Respiratory valuable (ARC)
and extensively
and the
used.
The synthesis
Particular of this revised
gratitude version
is accorded toisProfessor
based on Guy
the distressing
Marks andepidemiology
Ms Kerry Shawof TB
ofglobally
the ARCand
for
regionally. Further, it was recognized that new diagnostic and therapeutic methods have been
discovered, a number of public health challenges have emerged to hinder TB control efforts, and
innovative support from civil society institutions have been proved successful in most TB endemic
territories.
With the global explosion of HIV, and in some countries much ill-informed and chaotic treatment
Last but the
practices, notworld
the least, the contributions
is threatened and support
with an uncontrollable of the
epidemic following
of TB personnel
and MDR-TB. and
The only
institutions
way is acknowledged:
to prevent this is to ensure that the concepts and principles outlined in this guideline are
universally applied, both in the public and private sector.
Dr Iobi Batio
IfDrand when Mainawalala
Sakiusa the guidelines contained in this manual are followed, it will then be possible to reach
the overall aim of the National Tuberculosis Programme, which is to reduce morbidity, mortality
Dr Frank Underwood
and disease transmission due to TB.
We must therefore make every necessary effort to ensure that this vital objective is indeed
achieved. Time is not on our side and the need is urgent. This Guideline must have the widest
Grant Management
possible distribution. Unit of Fiji MOH and
Dr Neil Sharma
Minister of Health, Fiji
3

ABBREVIATIONS

_______________________________________________________________
ACKNOWLEDGEMENT
ACSM Advocacy Communication Social Mobilization
AFB Acid Fast Bacilli
_______________________________________________________________________________
AIDS Acquired lmmuno Deficiency Syndrome
ART Anti-retroviral therapy
BCG Bacillus Calmette Guerin (TB vaccine)
CSO Civil Society Organization
This Guideline wasDirectly
DOT preparedObserved
by Treatment
the Fiji National Tuberculosis Programme with the
DOTS Directly Observed Treatment Short course
DST Drug Susceptibility Testing
Global EPTB
Fund to fight AIDS, TB and Malaria
Extra pulmonary respectively.
tuberculosis
EQA External Quality Assessment
Particular
FDC gratitude is accorded
Fixed to Professor Guy Marks and Ms Kerry Shaw of the ARC for
Dose Combination
FPBS Fiji Pharmaceutical
their valuable contributions to the key & Biomedical Services of this Guide.
technical concepts
HCW Health care worker
HIV Human Immunodeficiency Virus
The indispensible
IPT comments and suggestions
Isoniazid preventative therapy by Dr Linh Nguyen of WHO office in Suva
must notISTCgo unrecognized.
International Standards for Tuberculosis Care
IUATLD International Union against Tuberculosis and Lung Disease
Last but not the least, the Resistant
MDR-TB Multidrug Tuberculosis
contributions and support of the following personnel and
MO Medical Officer
MOH Ministry of Health
Dr Josefa
NGOKoroivuetaNon-Government Organisation
Dr IobiNTP
Batio National Tuberculosis Programme (Fiji)
Dr Sakiusa
OCP MainawalalaOral contraceptive pill
Dr FrankPALUnderwoodPractical Approach to Lung Health
PICT Pacific Island Countries and Territories
PLWHA Person living with HIV & AIDS
Fiji RedPTB
Cross SocietyPulmonary Tuberculosis
Fiji Nursing
QMRL Association
Queenland Mycobacteria Reference Laboratory
SLT
Grant Management Senior
Unit ofLaboratory
Fiji MOH Technician
and
TB
Public health officialsTuberculosis
TBCO TB Control Officer
WHO World Health Organization
XDR-TB Extensively drug-resistant Tuberculosis
Anti-TB Medicines:
E Ethambutol
H Isoniazid
R Rifampicin
S Streptomycin
Z Pyrazinamide
TB Guideline - Fiji

INTRODUCTION

_______________________________________________________________
ACKNOWLEDGEMENT
Tuberculosis epidemiology
Globally TB incidence rates are falling ǯwith the exception
_______________________________________________________________________________
in the South-East Asia Region, where the incidence rate is stable. If these trends are
sustained, the MDG target1 will be achieved. Between 1995 and 2009, a total of 41
million TB patients were successfully treated in DOTS programmes, and up to 6
million lives were saved including 2 million among women and children.
This Guideline
In 2008,wastheprepared by 8%
Pacific had the fewer
Fiji National
TB casesTuberculosis Programme
than 2007 notified with TB
to National the
technical and funding support from the Australian Respiratory Council
Programmes. Excluding Papua New Guinea (PNG), 1,459 TB cases were notified, a (ARC) and the
Global notification
Fund to fightrate
AIDS, TBper
of 48 and100,000
Malaria of
respectively.
the total population. The numbers and rates of
TB cases notified in individual countries and territories varied significantly, ranging
Particular
fromgratitude is accorded
zero in Niue to 387 intoSolomon
Professor Guy Marks
Islands and in
to 13,984 MsPNG.
Kerry Shaw of the ARC for
The TB case notification rate continues to decline in Fiji. The case detection and
treatment success rates are now above or close to the internationally recommended
The indispensible
targets of 70%comments
and 85%,and suggestions
at 95% and 81%byrespectively.
Dr Linh Nguyen
Reasonsof WHO
for a low office in Suva
treatment
success rate are varied but can include: an interrupted TB drug supply, limited
access to TB clinic services, poorly functioning or non-effective directly observed
Last but not the
therapy least,
(DOT), andthe contributions
costs associated withandTB
support of the
treatment. followingthepersonnel
In addition, and
rate of death
in TB patients and defaulters influences the treatment success rate.
Dr IobiFigure
Batio 1. Trend of TB case notification 1990-2010
Dr Frank Underwood Case Notification of Tuberculosis in Fiji 1990-2010
260

240
220
Number of All TB
cases notified
200
180
Number of Cases
160

140 Notification of
120 New Smear
Positive Cases
100
80
60
40
20
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
Year
Fiji NTP 2010

1 TB incidence is predicted be decrease in 2015 compared to 1990 levels
3

Structure of the National Tuberculosis Programme

Currently there are three (3) DOTS centres in Fiji which are located in Labasa,

Lautoka and Tamavua-Twomey hospitals that take charge of TB control activities in
the North, West and Central/East respectively. The Fiji National Tuberculosis
ACKNOWLEDGEMENT
Programme (NTP) was established in late 1940s and adopted the DOTS strategy in
1997.
_______________________________________________________________________________
Figure 2. Fiji NTP Structure
This Guideline was prepared Ministry

by the Fiji National TuberculosisSchematic
of Health Programme with the
ĞŶƚƌĂů >ĞǀĞů
technical and funding support Publicfrom the Australian Respiratory Council
Health Services (ARC) of
presentation and the
Global Fund to fight AIDS, TB National
and Malaria
TB Programme respectively. the TB control
ŝǀŝƐŝŽŶĂů>ĞǀĞů programme in
Particular gratitude is accorded to Professor Guy Marks and Ms Kerry FijiShaw of the ARC for
their valuable contributions
Western Division to the key technical
Northern Division Central and concepts
Eastern Divisionof this Guide.
Lautoka Hospital Labasa Hospital Colonial War Memorial P J Twomey (Tamavua)

The indispensible
(DOTS center) comments and suggestions
(DOTS Center) by DrHospital
Hospital (CWMH, Suva) Linh(PJTH,
Nguyen
Suva) of WHO office in Suva
TB Laboratory TB Laboratory TB Laboratory w/culture
^ƵďĚŝǀŝƐŝŽŶĂů>ĞǀĞů
Dr Iobi Batio
Subdivisional Subdivisional Subdivisional
1 . Village health
workers
Hospitals Hospitals
Hospitals 2. Red Cross health
volunteers
Dr Frank Underwood
Health Health
Centers
Health
Centers Centers
Fiji Red WĞƌŝƉŚĞƌĂů>ĞǀĞů
Cross Society
Zone Nurses Zone Nurses Zone Nurses
Objectives of the National Tuberculosis Programme
x To reduce the impact of tuberculosis until it is no longer a public health
problem
x To limit the number of re-treatment case to an acceptable minimum
(10%)
x To effectively address emerging issues in TB control such as MDR-TB,
TB/HIV co-infection, TB among children and TB in high risk populations
x To address TB care and control in high risk populations
x To engage all health care providers
3

Targets of the National Tuberculosis Programme

x To maintain the treatment success rate (of smear positive cases) at >85%
x To increase case detection rate of smear positive TB up to >70%
ACKNOWLEDGEMENT
Strategies of the National Tuberculosis Programme
_______________________________________________________________________________
x To pursue high quality DOTS in all Divisions;
x To introduce Fixed Dose Combinations (FDCs) for first-line TB drugs;
x To formalize Public-Private Mix for TB care and control through an
This Guideline was improved referral
prepared by system;
the Fiji National Tuberculosis Programme with the
x
technical and funding support fromwith
To empower people the TB and communities;
Australian Respiratory Council (ARC) and the
Global Fund tox fight
To AIDS,
increase
TB case finding activities
and Malaria at rural communities through
respectively.
mobilization of community health care workers and volunteers;
x To improve
Particular gratitude supervised
is accorded treatment
to Professor duringand
Guy Marks theMs
continuation
Kerry Shawphase close
of the ARCtofor
the patient to
their valuable contributions through
the key mobilization of health
technical concepts ofcare
this workers
Guide. and volunteers.
To implement
The indispensible this strategy
comments the TB control
and suggestions programme
by Dr envisages
Linh Nguyen of WHOto:
office in Suva
x Be fully integrated in the general health care structure, including at the
periphery;
x
Last but not theBeleast,
effective
the nation-wide,
contributionsreaching rural and
and support of urban populations;
the following personnel and
institutions isxacknowledged:
Be permanent; and
x adapted to the needs of the people. TB services should be as close to the
Dr Iobi Batio community as possible for both diagnostic and treatment services.
TheUnderwood
Dr Frank Ministry of Health in Fiji has followed the principles of the WHO recommended
DOTS strategy
Dr Apisalome successfully since 1997.
Nakolinivalu
The five
Fiji Nursing elements of the DOTS strategy are:
Association
x Sustained
Grant Management Unit of Fiji MOH commitment
political and
x For case detection access to quality assured TB sputum microscopy
x Standardised short course chemotherapy for all cases of diagnosed TB
under proper case management conditions, including direct observation
of treatment
x Uninterrupted supply of quality anti-TB drugs for the duration of
treatment for each patient
x Recording and reporting system enabling outcome assessment of every
patient as well as of the overall programme performance
3

TB PROGRAM ELEMENTS
_______________________________________________________________
ACKNOWLEDGEMENT
1.1. Detecting and diagnosing people with tuberculosis
_______________________________________________________________________________
The major strategy for detecting tuberculosis in Fiji is to ensure that all people
with symptoms of TB are identified as TB suspects and appropriately
investigated. For this to be achieved the following public health interventions
This Guideline
mustwas prepared by the Fiji National Tuberculosis Programme with the
be applied:
technical and funding support
x Community from of
awareness thesymptoms
Australianthat
Respiratory
should leadCouncil
them (ARC)
to seekand the
health
Global Fund care;
to fight AIDS, TB and Malaria respectively.
x Community awareness of appropriate health care workers to attend;
Particular gratitude is accorded
x Knowledge to Professor
of the symptoms of Guy Marks ALL
TB among and Ms Kerry
health careShaw of theincluding
workers ARC for
village health workers, volunteers, and traditional healers.
x Capacity of health care workers to collect and dispatch sputum specimens
The indispensible comments
(or slides) and suggestions
of TB suspects by Dr
to the nearest Linh Nguyen
microscopy of WHO office in Suva
center;
must not go xunrecognized.
Laboratory capacity for high quality sputum microscopy and culture.
Last but notThe theimplementation

least, the contributions and support
of this strategy of the
for detecting andfollowing personnel
diagnosing and
people with
tuberculosis should be integrated with the implementation of the Practical
Approach to Lung Health (PAL).
Dr Iobi Batio
Dr Sakiusa1.1.1.
Mainawalala
TB suspects
Dr Frank Underwood
Any person who with symptoms or signs suggestive of TB should be
Dr Apisalome investigated
Nakolinivalufor tuberculosis. The most common symptom of pulmonary TB is
Fiji Red Cross aSociety
productive cough for more than 2 weeks, which may be accompanied by
other respiratory symptoms including shortness of breath, chest pains,
Grant Management Unit ofup
coughing Fijiblood
MOH(haemoptysis)
and and/or
constitutional symptoms including loss of appetite, weight loss, fever, night
sweats, and fatigue.

TB Suspect: Cough >2weeks, breathlessness, chest pain, haemoptysis, fever, night
sweats, and fatigue.
3

1.1.2. Investigation of TB suspects
Patients who are TB suspects should be investigated for TB. Those who

live near a DOTS centre should be referred for appropriate care and follow
up. However, those who would take more than one day to travel to the DOTS
ACKNOWLEDGEMENT
centre, who are too sick to travel, or cannot afford to travel should have the
initial investigations performed at the hospital or health centre nearest to
_______________________________________________________________________________
where they live.
Two sputum specimens should be collected, using the method decribed

below. One is collected immediately (spot), when the patient is first seen. The
This Guideline was specimen
second prepared should
by the beFijicollected
Nationalthe
Tuberculosis Programme
following morning. with
If this the
is not
technical andfeasible,
fundingthen
support from the Australian Respiratory Council (ARC) and the
the patient should be asked to wait at the health facility, and
Global Fund toproduce
fight AIDS, TB and Malaria respectively.
a second specimen one or two hours after the first specimen.
Sputum specimens:
1. Spot (collected immediately during first consultation)
2. Early morning sample (collected the following morning)
These specimens should be transported to the nearest DOTS or microscopy
Last but not centre
the least, the contributions
for slide andexamination.
preparation and support of The
the responsible
following personnel and
DOTS centre
institutions isshould
acknowledged:
then transfer the original sputum specimen to the DOTS centre in
Suva (at Tamavua-Twomey Hospital) for culture. The cost of sputum
Dr Iobi Batio transport should be borne by the NTP. Fo interior mainland or remote island
settings it is advisable to transport fixed slides after performing slide
Dr Frank Underwood
preparation.
Fiji Red CrossThe
Society
sputum specimen should reach the DOTS centre within two days of
collection. When this is not possible, then sputum should be sent to the
Grant Management Unit
nearest of Fijiwhere
facility MOH and
preparation and fixation of slides could be done and
and later sent to the DOTS centre for staining and microscopy. In these
circumstances it will not be possible to perform TB culture.
TB suspects whose sputum microscopy is negative should be referred to

the nearest Health Centre or sub-divisional hospital (if initially seen at a more
peripheral level). They should receive a course of simple antibiotics. If the
symptoms do not resolve with this treatment they should be referred to the
nearest DOTS centre with x-ray facilities where they can be investigated for
smear negative TB.
3

nearest DOTS centre with x-ray facilities where they can be investigated for
smear negative TB.
Figure 3. Diagnostic algorithm for a suspected case of Pulmonary TB
ACKNOWLEDGEMENT
_______________________________________________________________________________
Dr Iobi Batio
Dr Frank Underwood
1.1.2.1. Standard procedures for sputum collection, processing, transport
x Fill in the form "Request for sputum examination" (Tub 3 - See Appendix
3). Write the registration number and name of the patient on the form and
Grant Managementon Unit
theofside
Fiji of
MOHthe and
sputum cup.
x Demonstrate to the patient how a good sputum specimen is produced by
taking a deep breath and coughing deeply.
x Find an outdoor location, away from others, for the patient to expectorate
sputum into the sputum container. For children, the use of nebulizers may
help in stimulating the airways in order to obtain a good sputum sample.
x Ask the patient to screw the lid onto the container before returning it you.
x Make sure that the lid on the container is firmly close. Place the container
inside a plastic bag. Wash your hands.
3

x When two specimens have been collected, send both the specimens
together with the request form to the laboratory as soon as possible. If it
cannot be despatched immediately store in a fridge if one is available or a

cool place if there is no fridge.
x The specimen should be sent to the nearest DOTS centre within two days.
ACKNOWLEDGEMENT
1.1.2.2 Laboratory services
_______________________________________________________________________________
The details of laboratory procedures are beyond the scope of this guide and
should be dealt with in a separate Manual of Laboratory Procedures.
a) Microscopy
All health care technical staff should be trained to fix sputum smears on
microscopy slides and transport them to the nearest DOTS microscopy
centre. All three DOTS microscopy centres should:
x Perform AFB microscopy
x isProvide
Particular gratitude accordeda written reportGuy
to Professor on Marks
all AFBand
microscopy
Ms Kerry results
Shaw of(positive
the ARCand
for
negative) to the referring HCW.
x Enter the results of all AFB microscopy performed on TB suspects
onto standard
The indispensible comments Laboratory register
and suggestions on aNguyen
by Dr Linh daily basis.
of WHO office in Suva
x Send
must not go unrecognized. replacement sputum containers and request forms to each site
that submits sputum specimens for examination on a quarterly
Last but not the least,schedule.
the contributions and support of the following personnel and
b) Sputum
institutions is acknowledged:culture
Sputum
Dr Josefa Koroivueta culture remains the gold standard procedure to diagnose TB
Dr Iobi Batio however it takes 6-8 weeks to obtain results hence clinical dependency on
microscopy yield to determine earliest and appropriate intervention. TB
Dr Frank Underwood culture is only performed at the Central-Eastern DOTS centre (at
Tamavua-Twomey Hospital). At least one (1) diagnostic sputum specimen
of all the TB suspects should be sent to Daulako Mycobacterium
Laboratory (at Tamavua-Twomey Hospital) for culture.
Grant Managementc) Drug
UnitSusceptibility
of Fiji MOH and Testing (DST)
Drug susceptibility testing is not yet routinely available in Fiji but plans
are underway to carry out advance TB diagnostic tests (such as DST &

GeneXpert) in the year 2012. However, specimens can be referred to the
Queensland Mycobacterial Reference Laboratory in Brisbane for DST. This
should be done for: Index Case
x Those who come from areas with high endemicity of MDR-TB
x Re-treatment cases and their
Close contacts
contact
x Cases that remain smear positive after 3 months of TB
ACKNOWLEDGEMENT
Signs and
chemotherapy No signs or
symptoms of TB
x Cases that have been Symptoms
contacts of of patients
TB with known MDR-TB
_______________________________________________________________________________
Cases
TB Guideline - Fiji
dually infected with HIV
Investigate for TB: 14
2 sputum samples
Adult and/or child aged HIV infection
Chest x-ray five years and over, with Child under 5 years
no immune-suppressing Other immune-
conditions
This Guideline was prepared by the Fiji National Tuberculosissuppressing
Programme conditions
with the
technical and funding
TB support
TB Guideline - Fiji
No TB from the Australian Respiratory Council (ARC) and the
14
3
Global Fund to fight AIDS, TB and MalariaEducate
respectively.
and Tuberculin
Register Follow-up and discharge skin test If chest x-ray is
normal commence

d) Xpert MTB/RIF
The Xpert MTB/RIF test offers a potential solution for improving TB
diagnosis. A single Xpert MTB/RIF test is able to confirm active disease

among both smear positive and negative TB patients whilst concurrently
testing for rifampicin resistance, thus identifying patients who need
ACKNOWLEDGEMENTsecond-line drug treatment. AFB microscopy remains to be the first line
mode of TB diagnosis considering the cost and time factor for Xpert
_______________________________________________________________________________
MTB/RIF and culture respectively.
Sputum samples eligible for Xpert MTB/RIF test:

x All diagnostic smear positive sputum samples to ascertain TB disease and to
This Guideline was rule out rifampicin
prepared by theresistance
Fiji National Tuberculosis Programme with the
x Diagnostic smear negative sputum samples as decided by the clinician
x For patients with abnormal chest X-ray or as decided by clinician
e) Quality
Particular gratitude assurance
is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for
i)
their valuable contributionsQuality Assurance
to the for microscopy
key technical concepts of this Guide.
All three DOTS centers and microscopy units of Divisional hospitals
The indispensibleparticipate
comments in andExternal Quality
suggestions Assurance
by Dr (EQA).of This
Linh Nguyen WHOisoffice
achieved by
in Suva
sending selected AFB slides to the Senior Lab Technician (SLT) who is
based at the Daulako Mycobacteria Laboratory in Tamavua-Twomey
Last but not thehospital forcontributions
least, the viewing. The andNTP office of
support sends selected slides
the following from and
personnel the
Dauloka
institutions is acknowledged:Mycobacteriance Laboratory at the Tamavua-Twomey hospital to
QMRL on a quarterly rota for EQA purposes.
Dr Iobi Batio Panel testing: Ten(10) prepared slides are sent by QMRL to all labs that
Dr Sakiusa Mainawalala microscopy in Fiji annually. Lab technologists from the four
perform
Dr Frank Underwood microscopy centers2 who receive prepared slides read and send their
findings to the laboratory scientists at QMRL for verification of results
reported. Findings at all stages for EQA are exchanged among the
respective officers to ascertain quality of microscopy services in Fiji.
ii)
Public health officials Quality Assurance for culture
Daulako Mycobacterial Laboratory (based at Tamavua-Twomey Hospital)
performs culture for diagnostic purposes on all specimens (sputum &
body fluids) received from referring clinicians. Plans are underway to
implement quality assurance for culture procedures conducted at
National level in collaboration with QMRL.

2
All three DOTS centers & CWM hospital laboratory
3

1.1.2.3 Other investigations
a) Radiology

Tuberculosis should be diagnosed whenever possible by clinical
evaluation and sputum examination. Chest X-ray examination is valuable
ACKNOWLEDGEMENT for sputum smear negative cases. Chest X-ray findings suggestive of
pulmonary TB in patients with a sputum smear negative result should
_______________________________________________________________________________
always be supported by physical examination findings and a clinician
should decide on the diagnosis.
X-ray may be helpful in assessing the extent of lung damage in
complicated cases. It is also important in the diagnosis of tuberculosis in
children and extra-pulmonary TB.
b) Tuberculin skin test
Tuberculin skin test (TST or Mantoux test) detects tuberculosis infection
only. TST is not a test to diagnose active TB disease.
This is relevant to support the decision to give isoniazid for treatment of
latent tuberculosis infection (Isoniazid Preventative Therapy). It has no
role in the initial investigation of patients with suspected pulmonary
tuberculosis.
1.1.3 Case definitions and classification
Dr Iobi Batio A case of tuberculosis. A patient who is AFB smear positive and/or AFB
culture positive or in whom the medical officer has diagnosed TB and has
Dr Frank Underwood
decided to treat with a full course of treatment. It should be noted that
current techniques do not allow non-tuberculous mycobacteria to be
Fiji Red Cross distinguished
Society from M. tuberculosis in Fiji. Hence, this case definition may
overestimate the burden of TB. However, these cases will be identified as
Grant Management Unit of Fiji MOH
non-tuberculous anddo not respond to treatment and specimens are
if they
referred to QMRL for DST. Cases of tuberculosis are further classified
according to the anatomical site of disease, bacteriological status and the
history of previous treatment.
This classification is important for:
x Selecting appropriate treatment regimens
x Patient registration and notification, which is relevant to analysis of
treatment outcomes and evaluation of program performance
3

a) Anatomical site of disease

Pulmonary tuberculosis refers to a case of TB involving the lung
parenchyma (including miliary tuberculosis). All other cases where the

lung parenchyma is not involved (include intrathoracic
lymphadenopathy and pleural effusions) are classified as extra-
ACKNOWLEDGEMENT pulmonary tuberculosis (EPTB).
Diagnosis should be based on history and examination findings,
_______________________________________________________________________________
histological evaluation or strong clinical evidence consistent with active
EPTB, followed by a decision by a clinician to treat with a full course of
tuberculosis chemotherapy.
This Guideline
b) was prepared by
Bacteriological the Fiji National Tuberculosis Programme with the
classification
A case of pulmonarythe
support from TB Australian
is classifiedRespiratory Council if(ARC)
as smear positive one orand the
more
Global Fund to fightsputum
AIDS, TB and Malaria respectively.
specimens collected at the start of treatment are positive for
AFBs on microscopy. A case of pulmonary TB is classified as smear
Particular gratitudenegative
is accorded
if attoleast
Professor Guy Marks
two sputum and Ms Kerry
specimens Shawatofthe
collected thestart
ARC for
of
treatment are negative for AFBs on microscopy AND either:
x sputum culture is positive for M. tuberculosis, or
x decision by a clinician to treat with a full course of anti-TB therapy
x radiographic abnormalities consistent with active pulmonary TB
x no improvement in response to a course of broad-spectrum antibiotics
(excluding anti-TB drugs and fluoroquinolones and aminoglycosides).
c) History of previous treatment
Dr Iobi Batio
At the time of registration each patient meeting the case definition is
classified according to whether or not he or she has previously received
Dr Frank Underwood
TB treatment and, if so, the outcome.
The following definitions are used:
New. These are patients who have never had any treatment for TB or who
have taken anti-TB drugs for not more than a month.
Relapse. A patient previously treated for TB who has been declared cured or
treatment completed, and is diagnosed with bacteriological positive (smear
or culture) TB.
Treatment after default. A patient who returns to treatment, positive
bacteriologically, following interruption of treatment for 2 months or more.
Treatment after failure. A patient who is started on a re-treatment regimen
after having failed previous treatment.
Transfer in. A patient who has been transferred from another TB register to
continue treatment.
3

1.1.4 TB in children
The risk of TB in children is exposure to an active case of (smear positive)
tuberculosis in the household.

Symptoms of TB in children include
x Unexplained weight loss or failure to grow normally (failure to thrive)
ACKNOWLEDGEMENT
x Unexplained fever, especially when it last for more than two weeks
x Chronic cough
_______________________________________________________________________________
Signs of TB include
x Fast and shallow breathing (as in Pleural effusion)
x Enlarged non-tender lymph nodes, especially in the neck
This Guidelinex was
Signsprepared
of meningitis (withFiji
by the spinal fluid containing
National mostly
Tuberculosis lymphocytes,
Programme withlow
the
glucose and elevated protein)
Global Fund tox fight
Abdominal
AIDS, TBswelling with respectively.
and Malaria or without palpable lumps
x Progressive swelling or deformity in a bone or joint (including the spine)
The diagnosis
Particular gratitude of intrathoracic
is accorded to Professor (i.e.
Guy pulmonary,
Marks and Ms pleural,
Kerry and
Shawmediastinal
of the ARC or
for
their valuablehilar lymph node)
contributions to the tuberculosis in symptomatic
key technical concepts children with negative
of this Guide.
sputum smears should be based on the finding of chest radiographic
abnormalities
The indispensible comments consistent with tuberculosis
and suggestions by Dr LinhandNguyen
either a of
history
WHOofoffice
exposure to
in Suva
an infectious
must not go unrecognized. case or evidence of tuberculosis infection (positive tuberculin
skin test). Sputum specimens should be obtained (by expectoration, gastric
Last but notwashings,
the least,orthe
induced sputum) for
contributions andAFB microscopy
support of theand culture. personnel and
following
1.1.5Koroivueta
Dr Josefa Active case finding (screening) in high risk groups
Dr Iobi Batio At present there is no formal programme of active case finding by x-ray
screening in Fiji. However, operational research projects to establish the role
of active case finding in high risk groups are being planned by the NTP. A
Dr Frank Underwood
Dr Apisalomenecessary pre-condition for active case finding is the availability of an x-ray
Nakolinivalu
facility
Fiji Red Cross Society that is accessible to the population in whom screening is to be
undertaken.
1.1.5.1Unit
Grant Management Contact
of Fijiscreening
MOH and
Public health All care providers for patients with Tuberculosis should ensure that persons
officials
(especially if symptoms suggestive of TB, children <5years of age, persons
with HIV infection, and contacts to MDR/XDR-TB) who are in close contact
with patients who have infectious TB are screened and attended to
accordingly.
The key objectives of screening are to assess if the contact:
has undiagnosed TB
is at high risk of developing TB if infected.
is at high risk of having been infected by the index case
3

Priorities in contact screening

Higher risk of acquiring TB Higher risk of developing TB disease
infection
Close contacts of smear positive PTB Children <5years of age
People with HIV infection People with HIV infection
People who are highly exposed to People with other conditions that
ACKNOWLEDGEMENT smear +ve PTB suppress immunity (Diabetics, those
malignant disorders etc)
_______________________________________________________________________________
a) Adult contacts
x Assess all household members for signs and symptoms suggestive of
This Guideline was TB disease using
prepared by thecriteria in Page 11,(1.1.1)
Fiji National Tuberculosis Programme with the
x If signs
technical and funding & symptoms
support from theare present refer
Australian TB suspects
Respiratory for proper
Council (ARC)work
and up:
the
Sputum examination +/- chest
Global Fund to fight AIDS, TB and Malaria respectively. x-ray (if resources permit)
x Tuberculin skin testing (Mantoux test) could be used to determine the
Particular gratitude ispresence
accorded of to
latent TB infection
Professor (LTBI)
Guy Marks andif aMs
contact
KerryisShaw
cleared from
of the ARC for
clinical to
their valuable contributions and investigation
the key technicalassessments
concepts ofstated above. A positive TST
this Guide.
varies among contacts: i) >5mm induration for immune-suppressed
contacts (eg
The indispensible comments andPLWHA, malnourished,
suggestions by Dr Linhdiabetics);
Nguyen ii)
of >10mm indurated
WHO office in Suva
for all other contacts
x Once active TB is excluded, Isoniazid(INH) preventive therapy may be
Last but not the least,giventhe
to contacts with presumed
contributions or diagnosed
and support with LTBIpersonnel
of the following based on and
clinical and TST results. Recommended regimen:
Dr Josefa Koroivueta -INH 5mg/kg (max 300mg) daily for six months administered under
Dr Iobi Batio DOT strategy with Pyridoxine (vitamin B6) 10-20mg/day .
Dr Frank Underwood Screening methodology: Clinical assessment for TB related symptoms; chest
x-ray; and sputum smear microscopy. TST may help in establishing previous
exposure (+infection) with M. tuberculosis
b) Children
Grant Management contacts
Unit of Fiji MOH and (<5years old)
At this stage targeted treatment of latent tuberculosis infection in Fiji is
only recommended for children aged <5 years who are household
contacts of patients with smear positive pulmonary tuberculosis. These
children should be seen as soon as possible after the index (smear
positive) case is diagnosed. They should have a chest x-ray and clinical
review to exclude active TB. As TB may progress rapidly in young children
it is recommended that ALL such children (in whom active TB is
excluded) are commenced.
Isoniazid preventative therapy.
The dose of isoniazid is 5mg/kg daily for at least 6 (maximum 9)
months.
3

c) TB screening among Diabetics and vice versa

Type 2 diabetes involving chronic high blood sugar, is associated with
altered immune response to TB. This leads to patients with diabetes and
TB take longer to respond to anti-TB treatment. Patients with active
tuberculosis and Type 2 diabetes are more likely to have multi-drug
ACKNOWLEDGEMENT resistant TB. The Fiji NTP promotes screening for diabetes for all
registered TB cases and vice versa. This is achieved through a robust
_______________________________________________________________________________
collaborative initiative with the NCD unit of MOH, Divisional and sub-
divisional hospitals.(Standard TB screening procedures must be
applied to known cases of diabetes depending on resources
available at the respective levels of care.) On the other hand, all
This Guideline was prepared
confirmed TB by the Fiji
patients National
must Tuberculosis
be screened Programme
for diabetes on thewith
day the
of
technical and funding support from the Australian Respiratory Council (ARC) and
enlistment at a DOTS centre. The following assessment protocol should the
Global Fund to fight
be AIDS, TB and Malaria respectively.
applied:
x If known diabetic Ȃ ensure proper control of blood glucose with diet
and to Professor
prescribed Guy Marks and Ms Kerry Shaw of the ARC for
medications
their valuable contributions to the key
x If unknown diabetic:technical concepts of this Guide.
Dr Iobi Batio
Dr Frank Underwood
d) TBUnit
Grant Management Screening among
of Fiji MOH andPLWHA
People
Public health officials living with HIV infection who are also infected with TB are at
greater risk of developing active TB. The clinical features of TB in people
with HIV infection may be atypical. Extrapulmonary and disseminated TB
disease are common among PLWHA. PLWHA should be thoroughly
screened for active TB disease before considering the administration of
Isoniazid preventative therapy (IPT). Standard screening techniques
above [1.1.5.1 (a)] apply.
3

e) TB screening in Prisons & Correctional Facilities

All Prisons & Correctional facilities should designate a person or a
working group with experience in infection control, occupational health
and building design to be responsible for the TB infection-control
ACKNOWLEDGEMENT program. These persons should have the capacity and authority to
develop, implement, enforce, and evaluate TB infection-control policies in
_______________________________________________________________________________
collaboration with NTP. The detail of TB control in Correctional facilities
is beyond the scope of this Guideline. Standard screening protocol [as in
1.1.5.1 (a)] is used to identify persons who have active TB disease or
latent TB infection:
This Guideline wasx Allprepared by the
correctional Fiji employees
facility National Tuberculosis Programme
and inmates who with the
have suspected or
technical and funding confirmed TB disease should be identified promptly, and theand
support from the Australian Respiratory Council (ARC) the
case(s)
Global Fund to fight AIDS, TB and Malaria
or suspected case(s)respectively.
should be reported to the nearest Public health
facility or DOTS center.
Particular gratitude
x isEmployees
accorded to andProfessor
long-term Guy Marks infected
inmates and Ms Kerry Shaw
with M. of the ARC(i.e.,
tuberculosis for
those who have positive skin-test results) should be identified and
evaluated for Isoniazid preventive therapy.
The indispensible
comments and suggestions by Dr Linh Nguyen of WHO office in Suva
&ŝŐƵƌĞξ͘ŽŶƚĂĐƚƐĐƌĞĞŶŝŶŐƉƌŽĐĞĚƵƌĞ
Index Case
Dr Iobi Batio
Close contact
Dr Frank Underwood
ACKNOWLEDGEMENT
Signs and
Fiji Red Cross Societyof TB No signs or
symptoms
Fiji Nursing Association Symptoms of TB
_______________________________________________________________________________
Investigate for TB:
2 sputum samples
Adult and/or child aged HIV infection
Chest x-ray five years and over, with Child under 5 years
no immune-suppressing Other immune-
conditions
This Guideline was prepared by the Fiji National Tuberculosissuppressing
Programme conditions
with the
TB No TB
Global Fund to fight AIDS, TB and MalariaEducate
respectively.
and Tuberculin
Register Follow-up and discharge skin test If chest x-ray is
and treatis accorded
consider to
IPTProfessor
if normal commence
Particular gratitude Guy Marks and Ms Kerry Shaw of the ARC for
indicated Isoniazid preventative
their valuable contributions to the key technical concepts of this Guide. therapy (monitor)*
Negative Positive
If chest x-ray is
The indispensible comments and suggestions by Dr Linh Nguyen of WHO officeinvestigate
abnormal in Suva
must not goTB
unrecognized.
Guideline - Fiji for TB 21

1.1.11 The role of Civil Society & Private health care providers in case finding
TB Guideline - Fiji
Dr Iobi Batio 21
3
The NTP promotes the participation of community/faith based, civil society
organizations and private health care facilities3 to support national efforts to
Dr Frank Underwood
If chest x-ray is
The indispensible comments and suggestions by Dr Linh Nguyen of WHO officeinvestigate
abnormal in Suva
must not go unrecognized. for TB

Last
but not the least, the contributions and support of the following personnel and
Dr Josefa Koroivueta Index Case
1.1.11 The x roleTakeof Civil
overallSociety & Private health
responsibility to work careup providers
suspectsinreferred
case finding from
Dr Iobi Batio
The NTP
Sakiusa Mainawalala community/faith
promotes the based,
participation civil ofsociety organizations
community/faith and
based, private
civil health
society
Dr Close contact
organizations careandfacilities,
privatetohealth
confirm careor facilities
rule out3TB to and to design
support and efforts
national apply the to
Dr
Frank Underwood
scale up TBSignsappropriate
caseanddetection. treatment regimen
ACKNOWLEDGEMENT
xsymptoms
Supply
a) Community/faith
Fiji Red Cross Society of TBanti-TB medicines
based, Nosupplies
civil society signs or free
groups andofprivate
charge to civil
health care society
ACKNOWLEDGEMENT
Symptoms of TB
organizations
facilities should: and private health care facilities with adequate shelf life
_______________________________________________________________________________
and establish
x Follow
Investigate nationalaguidelines
reliable system
to detect forTBre-supply (in events where the
Grant Management Unit offorFiji
TB:
_______________________________________________________________________________
MOH and Adult and/or child aged HIV infection
2xsputumpatient
Refer all
samples opts
TB for care by
suspects to private
the health
nearest DOTScarecenter
provider or CSO
or public rep
health
Public health officials Chest x-ray five years and over, with Child under 5 years
x facility
Supplyfor diagnosis
reporting and
and
no treatmentformats to community/faith
recording
immune-suppressing Other immune- based,
x
This Guideline was civil Report on programme
societyby
prepared activities
conditions
organizations using
and private
the Fiji National MOH systems
suppressing
health care
Tuberculosis conditions
facilities with the
Programme
technical and xxTB Neither
funding support
Nopossess
TB from nor
thesell anti-TB
Australian medicines
Respiratory Council (ARC) and the
This Guideline was In collaboration
prepared by the Fiji withNational
community/faith
Tuberculosis based,
Programme civil with
society
the
Global Fund
technical and x
to fight
funding Communicate
AIDS, TB andfrom
organizations
support promptly
Malaria with
respectively.
andtheEducate
private
Australian the NTP
health
and
regarding
care
Respiratory defaulters
facilities
Tuberculin carry
Council and
out and
(ARC) ACSM the4
Global Fund toRegister absentees
fight AIDS, Follow-up
activities
TB and andaim to
that
Malaria discharge
improve attitude,
respectively. behaviourIf chest
skin test x-ray is
and practice to
and treatiscontrol
consider IPTFiji
if normal commence
Particular gratitude accordedTB in to Professor Guy Marks and Ms Kerry Shaw of the ARC for
indicated Isoniazid preventative
their valuable b)
Particular gratitude The NTP
contributions should:
to the key technical concepts of this Guide.
x isMonitor
accorded andtoreport
Professor Guy Marksbased
onNegative
community andPositive
MsDOTKerry Shaw
activities of athe
therapy
on ARC for
(monitor)*
quarterly

their valuable contributions to the
and annual key technical concepts of this Guide. If chest x-ray is
basis.
The indispensible x Take
3 Privately administered healthoverall
comments centers
and &responsibility
pharmacy
suggestions bytoDrwork
outlets Linh up suspects
Nguyen of WHO referred from
officeinvestigate
in Suva
x community/faith
Lead and provide capacity development opportunities abnormal
for
must not go unrecognized. based, civil society organizations and private health
for TBoffice in Suva
The indispensible comments communities and suggestions by Dr Linh Nguyen of WHO
TB Guideline - Fiji care facilities, toonconfirm
TB ȂDOT or care.
rule out TB and to design and apply the
22
Last but not the least, appropriate treatment regimen
institutions is x Supply
acknowledged: anti-TB medicines supplies free of charge to civil society
ACKNOWLEDGEMENT
institutions
organizations and private health care facilities with adequate shelf life
1.1.11is acknowledged:
Theand roleestablish
of Civil Society & Private
Dr Iobi Batio a reliable systemhealth care providers
for re-supply (in eventsin case
wherefinding
the
_______________________________________________________________________________
The NTP
TB Guideline - Fijipromotes the participation of community/faith based, civil society
Dr patient opts for care by private health care provider or CSO rep 22
3
Iobi Batio
organizations and private health care facilities3 to support national efforts to
Dr Frank x Supply reporting and recording formats to community/faith based,
Underwood
Dr Sakiusascale
Mainawalala
up TB case detection.
Dr
Frank Underwood civil society organizations and private health care facilities
a) Community/faith based, civil society groups and private health care
Fiji Red Cross
Dr Apisalome Society
This Guideline Nakolinivalu
x facilities
was In collaboration
prepared by the Fiji
should: withNational
community/faith
Tuberculosis based,
Programme civil with
society
the
Fiji
Fiji Nursing
Red CrossAssociation
Society organizations and private health care facilities carry out ACSM
technical and funding x Followsupportnational
from the Australian
guidelines Respiratory
to detect TB Council (ARC) and the4
Grant
Fiji Management
Nursing Association Unit of
activitiesFiji MOH
that and
aim to improve attitude,
Global Fund to fightxAIDS,
TB all
Refer and TBMalaria
suspects respectively.
to the nearest DOTSbehaviour and practice
center or public health to
Grant Management Unit of TB
control Fijiin
MOH Fiji and
facility for diagnosis and treatment
Public health
Particular officials
gratitude x x isMonitor
accorded
Reportand ontoprogramme
Professor
report Guy
on communityMarksbased
activities and Ms
using DOT
MOHKerry Shaw on
activities
systems of athe ARC for
quarterly
x and to the
annual
Neither key technical
basis.
possess concepts
nor sell anti-TB of this Guide.
medicines
x x Lead and providepromptly
Communicate capacity with
development opportunities
the NTP regarding for
defaulters and
The indispensible comments communities and on suggestions
TB ȂDOT by Dr Linh Nguyen of WHO office in Suva
care.
absentees
b) The NTP should:

3 Privately administered health centers & pharmacy outlets
Dr
Josefa Koroivueta
4 Advocacy Communication Social Mobilization
Dr Iobi Batio
Dr Frank Underwood
3
Grant Management
TB Guideline -Unit
Fiji of Fiji MOH and 23
3

1.2 TREATMENT OF PEOPLE WITH TUBERCULOSIS
1.2.1 Registering the case and initiating treatment

All patients diagnosed with tuberculosis must be registered by the Divisional
TB control officer right after diagnosis and at the start of treatment. A unique
ACKNOWLEDGEMENT
registration number is assigned for each new patient. Details of the
registration procedure are enclosed in the TB register (Appendix 5).
_______________________________________________________________________________
A treatment card is completed and a TB identity card is given to the patient
upon registration. In the event the diagnosis of TB is made at a regional or
peripheral location, the patient is transfered to the nearest DOTS center for
This Guidelinecommencement
was preparedofby intensive
the Fijiphase of treatment.
National Tuberculosis Programme with the
Global1.2.2
Fund toRecommended
fight AIDS, TB andregimens
Malaria respectively.
NTP now uses Fixed Dose Combination (GDF Kits-antiTB medicines) for
intensive
Particular gratitude and continuation
is accorded phase
to Professor Guy of treatment.
Marks and MsRegimens areofavailable
Kerry Shaw for
the ARC for
adults and children
their valuable contributions to the keyand for new
technical patient
concepts andGuide.
of this re-treatment cases. The
regimens below are based on FDC preparations. For adults these are available
in patient
The indispensible commentskits which should be by
and suggestions supplied forNguyen
Dr Linh individual patients.
of WHO Paediatric
office in Suva
preparations are available upon request from FPBS.
Last but not 1.2.2.1

the least, New cases
institutions is acknowledged: children > 30kg Table 1. Standard regimen: 2RHZE/4RH
a) Adults and
Dr Josefa KoroivuetaTreatment Essential anti-TB medicine Dosage (mg/kg)
Dr Iobi Batio phase
Intensive
Dr Sakiusa Mainawalala Rifampicin (R) 10
Dr Frank Underwood Isoniazid (H) 5
Dr Apisalome Nakolinivalu Pyrazinamide (Z) 25
Fiji Red Cross Society Ethambutol (E) 15
Continuation
Fiji Nursing Association Rifampicin (R) 10
Grant Management Unit of Fiji MOH and Isoniazid (H) 5
b) Children < 30 kg
Regimen: 2RHZ/4RH or 2RHZE/4RH
Table 2. Children between 5kg and 20kg (without ethambutol)
Intensive Phase (2 months) Continuation phase (4 months)
Weight R 30 R 60 R 60 R 60
H 30 H 60 H 30 H 60
Z 150
5 to 7 kg 1 1 1 1
8 to 14 kg 2 1 2 1
15 to 20 kg 3 2 3 2
323
Table 3. Children between 5kg and 20kg (with ethambutol)
Weight R 30 R 60 E 100 R 60 R 60
H 30 H 60 H 30 H 60
Z 150
5 to 7 kg 1 1 1 1 1
8 to 14 kg 2 1 2 2 1
Table 3. kg
15 to 20 Children between
3 5kg
2 and 20kg
3 (with ethambutol)
3 2
Weight R 30 R 60 E 100 R 60 R 60
H 30 H 60 H 30 H 60
Table 4. Children betweenZ 15021kg and 30kg without ethambutol
5 to 7 kg 1
Intensive 1 (2 months)
Phase 1 1
Continuation 1
phase (4 months)
8 to 14 kg 2 1 2 2 1
Weight
15 to 20 kg R 150
3 R 60
2 Z3 R 1503 R 602
H 75 H 60 H 75 H 60
5 to 7 kg 2 2 2 2 2
Table 4. Children between 21kg and 30kg without ethambutol

Table 5. Children between 21kg and 30kg with ethambutol
Weight R 150
Intensive R 60 (2
Phase Z R 150 phase (4 months)
Continuation R 60
H 75months)
H 60 H 75 H 60
5Weight
to 7 kg 2
R 150 2 R 60 2 R 1502 R 260
H 75 H 60 H 75 H 60
Z 400
E 275
Table215.toChildren
30 kg between 2 21kg and 230kg with ethambutol
2 2
Intensive Phase (2 Continuation phase (4 months)
months)
Weight R 150 R 60 R 150 R 60
1.2.2.2 Re-treatment cases
H 75 H 60 H 75 H 60
All re-treatment patients should have cultures sent to the QMRL in Brisbane
Z 400
for DST. While awaitingE the 275 results of DST, re-treatment patients who have
21 to 30 kg 2 2 2 2
defaulted or relapsed after their first treatment regimen should be started on
the standard re-treatment regimen. The treatment regimen should be
adjusted
1.2.2.2 onRe-treatment
the basis of DST when results are available.
cases
All re-treatment patients should have cultures sent to the QMRL in Brisbane
Table 6. Standard
for DST. re-treatment
While awaiting regimen:
the results of DST,2RHZES/1RHZE/5RHE
re-treatment patients who have
defaulted
Treatment or relapsed after their
Intensive phase first treatment regimen should
Intensive phase be started
Continuation phaseon
standard re-treatment
thephase (2months) regimen. The treatment
(1month) regimen
(5months) be
should
Regimen*on the basis
adjusted of DST when results
Rifampicin are available.
Rifampicin Rifamipicin (5)
Isoniazid Isoniazid Isoniazid (5)
Table 6. Standard re-treatment regimen:
Pyrazinamide 2RHZES/1RHZE/5RHE
Pyrazinamide Ethambutol (5)
Ethambutol Ethambutol
Treatment Intensive phase
Streptomycin Intensive phase Continuation phase
* phase (2months) (1month) (5months)
Regimen*For doses
Rifampicin Rifampicin
refer to 3.2.2.1 above. Rifamipicin (5)
Isoniazid Isoniazid Isoniazid (5)
Pyrazinamide Pyrazinamide Ethambutol (5)
Ethambutol Ethambutol
TB Guideline - Fiji Streptomycin 25
*
For doses refer to 3.2.2.1 above.
25

If the organism is confirmed as fully-susceptible to the standard

x
first-line drugs then the re-treatment regimen should be continued.
x Streptomycin is ceased after two months, the other intensive phase
therapy (rifampicin, isoniazid, pyrazinamide and ethambutol) is
continued for a third month.
ACKNOWLEDGEMENTx The standard continuation phase (rifampicin,isoniazid & ethambutol)

then begins and continues for five months. This regimen totals at least
_______________________________________________________________________________
8 months. Streptomycin should not be used in children, in
pregnant women or people with renal failure.
1.2.2.3 MDR-TB
technical andFiji has never
funding encountered
support from the aAustralian
case of MDR-TB. However,
Respiratory Councilthe(ARC)
NTP and
has the
the
capacity to recognise and diagnose MDR-TB,
Global Fund to fight AIDS, TB and Malaria respectively. should it occur. If MDR-TB is
suspected, on the basis of treatment failure, or confirmed on DST then
consultation
Particular gratitude with an
is accorded to expert (through
Professor WHO)and
Guy Marks in the
Ms management
Kerry Shaw of ofthe
MDR-TB is
ARC for
their valuableadvised. The patient
contributions should
to the key be placed
technical in aofsingle
concepts room with respiratory
this Guide.
isolation precautions in one of the three(3) DOTS centers. Usually, it is
safestcomments
The indispensible to withhold
andsecond-line
suggestionsdrugs
by Druntil
Linh susceptibility
Nguyen of WHO is confirmed on
office in Suva
DST. Emperical regimens of second line drugs will be used for the MDR-
TB patients based on the DST results.
institutions is1.2.2.4 Regimens for extra-pulmonary tuberculosis
acknowledged:
The
Dr Josefa Koroivuetaregimens described above are given for all forms of tuberculosis except
Dr Iobi Batio that the continuation phase should be extended to 10-12 months (or directed
by the TBCO) in patients with miliary, meningeal, and bone or osteo-articular
tuberculosis. Patients with tuberculous pericarditis or tuberculous meningitis
Dr Frank Underwood
should receive prednisone for the first 10 Ȃ 12 weeks of therapy. The
Dr Apisalome dose
Nakolinivalu
should start at 50 mg daily (1 mg/kg/day in children) and taper of
Fiji Red Cross this
Society
period.
1.2.2.5
Grant Management Unit Regimens
of Fiji MOHfor
andpatients with liver disease or renal failure
Standard TB treatment can be administered to patients with mild
abnormalities of liver function. However, expert consultation is
recommended before embarking on treatment of TB in patients with severe
underlying liver disease. For patients with renal failure or severely impaired
renal function it is recommended that ethambutol and pyrazinamide are
given only three times per week (in the standard doses). This means that,
during the intensive phase, the regimen described above is given three days
per week and on the remaining four days per week, the four drug FDC is
replaced by rifampicin 150 / isoniazid 75 FDC.
3

1.2.3 Ensuring adherence

Every dose of chemotherapy taken by a patient with tuberculosis should
be directly observed by an appointed DOT supervisor. At present this is

being achieved during the intensive phase by keeping all patients in hospital
throughout this phase. It is not generally being achieved during the
ACKNOWLEDGEMENT
continuation phase. The implementation of strategies to ensure direct
observation of therapy during the intensive phase is a high priority. This
_______________________________________________________________________________
should be accompanied by implementation of strategies to enable direct
observation of treatment in the community during the intensive phase.
1.2.3.1 Strategies for direct observation of therapy (DOT) in the

This Guideline was prepared community by the Fiji National Tuberculosis Programme with the
technical andAll funding
patients who dofrom
support the Australian
not otherwise need toRespiratory Council
be hospitalised (ARC) reasons
for medical and the
Global Fund tocanfight
beAIDS, TBinand
treated theMalaria respectively.
community, in either or both the intensive phase and
the continuation phase. Patients who do NOT adhere to DOT will need to be
hospitalised
Particular gratitude for supervised
is accorded treatment.
to Professor Guy MarksA range
and Msof Kerry
alternative
Shaw strategies
of the ARCwill
for
their valuablebe required to to
contributions enable DOT
the key in the community.
technical concepts ofThese may include:
this Guide.
x Requiring patients to attend a nearest health or DOTS centre for
treatment
x Arranging for zone nurses to visit patients at home on a fortnightly basis
to supervise implementation of DOT.
Last but not xtheArranging
least, thefor DOT to be administered
contributions and support byof peripheral
the followinghealth centresand
personnel or
nursing
institutions is acknowledged:stations.
x Arranging for DOT to be administered by trained community based
Dr Iobi Batio volunteers from civil society (such as Red Cross), village health workers
or faith based organisations.
x Arranging for DOT to be administered by traditional healers in the village
Dr Frank Underwood
dispensary.
x Identifying other appropriate, independent and trustworthy individuals
who can deliver DOT in the village setting.
The Divisional TBCO should identify the appropriate DOT supervisor, in
consultation with local health staff and other civic leaders, at the time of
commencing therapy or prior to discharge from hospital. The Divisional
TBCO will need to ensure that the designated TB supervisor receives:
x Motivation and instruction about DOT
x Advice about how to report non-adherence
x Advice on adverse effects and how to report them
x Treatment cards
x The appropriate medication supply (kits) for the patient
x A contact number for assistance
3

During the continuation phase, daily regimens should be used, to implement

DOT. Where DOT supervision is undertaken by non-health system staff, the
Zone nurse responsible should make a fortnightly visit to supervise the DOT
process and more importantly to obtain regular upd ǯ
progress.
ACKNOWLEDGEMENT
1.2.3.2 Defaulter tracing
x The peripheral health staff (particularly zone nurses) should organise
_______________________________________________________________________________
the tracing of patients who are reported by their DOT supervisors to
have missed more than one dose during the intensive phase or more
than one week of treatment during the continuation phase.
x The Divisional TBCO and the Divisional Medical Officer should be
This Guideline was made awarebyof the
prepared all such
Fiji cases. Priority
National must always
Tuberculosis be given to
Programme smear
with the
positive TB patients.
x AIDS,
Global Fund to fight If theTB
patient is absent
and Malaria for more than two months, he or she is declared
respectively.
a defaulter and his/her sputum must be investigated again. Such
patients should be re-admitted to hospital to undergo re-treatment
regimen.
1.2.3.3 Clinical monitoring of treatment
The indispensiblex comments
Patients and should have regular
suggestions by Drmedical monitoring
Linh Nguyen of WHOplanned bySuva
office in the
responsible TB medical officer.
x This should include medical examination, particularly on biochemical
assays for liver, kidney and hematological functions, at the DOTS
centre at least at the end of the intensive phase and at the end of
treatment.
x The patients should bring his/her treatment card to all these
Dr Iobi Batio appointments.
1.2.3.4 Bacteriological monitoring of patients
Dr Frank Underwood
Dr Apisalome Sputum smear examinations should be performed:
Nakolinivalu
Fiji Red Cross Society the end of the intensive phase, that is, two months for new patients
x at
and three months for the standard, non-MDR, re-treatment regimen;
x at the end of three months if they were smear positive at the two
Grant Management Unit monthof Fiji MOH and
examination;
x one month before the end of treatment, that is, five months for new
patients and seven months for the standard, non-MDR, re-treatment
regimen. (This only applies patients who were smear positive at the
start of treatment).
x Patients with positive sputum smears at the end of three months or
one month before the end of treatment should have specimens sent
for culture and DST.
3

1.2.4 Adverse events (side-effects) & drug interactions

x Patients with HIV infection, alcohol dependency, malnutrition,
diabetes, chronic liver disease or renal failure as well as pregnant or
breastfeeding women should receive pyridoxine (vitamin B6)
throughout their course of treatment to prevent peripheral
neuropathy.
ACKNOWLEDGEMENT x Patients taking the oral contraceptive pill (OCP) should be advised to
use alternative means of contraception during TB treatment as
_______________________________________________________________________________
rifampicin makes the OCP unreliable.
x Patients should be warned that their urine will turn orange and
advised that they should not be alarmed.
x Patients should be informed of the more common or serious side
This Guideline was effects
prepared by the Fiji
of treatment National
at the time theyTuberculosis
commence on Programme
treatment. with the
Global FundTable 7. Symptom
to fight AIDS, TBbased approach
and Malaria to side effects of anti-TB drugs.
respectively.
SIDE EFFECT ANTI-TB DRUG MANAGEMENT

Particular gratitude is accorded to Professor Guy Marks and Ms Kerry
RESPONSIBLE
Shaw of the ARC for
Minor to the key technical concepts of this Guide.
Continue anti-TB drugs, check doses
Anorexia, nausea, R, Z Give drugs with small meals or last thing at

The indispensible comments and suggestions by Dr night.
abdominal pain
Linh Nguyen of WHO office in Suva
Joint pains Z Aspirin
Last but notBurning
the least, the in
sensation contributionsH,andR support of the
Pyridoxine following
100mg daily personnel and
feet, Orange/red urine Reassurance
Major Stop responsible drug(s)
Dr Iobi Batio
Itching, skin rash H, R, Z, S Stop anti-TB
Deafness, no wax on
Dr Frank Underwood
auroscopy S Stop S, use E
Fiji Red CrossDizziness
Society(vertigo &
nystagmus) S Stop S, use E
Grant Management
JaundiceUnit of causes
(other Fiji MOH and
excluded)
Public health officials H, Z, R Stop anti-TB drugs
Confusion (acute liver Most anti-TB Stop anti-TB drugs, urgent LFTs & PTTK
failure if jaundice is drugs
present)
Visual impairment E Stop E

(other causes excluded)
Shock, purpura, acute R Stop R
renal failure
3
facilities should:
x Follow national guidelines to detect TB
x Refer all TB suspects to the nearest DOTS center or public health
facility for diagnosis and treatment
x Report on programme activities using MOH systems
1.2.5 xCo-management
Neither possess ofnor
HIVsell
and activemedicines
anti-TB TB disease
x Communicate promptly with the NTP regarding defaulters and
1.2.5.1 HIV pre-test counselling should be offered to all newly diagnosed cases of
absentees
TB by a health care worker trained in provider intitiated counselling &
testing (approved by PSH) who is responsible for their care. HIV testing
b) The NTP should:
ACKNOWLEDGEMENT
1.2.5.2
must be aligned with the new HIV Decree in Fiji.

Standard TB treatment regimens should be implemented without delay
3 Privately administered health centers & pharmacy outlets
_______________________________________________________________________________
for all patients with HIV infection who are diagnosed with tuberculosis.
Daily therapy should be administered throughout both intensive and
continuation phases. TB treatment should be observed daily for HIV
infected TB patients either at DOTS centres or if this is not feasible by
This Guideline was zoneprepared
nurses inby thetheFiji
both National
intensive andTuberculosis Programme
continuation phase with the
of treatment.
technical 1.2.5.3
and funding support from
Co-trimoxazole the Australian
preventive Respiratory
therapy should Council
be provided to (ARC) and the
all HIV-infected
TB Guideline - Fiji TB patients at the time of diagnosis and should be available at both TB 22
3
and HIV care facilities.
Particular1.2.5.4
gratitude AllisTBaccorded
patientstowith
Professor GuyHIV
a positive Marks
testand Ms Kerry
should Shaw ofwith
be discussed the HIV
ARCcare
for
facilities for key technical
appropriate concepts of therapy
anti-retroviral this Guide.
(ART). ART should be
commenced as soon as possible and within eight weeks of commencing
The indispensibleTB comments and The
treatment. suggestions by Dr Linh
administration Nguyen
of ART mustof WHO
followoffice in Suva
standardised
national HIV guidelines.
Adverse drug effects are common in HIV-positive TB patients, and some
toxicities are common to both ART, co-trimoxazole and TB drugs. Careful
Dr Josefa Koroivueta monitoring for adverse events is important.
Dr Iobi Batio All adverse drug reactions must be reported by the responsible health
Dr Sakiusa Mainawalala worker and shared with FPBS
Dr Frank Underwood
3

4
1.3 PREVENTING TUBERCULOSIS

Advocacy Communication Social Mobilization
TBThe prevention
Guideline - Fiji of TB involves the protection of the population vulnerable from 23
infection and suppressing the development of active disease among those already
infected with M. tuberculosis.
ACKNOWLEDGEMENT
_______________________________________________________________________________
TB Guideline - Fiji Vulnerable Infection with
23
3
population D͘
ƚƵďĞƌĐƵůŽƐŝƐ
This
This Guideline
Guideline was
was prepared
prepared by
by the
the Fiji
Fiji National
National Tuberculosis
Programme with
with the
the
technical
technical and
and funding
funding support
support from
from the
the Australian
Australian Respiratory
Respiratory Council
Council (ARC)
(ARC) and
and the
the
Global
Global Fund
Fund to
to fight
fight AIDS,
AIDS, TB
TB and
and Malaria
respectively.
Active TB
disease
Particular
gratitude is
is accorded
accorded to
to Professor
Professor Guy
Guy Marks
Marks and
and MsMs Kerry
Kerry Shaw
Shaw of
of the
the ARC
ARC for
for
their
their valuable
valuable contributions
contributions to
to the
the key
key technical
technical concepts
concepts of
of this
this Guide.
Guide.
1.3.1 Infection control
The
The indispensible
indispensible
The comments
comments and
and suggestions
suggestions
goal of infection by
by Dr
Dr Linh
Linh
control activities is Nguyen
Nguyen of
of WHO
WHO
to minimise theoffice
office
riskin
inofSuva
Suva
TB
must
must not
not go
go unrecognized.
unrecognized.
transmission. ǲ-Infection Control Manual
ǳ Ǥo TB, as a
Last
Last but
but not
not the
the least,
least,
matter of the
the contributions
contributions
priority, and
and
all patients support
support with
diagnosed of
of the
the
orfollowing
following
suspectedpersonnel
personnel
of having and
and
TB
institutions
institutions isis acknowledged:
acknowledged:
must be separated from other patients, placed in adequately ventilated areas,
Dr
Dr Josefa
Josefa Koroivueta
Koroivueta
educated on cough etiquette and respiratory hygiene, and assessed for risk
Dr
Dr Iobi
Iobi Batio
Batio for TB transmission.
Dr
Dr Sakiusa
Sakiusa Mainawalala
Mainawalala
x All patients with TB or suspected TB should be categorised as having a
Dr
Dr Frank
Frank Underwood
Underwood high, medium, low or negligible risk for transmission of TB. This will
Dr
Dr Apisalome
Apisalome Nakolinivalu
Nakolinivalu
guide isolation requirements for the TB patient or suspect.
Fiji
Fiji Red
Red Cross
Cross Society
Society
x All care should be taken to minimise the exposure of non-infected
Fiji
Fiji Nursing
Nursing Association
Association
patients (in particular, those who are immunocompromised) to TB.
Grant
Grant Management
Management Unit
Unit of
Patientsof Fiji
Fiji MOH
MOH
living and
and
with HIV or with strong clinical evidence of HIV infection,
Public
Public health
health officials
officials
or with other forms of immunosuppression, should be physically
separated from those with suspected or confirmed infectious TB.
x To minimise the spread of droplet nuclei, patients with or suspected of
having TB, should be educated in cough etiquette and respiratory hygiene
that is, in the need to cover their nose and mouth using a piece of cloth,
tissue or surgical mask when sneezing and or coughing. The cloth, tissue
or a surgical mask should be disposed of as infectious waste.
TB
TB Guideline
Guideline -- Fiji
Fiji 30
3330

1.3.1.1 Isolation
Each DOTS centre or hospital caring for patients with tuberculosis should
have well ventilated rooms suitable for housing patients with TB. Airborne
precautions should be implemented when these rooms are occupied.
DOTS centers should also have a few isolation rooms with acceptable
standards for housing the following patients:
x People suspected of having infectious drug resistant TB. These are all
re-treatment or treatment failure cases. They should be
accommodated in a single room until MDR-TB is excluded by DST.
x People with confirmed MDR-TB or XDR-TB. They should remain in a single
room until sputum is culture negative.
While patients are in isolation (they are considered infectious).
x Contact with visitors should be minimised (or appropriate infection
control measures adhered to),
x Visitors who are less than 5 years of age or those who are immuno-
suppressed (eg HIV) should be discouraged from visiting patients in
the isolation room
x Patients should wear surgical masks (not N95 masks) to reduce the
risk of transmission when they are not in isolation rooms eg during
transportation.
x Mothers with infectious TB should wear surgical masks if/when
caring for their infants eg breastfeeding.
1.3.1.2 Use of N95 masks

Personal protective equipment should be used by health workers and visitors
in situations where there is an increased risk of transmission to reduce the
risk of infection or re-infection with TB. These situations include:
x Those entering the isolation rooms described above;
x HCWs performing or attending aerosol-generating procedures associated
with high risk of TB transmission (e.g. bronchoscopy, intubation, sputum
induction procedures, aspiration of respiratory secretions, and autopsy or
lung surgery)
N95 masks are recommended for this purpose. HCWs should be trained in
the use of N95 masks and educated on managing stigma which may arise as a
result of using N95 masks.
1.3.1.3 Natural ventilation

Simple natural ventilation may be effective in reducing the risk of
transmission. This should be optimized in DOTS center by maximizing the
size of the opening of windows and locating them on opposing walls.
31

1.3.2 BCG vaccination

BCG vaccination is included in the Expanded programme of Immunisation. In
Fiji BCG vaccination is given at birth. The dosage is 0.05ml of BCG vaccination
injected intradermally on the upper aspect of the right arm (at the point of
insertion of the deltoid muscle into the humerus). BCG vaccination after infancy
ACKNOWLEDGEMENT
is not recommended.
_______________________________________________________________________________
1.3.3 Preventative chemotherapy
The following group of persons should be properly examined for the presence
of active TB disease. Once active TB is ruled out, Isoniazid preventative
treatment (IPT) should be instituted for at least 9 months:
a) People living with HIV/AIDS
Patients with HIV infection who are also infected with TB are at great risk of
developing active TB. The clinical features of TB in people with HIV infection
may be atypical. Extrapulmonary and disseminated TB disease is common
among PLWHA.
PLWHA should be evaluated for the presence of TB and, if this is not present,
should receive isoniazid preventive therapy
If acknowledged:
institutions is active TB is excluded, they should be screened for latent tuberculosis
Dr Josefa Koroivueta by Mantoux test. The Mantoux test should be performed by a HCW
infection
Dr Iobi Batioexperienced in performing this test. Patients with HIV infection who have a
η ͷ should be considered to have latent
tuberculosis infection and should be prescribed a six month course of Isonazid
Dr Frank Underwood
300 mg daily (5mg/kg up to a maximum of 300mg daily in children) together
Fiji Red Crosswith vitamin B6 (pyridoxine) 25 mg daily. They should be reviewed on a
Society
monthly
Fiji Nursing Association schedule to ensure proper adherence to prescribed treatment.
Public healthb)officials
All children contacts (<5yrs old):Refer to Page 19. Management of latent
TB infection in children.
3

1.4 Monitoring & evaluation
1.4.1 Cohort analysis

Evaluation of treatment outcome in new pulmonary smear-positive patients
is used as a major indicator of programme quality and performance.
ACKNOWLEDGEMENT
Outcomes in other patients (re-treatment, pulmonary smear-negative, extra-
pulmonary) are analysed in separate cohorts. Each registered patient should
_______________________________________________________________________________
have his/her outcome recorded in the register as soon as treatment course is
completed. The following treatment outcome definitions should be used for
sputum smear-positive patients.
Table 8. Treatment outcome definitions
Global Fund toOutcome
fight AIDS, TB andDefinition
Cured is accorded to Professor
A patient Guy
whose Markssmear
sputum and MswasKerry Shaw
positive of beginning
at the the ARC for
of key
the technical
treatmentconcepts
but whoofwas
thissmear-negative
Guide. in the last
month of treatment and on at least one previous occasion.
Treatment
The indispensible comments and A patient who completed
suggestions by Dr Linhtreatment
Nguyen butofwho
WHO does not have
office a
in Suva
completed
must not go unrecognized. negative sputum smear result in the last month of treatment
and on at least one previous occasion.
Last but not Treatment A patient whose
the least, the contributions sputum of
and support smear
the isfollowing
positive personnel
(and cultureand
failure positive) at 5 months or later during treatment. Also
included in this definition are patients found to harbour a
multidrug-resistant (MDR) strain at any point of time during
Dr Iobi Batio the treatment, whether they are smear-negative or positive.
Died A patient who dies for any reason during the course of TB
Dr Frank Underwood treatment.
Dr ApisalomeDefault
Nakolinivalu A patient whose treatment was interrupted for 2 consecutive
Fiji Red Cross Society months or more.
Transfer out A patient who has been transferred to another recording and
Grant Management Unit of Fiji MOH reporting
and (DOTS) unit and whose treatment outcome is
Public health officials unknown.
Treatment A sum of cured and completed treatment.
success
These treatment outcomes should be determined by the Divisional TBCO in

charge. This will allow the National TB Office to perform cohort analysis on a
quarterly and annual basis.
3

1.4.2 Recording and reporting system
1.4.2.1 TB patient register

The TB patient register is kept at the:
x Divisional DOTS centers Ȃ should contain register of all patients covered
ACKNOWLEDGEMENT
ACKNOWLEDGEMENTunder the respective Divisional DOTS center.
x Sub-divisional hospitals Ȃ should contain register of all patients covered
_______________________________________________________________________________
_______________________________________________________________________________
under the respective sub-divisional hospital.
x Primary health care centers (Health centers) Ȃ should contain register of
all patients covered under the respective primary health care center.
This
This Guideline
Guideline was
was prepared
1.4.2.2 prepared by
Laboratoryby the
the Fiji
Fiji National
registers National Tuberculosis
Programme withwith the
the
technical
funding support
andLaboratory support from
from the
the Australian
Australian Respiratory
Respiratory Council
Council (ARC)
(ARC) and
and
aspects of tuberculosis management are beyond the scope of this the
the
Global
GlobalFund
Fundtotofight
fightAIDS,
Guide. AIDS,TB
TBand
However, and Malaria
Malaria
each respectively.
respectively.
laboratory performing TB microscopy (in the three
DOTS centres) should keep a laboratory register. The technologist in charge
Particular
Particulargratitude
of the is
gratitude isaccorded
accordedistoto
laboratory Professor
ProfessorGuy
responsible for Marks
Guy Marksand
andMs
maintaining Ms Kerry
Kerry
this Shaw
Shaw
register ofofthe
theARC
up-to-date onfor
ARC for
a
their
theirvaluable contributions
valuabledaily
contributions
basis. to
tothe
the key
keytechnical
technicalconcepts
conceptsof
ofthis
thisGuide.
Guide.
The
Theindispensible
indispensible comments
1.4.2.3comments and
Treatmentandsuggestions
suggestions
cards by
byDrDrLinh
LinhNguyen
NguyenofofWHO WHOoffice
officeininSuva
Suva
must
mustnotnotgo
gounrecognized.
unrecognized.
The treatment card contains all the information about the patient. Two copies
of a treatment card will be completed for each patient, as well as a patient's
Last
Last but
but not the
the least,
least, the
notidentification the contributions
contributions
card. One copy ofand
thesupport
and support ofof the
treatment the following
card following personnel
is retainedpersonnel
at the DOTSand
and
institutions
institutionsisiscentre
acknowledged:
acknowledged:
responsible for the patient.
Dr
DrJosefa
JosefaKoroivueta
Koroivueta
Dr Iobi Batio The second copy of the treatment card is sent to the health facility/person
Dr Iobi Batio
Dr
DrSakiusa (TB liaison officer) responsible for delivering supervised treatment to the
SakiusaMainawalala
Mainawalala
Dr
DrFrank patient. The person administering treatment (either in hospital or in the
FrankUnderwood
Underwood
Dr Apisalomecommunity)
DrApisalome Nakolinivalumust record the patient's daily intake of prescribed drugs
Nakolinivalu
Fiji
FijiRed Crossaccording
RedCross Society to that patient's treatment schedule on this treatment card. Each
Society
Fiji
FijiNursing Association dose should be signed for (with initials). The Treatment card,
administered
NursingAssociation
Grant
GrantManagement domiciallery
Management Unit form
UnitofofFiji andand
FijiMOH
MOH Patient
and identification card can be found in the enclosed
Public
Publichealth Appendices.
healthofficials
officials
1.4.2.4 Reporting mechanisms
a) DOTS centres should report the following on a quarterly (within the first
month of new quarter) and annuall schedule to the National TB
Programme Office in Suva on:
x TB Case Notification: number (age/gender distribution, classification)
x TB-HIV coinfection & MDR-TB
x Treatment outcome (highlighting those cured, treatment completed,
died, failures, defaulters, & transfers)
TB
TBGuideline
Guideline- -Fiji
Fiji 334
34
3

b) The National TB Programme reports to Health Information Unit at the

MOH quarterly & annually on:
x TB Case Notification - number & rate (age & gender distribution,
ACKNOWLEDGEMENT x
classification & type of TB case)
TB-HIV coinfection & MDF-TB + TB -Diabetes co-infection
_______________________________________________________________________________
x Number and proportion of children (0 - 13 years) screened for TB and
starting TB prophylaxis.
x Treatment outcome (highlighting those cured, treatment completed,
died, failures, defaulters, & transfers)
1.4.3the least,
Last but not Managing anti-TB drugand
the contributions supply
support of the following personnel and
The FPBS
institutions is acknowledged:work in partnership with the NTP in determining the required
supply
Dr Josefa Koroivueta of anti-TB drugs on an annual basis. Procurement and distribution
Dr Iobi Batio of anti-TB drugs to DOTS centres and Divisional hospital pharmacies are
solely the responsibility of the FPBS. Divisional hospitals also possess anti-
TB
Dr Frank Underwood drugs, and advise their respective DOTS centres of a newly diagnosed
case of TB before or when commencing treatment. DOTS centres are
responsible
Fiji Red Cross Society for the dispensing and recording of appropriate supply of anti-
TB drugs on a case by case basis to Sub-divisional or peripheral level.
36
3

1.5 PROGRAMME SUPERVISION
1.5.1 National supervision

The NTP office at Tamavua-Twomey hospital in Suva provides technical and
programmatic oversight of all TB control activities in Fiji. This is done through:
ACKNOWLEDGEMENT x conduct of quarterly supervisory visits to the three(3) DOTS centres
x standardising operating procedures
_______________________________________________________________________________
x provision of technical support to other TB stakeholders .ie. FRCS, FNA,
FNU, NRL, HIU and FPBS.
x liaison to donor and technical partners .ie. WHO, GFATM, GMU-MOH,
This Guideline wasSPC prepared by the Fiji National Tuberculosis Programme with the
1.5.2
Global Fund Divisional
to fight AIDS, TBsupervision
and Malaria respectively.
The three(3) DOTS centres are located in Lautoka (Tagimoucia unit), Labasa
and Tamavua-Twomey
Particular gratitude hospitals.Guy
is accorded to Professor They provide
Marks andand
Ms conduct:
Kerry Shaw of the ARC for
x Divisional
their valuable contributions to TB
thecontrol services
key technical concepts of this Guide.
x Supervision of sub-divisional health centres (TB patient Ȃ health care
provider-health
The indispensible comments service) andbytoDr
and suggestions community settings
Linh Nguyen whereoffice
of WHO TB patient
in Suva
is
must not go unrecognized.under DOT care by community health worker.
x Report to NTP head office on quarterly & annual basis
1.5.3
institutions Sub-divisional supervision
is acknowledged:
The sixteen (16) sub-divisional hospitals in Fiji are in charge of the following
Dr Iobi Batio TB control activities:
x Supervision of identified health centres and communities
x
Dr Frank UnderwoodProvide complementary TB services particularly on suspect referral,
contact screening and continuum of care for patients undergoing
Fiji Red Cross Societycontinuation phase of treatment
x Report on quarterly & annual basis to their respective DOTS centers
Grant Management Unit (indicator
of Fiji elements
MOH and pertaining to TB case notification, and treatment
outcome)
1.5.4 Laboratory supervision and EQA

Daulako Mycobacterium laboratory (at Tamavua-Twomey hosp.) offers the
following services:
x Supervises and provides EQA for all three(3) divisional hospital
laboratories
x Offer technical support to staff of the three(3) divisional laboratories
37
3
Appendix 2 Organises capacity building programmes planned for divisional
_____________________________________________________________________
technicians related to TB microscopy and culture
 Collaborates with QMRL (Queensland) on the conduct of DST for MDR-
Tuberculosis
Referral/Transfer Form
TB suspects
ACKNOWLEDGEMENT
Divisional laboratories play a pivotal role in:
 Supervising and conductingMinistry
EQAoffor
Health
sub-divisional laboratories
TUB 1

_______________________________________________________________________________
 Offering technical support to all sub-divisional labs
 TUBERCULOSIS
Providing quarterly andREFERRAL/TRANSFER
annual reports to DaulakoFORM Mycobacterium
laboratory on TB (cases, TB cases tested for HIV, TB-HIV coinfected,
Name:smear negative-culture positive, smear positive-culture
Phone: positive,
This Guideline was prepared
Address: by the Fiji National
smear positive-culture negative) Tuberculosis Programme with the
technical and funding support capacity
Koro dina:
 Providing from the Australian
Tikina:
building Respiratory
opportunities Council (ARC)laboratory
Yasana:
to sub-divisional and the
DOB:
Global Fund to fight AIDS, TB and Malaria Sex:
respectively. Age: Ethnicity:
staff.
Contact person: Phone:
TUBERCULOSIS PATIENT TRANSFER
TB REG No.: OPF No.: Date Treatment started:
Transferred From:
The indispensibleTo:comments and suggestions by Dr Linh Nguyen of WHO office in Suva
Diagnosis: PTB Smear Pos. PTB Smear Neg. EPTB
Treatment: SCC (new case) Re-treatment (relapse, failure, default)
RIF/ INH ETH PZA STREP
Last but not the least, the contributions
150/100mg 100mg
and support ġ5of
00mg
ġ 300/150mg 400mg 400mg inj. g
Remarks:
Date of Transfer: Signed:
Dr Iobi Batio
TUBERCULOSIS SUSPECT REFERRAL
Dr Frank Underwood
Referred From:
To:
Cough for more than 2 weeks
Other symptoms:
Grant Management Unitspecimen
Sputum of Fiji No.:
MOH and Date produced:
Remarks:
Date: Signed:
Cut/Tear Here
TUBERCULOSIS TRANSFER/ REFERRAL ACKNOWLEDGEMENT

The patient/suspect: Address:
1. Who was transferred to reported/ did not report for treatment
2. Who was referred to
Has been diagnosed with PTB smear pos. PTB smear neg. EPTB
Tuberculosis treatment will be started at: on date
Has NOT been diagnosed with tuberculosis
Date: Signed:
37
3
42 TB Guideline Fiji

REFERENCES
1. Ministry of Health-Fiji. Technical Guide for Tuberculosis Control in Fiji; 2nd edition,
2004
ACKNOWLEDGEMENT
2. Ministry of Health-Fiji. Tamavua-Twomey Hospital Annual Report, 2008
3. Ministry of HealthȂFiji. NTP Review Report, 2008
_______________________________________________________________________________
4. Ministry of Health-Fiji. Annual Report, 2008
5. Ministry of Health-Fiji. Fiji Global Fund Proposal (R 8/9), 2008
6. WHO. Stop TB Global Plan, 2010
7. WHO. Guidelines for intensified TB case finding & Isoniazid preventative therapy for
PLWHA, 2010
technical andTB
8. WHO. funding support
Treatment from the
Guidelines, 2010Australian Respiratory Council (ARC) and the
9. WHO. Guidelines for intensified tuberculosis case finding and isoniazid preventive
therapy for people living with HIV in resource constrained settings, 2010
Particular gratitudeTuberculosis
10. WHO/IFRC. is accorded to Professor
control Guy Marks
in prisons, 2001 and Ms Kerry Shaw of the ARC for
their11.
valuable
WHO. Guidelines fro surveillance of drug resistanceofinthis
contributions to the key technical concepts Guide.
tuberculosis-4th edition, 2009
12. SPC. Guidelines for TB contact tracing in Pacific Island Countries & Territories, 2010
The13.
indispensible comments
SPC. TB Surveillance in and suggestions
the PICTs, 2010 by Dr Linh Nguyen of WHO office in Suva
must not
14. TBgo unrecognized.
ȱCTA. International standards for tuberculosis care, 2006
15. IUATLD. Interventions for tuberculosis control & elimination, 2002
Last16.
but not the
IUATLD. least, the of
Management contributions
tuberculosis and support
(A guide of essentials
for the the following personnel
of good practice);and
6th edition, 2010
Dr Iobi Batio
Dr Frank Underwood
3

APPENDICES
Tub 1 Referral/transfer forms

ACKNOWLEDGEMENT
Tub 2 Laboratory Register
_______________________________________________________________________________
Tub 3 Laboratory (AFB microscopy) request form
Tub 4 AFB Microscopy Register

Tub 5 and TB
technical Register
funding support from the Australian Respiratory Council (ARC) and the
Tub 6 TB Patient ID Card
Tub 7 TB Contact Register
Tub 8 TB Treatment Card
Tub 9not go unrecognized.
must HIV testing Consent form
Tub 10
Last but not Pharmacy form
the least, the contributions and support of the following personnel and
Tub 11 Domicilliary Treatment Supervision form
Dr
Tub Iobi
12Batio Treatment Completion form
Tub
Dr 13 Underwood
Frank Quarterly Report on Sputum Conversion
TubRed
Fiji 14Cross Quarterly
Society Report on TB case registration
Tub 15
Grant Quarterly
Management Unit ofReport
Fiji MOHon Treatment Outcome
and
3
Appendix 2
_____________________________________________________________________
Tuberculosis
Referral/Transfer Form
ACKNOWLEDGEMENT Ministry of Health

TUB 1

_______________________________________________________________________________
TUBERCULOSIS REFERRAL/TRANSFER FORM
Name: Phone:
Address:
technical and funding support from the Australian
Koro dina: Tikina: Respiratory Yasana:
Council (ARC) and the
Global Fund to fight AIDS, TB and Malaria respectively. Age:
DOB: Sex: Ethnicity:
Contact person: Phone:
TUBERCULOSIS PATIENT TRANSFER
TB REG No.: OPF No.: Date Treatment started:
Transferred From:
The indispensibleTo:comments and suggestions by Dr Linh Nguyen of WHO office in Suva
Diagnosis: PTB Smear Pos. PTB Smear Neg. EPTB
Treatment: SCC (new case) Re-treatment (relapse, failure, default)
RIF/ INH ETH PZA STREP
Last but not the least, the contributions
150/100mg 100mg
and support ġ5of
00mg
ġ 300/150mg 400mg 400mg inj. g
Remarks:
Date of Transfer: Signed:
Dr Iobi Batio
TUBERCULOSIS SUSPECT REFERRAL
Dr Frank Underwood
Referred From:
To:
Cough for more than 2 weeks
Other symptoms:
Grant Management Unitspecimen
Sputum of Fiji No.:
MOH and Date produced:
Remarks:
Date: Signed:
Cut/Tear Here
TUBERCULOSIS TRANSFER/ REFERRAL ACKNOWLEDGEMENT

The patient/suspect: Address:
1. Who was transferred to reported/ did not report for treatment
2. Who was referred to
Has been diagnosed with PTB smear pos. PTB smear neg. EPTB
Tuberculosis treatment will be started at: on date
Has NOT been diagnosed with tuberculosis
Date: Signed:
3
Laboratory Request for Sputum Examination
ACKNOWLEDGEMENT
TUB 2a
LABORATORY REQUEST FOR SPUTUM EXAMINATION

_______________________________________________________________________________
Collection Date:
Hosp. No.
Signature:
Received:
Specimen
Drug Susceptibility Test

Ward
Gender Ethnicity
Ministry of Health
Follow-up:

Clinical Note:
Note: This form is to be used for Tuberculosis diagnosis only.

DOB
3rd Specimen
TB Culture
Dr Iobi Batio
Dr Frank Underwood
Other Name:

2nd Specimen

Facility:

AFB Microscopy
1st Specimen
MO I/Charge
REMARKS:
Name:
3
TB Guideline Fiji 43
Laboratory Report of TB Examination

TUB 2b
ACKNOWLEDGEMENT
SENSITIVITY
DRUG SUSCEPTIBILITY TEST
Lab Reg. No.
_______________________________________________________________________________
Specimen Collection Date:
LABORATORY REPORT OF TB EXAMINATION
Hosp. No.
Officer In-charge
Received:
DRUGS
Pyrazinamide
Streptomycin
Ward
Ethambutol
Rifampicin
Isoniazid
Ethnicity
Ministry of Health
REPORT

Gender
Facility:
CULTURE
DOB
Dr Iobi Batio Date Reported
:
Dr Frank Underwood
Other Name

Brief Clinical Note (Diagnosis):

AFB MICROSCOPY
Examined by:
No AFB Seen
MO I/Charge
Actual No.
Negative/
1+
2+
3+
Name
TB Guideline - Fiji TB Guideline Fiji 42

3
Laboratory Register for AFB Microscopy (a)
TUB 3
OFFICER³
ACKNOWLEDGEMENT
_______________________________________________________________________________ REFERRAL
CENTRE²
LABORATORY REGISTER FOR AFB MICROSCOPY

PATIENT'S
ADDRESS
DOB
Ministry of Health

SEX
¹ Note TB REG. No. if patient is registered TB case, otherwise note hospital no.
Dr Iobi Batio
NAME
Dr Frank Underwood
² Where patient/specimen is referred from.
TB REG. No./

Hosp. No.¹

³ Person sending specimen.
DATE
REG. No.
LAB
TB Guideline Fiji 45
3
Laboratory Register for AFB Microscopy (b)
ACKNOWLEDGEMENT
_______________________________________________________________________________
TUB 3
REMARKS
DONE
TEST
(Y/N)
HIV
Indicate result with (N) No AFB, Positive as 3+ 2+ 1+ or actual number (mark positives with red pen) with dates of respective
LABORATORY REGISTER FOR AFB MICROSCOPY
SENT

(Y/N)
DST
CULTURE
DONE

(Y/N)
3
Ministry of Health
RESULT 6
SMEAR
2
Dr Iobi Batio
1
DIAGNOSIS 5
REASON FOR
Dr Frank Underwood
(D or F)
CLINICAL
NOTE
Write D for Diagnosis or F for Follow-up

Macroscopic appearance of specimen.
results in the space below.

SPECIMEN΀
NATURE
OF
YEAR:
6
4
46 TB Guideline Fiji 3
Laboratory Register TB Culture (a)
ACKNOWLEDGEMENT
TUB 4
Collected Inoculated
Specimen Specimen
Date
_______________________________________________________________________________
Date
Clinician
LABORATORY REGISTER FOR TB CULTURE
Health Facility
Referral

Age
Ministry of Health
(M/F)
Sex
Dr Iobi Batio
Patient's Name
Dr Frank Underwood
Specimen

Serial No. No./Hosp.
TB Reg.
No.
Lab
TB Guideline Fiji 3
47
Laboratory Register TB Culture (b)
ACKNOWLEDGEMENT
_______________________________________________________________________________
TUB 4
¹ Write D for Diagnosis or F for Follow-up; 2 Outcome of culture reported as follows; ͵ Indicate sensitivity with (I) intermediate (S) sensitive (R) resistant
Comments
Signature
Reported
Z Result
Date
DST

Sensitivity Test 3
E S
Write the number of colonies

Ministry of Health
R
Dr Iobi Batio
+++
Sent for
Culture
++
+
0
(Y/N)
DST
Dr Frank Underwood
Confirmatory Reported

Date

3 4 5 6 7 8 Test for MTB

(pos /neg)
Result of Culture 2 Result of
Innumerable or confluent growth

(Weeks)
More than 100 colonies

Fewer than 10 colonies
No growth reported
10 – 100 colonies
Examination¹
Reason for
(D or F)
Tuberculosis Register (a)

TUB 5
ACKNOWLEDGEMENT
Remarks
Enter S (Sensitive) or R (Resistant), 7A smear at the end of 3rd and 5th months are only done for those who failed to convert, 8 Cured (C), Treatment Completed
_______________________________________________________________________________
(Y/N)
Done
HIV
Test
Result
Treatment
Result Ͼ
Date
Smear
(TC), Treatment Failure (F), Died from whatever cause (M), Defaulted or lost to follow-up (D), Transferred Out (O)
Treatment

End of
TUBERCULOSIS REGISTER
Date
Smear
Ministry of Health
End of 5th
MonthϽ
Date
Dr Iobi Batio
End of 2nd or 3rd
Smear
LABORATORY RESULTS
MonthϽ
Dr Frank Underwood
Date
S

Drug Sensitivity

Testϼ
HIV test conducted. Enter Y (Yes) N (No)

E
H
Start of Treatment
R
Smear Culture
Date
TB Guideline Fiji 3
49
Tuberculosis Register (b)
ACKNOWLEDGEMENT
TUB 5
_______________________________________________________________________________
¹ Date when the patient was entered into the sub divisional register, ² Male (M), Female (F), ³ HRZE or HRZES, Ϻ Smear positive pulmonary TB (PTB+), smear
Patientϻ
Type of
negative pulmonary TB (PTB-), Extra - pulmonary TB (EPTB), ϻ Enter the correct code: New (N), Relapse (R), Treatment After Failure (F), Treatment After
Disease
ClassϺ
Regimen³
Treatment
Treatment
Centre

TUBERCULOSIS REGISTER
Ministry of Health
Address
Dr Iobi Batio
Dr Frank Underwood
DOB
Sex ²

Name
Default (D), Transfer in (I), Others (O).

Date of
Reg.¹
Reg. No.
TB
Patient ID Card
ACKNOWLEDGEMENT
_______________________________________________________________________________
PATIENT ID CARD
FIJI NATIONAL TUBERCULOSIS PROGRAMME (NTP)
Dr Iobi Batio
Dr Sakiusa Mainawalala PATIENT IDENTITY CARD DISEASE CLASSIFICATION
Dr Frank
Name: Underwood Sex : M F PULMONARY EXTRA-PULMONARY
SMEAR POS. SITE:
OPF No. /NHN TB Reg. No.
SMEAR NEG.
Address:
Fiji Red Cross Society TYPE OF PATIENT
DOB Phone:
Treatment Centre:
NEW TREATMENT AFTER FAILURE
TRANSFER IN TREATMENT AFTER DEFAULT
Grant Date
Management
Treatment Started:
Unit of Fiji MOH and
Completed RELAPSE OTHER
PublicREMINDER:
health officials TREATMENT REGIMEN
Remember that:
1. If you miss taking your medicine (even 3 doses in a month) INTENSIVE PHASE CONTINUATION
DRUG RESISTANCE can develop. PHASE
2. This is bad for you and your community. RIF 150/300 mg
3. If you stop you will become ill within months or a year.
4. Medicines MUST NOT be shared with family and friends. INH
5. If you find it difficult taking your medicine regularly, DISCUSS 100/150 mg
with health workers.
6. Seek support from your treatment supervisor, family or friends. ETH 100/400 mg
7. If you change your address please notify your nurse or doctor,
AS SOON AS POSSIBLE PZA 400/500 mg
8. If you feel unwell when you take your medicine, see your nurse
or doctor. STREP ___________mg
9. Visit your doctor at least once a month for review.
Possible Side Effects of Anti-TB Medicines: APPOINTMENT DATES

No appetite Orange/red urine
Abdominal pain Skin rash
Nausea Dizziness Doctor’s Visit Dates:
Tingling/numbness around Ringing in the ears
the mouth Drug Collection Dates:
PLEASE SEE YOUR DOCTOR AS SOON AS POSSIBLE IF YOU
HAVE ANY OF THE ABOVE Final Review Dates:
TB Guideline Fiji 3
51
Register of TB Contacts
¹ List all contacts consecutively under the name of the index case. 2Enter method of screening: Symptom Screening (Sym), Tuberculin Skin test (TST),
TUB 7
Facility_____________________________
ACKNOWLEDGEMENT
Prophylaxis3 Remarks/Relationship
to Index Case
_______________________________________________________________________________
Method Result
SCREENING
REGISTER OF TB CONTACTS

Date
Chest x-ray(CXR) or sputum smear examination (SSE). 3Prophylaxis Regimen: 9H or 6HR

Ministry of Health
Address of
Contact
Dr Iobi Batio
Sex Age
Dr Frank Underwood
Name of Contact ¹

TB Register
Year________________
No.
Name of Index
Cases
52 TB Guideline - Fiji TB Guideline Fiji 50

3

Ministry of Health TUB 8
TUBERCULOSIS TREATMENT CARD
Dr Iobi Batio
Name 1: Phone:
TB Guideline Fiji
Address: Occupation:²²
Koro dina Tikina Yasana
Contact Person: Phone:
TB Guideline - Fiji
Dr Frank Underwood

Sex:ϼ Date of Birth ϻ: EthnicityϽ:

Paediatric Cases Ͽ (<15 years) Yes F No F Country of Birth8: DISEASE CLASSIFICATION/ SITE OF TB DISEASE ¹¹
History of TB contact: Yes F No F
Previous diagnosis of TBϺ: Yes F No F If yes, year of diagnosis: PULMONARY F EXTRA PULM F SITE
Sputum date collected ¹²
(INTENSIVE PHASE) DRUG REGIMEN29 Weight: (DOTS) START:__________kg.
Smear: Positive F Negative F
__
Tuberculosis Treatment Card (a)
RHZE 150/75/400/275mg TABS OD RIFAMPICIN SUSPN ml OD TYPE OF PATIENT ²Ͼ

Status: Dead F Alive F
RIF/INH 150/100 mg TABS OD ISONIAZIDE SUSP N ml OD New Transfer in Relapse

RIF/INH 300/150 mg TABS OD Defaulter Treatment Failure Others
ACKNOWLEDGEMENT
DOTS Therapy Stopped/Not Started 38: F Died F Others Date Stopped

DOTS Therapy Extended 39 NO F YES F Duration ___________ months. Status at TB Diagnosis10: F Dead F Alive
INTENSIVE PHASE (DOTS) START DATE 27 _________________

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Laboratory Results
Date Lab Smear Culture
Month No.
ENTER X on day of supervised drug administration or DC when drugs are collected. DRAW A LINE to include number of days supply given.TICK appropriate box after the drugs have been taken by the patient.
13
Sputum Culture Not Done Neg. Pos. Date:____________ Reference Lab _______________14Smear/Pathology/Cytology of Tissue/Other body Fluids . Done? Yes No
16
CXR: Normal Abnormal Cavity: Yes No
17 15
Skin Test (TST) Date______________ Pos. Neg. Not done Culture of Tissue/Other Body Fluids, Done? Yes No
18
Primary reason evaluated for TB:_______________________________ TB Symptom Onset Date________________
19
TB Symptoms: Cough Coughing of blood Chest pain Loss of appetite Loss of weight Fatigue
NOTE: SUPERSCRIPT NUMBERS CORRESPOND TO EPIANYWHERE DATA INFO

_______________________________________________________________________________
53
3
51
54

Dr Iobi Batio
CONTINUATION PHASE (DOT) START DATE :_______________ WEIGHT: START _____ kg ; END ______ kg
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Laboratory Results
TB Guideline - Fiji
Dr Frank Underwood

Month Date Lab Smear Cult

No.
Tuberculosis Treatment Card (b)

ACKNOWLEDGEMENT
ENTER X on day of supervised drug administration or DC when drugs are collected. Drug regimen: F HR F HRE
DRAW A LINE to include number of days supply given. (DOT) Others___________________________________________
TICK appropriate box after the drugs have been taken by the patient
NOTE: SUPERSCRIPT NUMBERS CORRESPOND TO EPIANYWHERE DATA INFO
20 21
HIV Testing at TB Diagnosis: NO YES Homeless within past year NO YES
23
Illegal drug use within past year: NO YES INJ NON-INJ 24
25
Weekly Alcohol Use within past year: NO YES Not Known
26
TB Risk Factors: Diabetes Pos Neg Others: Missed contact 2 years or less Contact with TB Disease Others ______________
30
Genotype Testing Done: NO YES Isolate submitted for genotype testing: NO YES Date isolate received at genotyping laboratory:_________________
31
Drug Susceptibility Testing done: NO YES Date: ______________ If yes, genotyping accession number for episode:______________________
Enter specimen type: Sputum or Anatomic Code: Pulmonary Extrapulmonary________________
32 39
Drug Susceptibility Results: Sensitive to: ________________ Resistant to: __________ Reason standard therapy regimen extended:______________
33 40
If MDR, is the case Green Light Committee Approved: NO YES Local Health Provider Available NO YES
34
Sputum Smear Conversion: Date 1st sputum smear negative:______________ Date 2nd sputum smear negative:___________________
35 41
Sputum Culture Conversion: Date 1st sputum culture negative___________ Directly Observed Therapy (DOT): NO YES No. of weeks _______
36 42
Transfer/ Moved: Did the patient move/ transfer during TB Therapy? NO YES Treatment Outcome:
Out of Division: Specify: WD CE ND Out of Country; __________________ CURED TREATMENT COMPLETED DIED
38 37
Reason DOT therapy stopped/ Never started:______________ Date stopped:_________ DEFAULTED TRANSFERRED OUT FAILED
Was TB death registered in the registration system of: NO YES Date: ___________
_______________________________________________________________________________
TB Guideline Fiji
3
52
Consent Form (HIV/AIDS and TB)

TUB 9
Ministry of Health
ACKNOWLEDGEMENT Fiji National Tuberculosis Programme
_______________________________________________________________________________
CONSENT FORM
HIV/AIDS and TB
_____________________
technical and funding support from the(Name Australian Respiratory Council (ARC) and the
of Facility)
Name: __________________________________ DOB: __________________ Sex: F/ M
Contact Home: to Professor Guy___________________NHN_____________
__________________Work: Marks and Ms Kerry Shaw of the ARC for
Address: to the key technical concepts of this Guide.
_________________________________________________________________
Occupation:_________________________ Marital Status: ______________________
History of presenting complaint:
________________________________________________________________________
Last but not________________________________________________________________________

the least, the contributions and support of the following personnel and
________________________________________________________________________
COUNSELLING AND TESTING PICT VCCT
Dr Iobi Batio
Explanation of the signs/ symptoms of TB and HIV/AIDS
Dr Frank Underwood
x Officer provides knowledge on HIV/AIDS and TB
x Assess client's knowledge on HIV/AIDS and TB
Fiji Red Cross Societyo What is the difference between HIV/AIDS and TB
o What are some of the signs and symptoms of HIV/AIDS and TB
o What are some of the ways to protect oneself from getting HIV/AIDS and TB
x Client understands the risks associated with HIV/AIDS and TB
x Client knows what to do if result is positive or negative
I, __________________________________ agree/disagree to be tested for HIV/AIDS.
Signature: ___________________________ Date: _______________
Counsellor: __________________________ _______________

(Name) (Signature)
TB Guideline Fiji 3
55
Pharmacy Form
TUB 10
Ministry of Health
ACKNOWLEDGEMENT Fiji National Tuberculosis Programme
_______________________________________________________________________________
PHARMACY FORM
ANTI TUBERCULOSIS MEDICATION
This Guideline
TO: was prepared by the Fiji FOR:(RECIPIENT
National Tuberculosis Programme with the
OF TB MEDICATION)
NAME:
technical and PATIENTS FULL
funding support from the Australian NAME :
Respiratory Council (ARC) and the
DESIGNATION: ADDRESS:
ADDRESS: SEX:
FACILITY: DOB:
TB MEDICATION:
their valuable contributions to the key INTENSIVE PHASE
technical concepts ofCONTINUATION
this Guide. PHASE
Name & Strength Dosage Quantity Comments

Supplied
RHZE 150/75/400/275 mg
must not go unrecognized. ______ tabs OD __________ ________________
Rif/Inh 150/100 mg ______ tabs OD __________ ________________

Last but not Rif/Inh
the least,
300/150the
mg contributions and
______ tabs OD support
__________of the following personnel and
________________
Rifampicin Suspension __ ______ ml OD __________ ________________
Dr Iobi Batio Isoniazide Suspension __ ______ ml OD __________ ________________
____________________ _____________ __________ ________________
Dr Frank Underwood
____________________ _____________ __________ ________________
STATUS OF SUPPLY: Balance__________________ Final/ Last Supply(Y/N) ____________
SIGNATURE (PHARMACIST IN CHARGE) _______________DATE SENT_______________
DATE TAKEN BY PATIENT (FILLED BY ZONE NURSE): ____________________________
.......................................................Cut and send back to the pharmacist........................................................................
ACKNOWLEDGEMENT LETTER
Pharmacist Date received

Facility
Patient's Name/ Recipient:
Drugs Supplied Quantity
1) ___________________________ _______________
2) ___________________________ _______________
3) ___________________________ _______________
Receiver's Name__________________________ Signature_________________________
Facility ___________________________________________________
3
Domicillary Supervision Form
ACKNOWLEDGEMENT
TUB 11
Zone nurse home visit dates (once every 2 weeks):_____________________________________________________________________________

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
_______________________________________________________________________________
Streptomycin
400/500mg
400mg
INTENSIVE / CONTINUATION PHASE MEDICATIONS (DOT)

DOMICILLARY SUPERVISION FORM

Pyrazinamide
Ethambutol
Ministry of Health
Dr Iobi Batio
Ethnicity:
Yasana:
Phone:
Phone:
Dr Frank Underwood
300/150mg
150/100mg
Age:

Tikina:
Sex:
Rifampicin/ Isoniazid Combination

YEAR: ___________________
Contact person:
DAYS
Remarks:
Koro dina:
MONTH
Address:
Name:
DOB:
TB Guideline Fiji 3
57
Treatment Completion Form
ACKNOWLEDGEMENTMinistry of Health TUB 12

_______________________________________________________________________________
TREATMENT COMPLETION FORM
(To be completed by a Medical Officer)
NAME: DOB: SEX:
ADDRESS: to the key technical concepts of this Guide.
HOSPITAL NO/NHN:
TB REGISTER NO.:
DIAGNOSIS:
INTENSIVE PHASE STARTED IN: INCLUSIVE DATES:
Dr Josefa Koroivueta FACILITY
Dr Iobi Batio CONTINUATION PHASE STARTED IN: DATE STARTED:

Dr Sakiusa Mainawalala FACILITY
Dr Frank Underwood
DURATION OF CONTINUATION PHASE: DATE COMPLETED:
*Pharmacist to fill-up Patient’s name and details.
SUBMITTED BY:
FACILITY:
SIGNATURE: DATE SUBMITTED:
CC TO:
1. DIVISIONAL TB CONTROL OFFICER - White
2. SDMO - Yellow
3. MO HEALTH CENTRE - Pink
4. BOOK COPY - Green
THANK YOU FOR YOUR COOPERATION TOWARDS OUR GOAL OF A TB FREE FIJI.

Dr Iobi Batio
TB Guideline Fiji
QUARTERLY REPORT ON SPUTUM SMEAR MICROSCOPY CONVERSION
TB Guideline - Fiji
Dr Frank Underwood

Name of Division:

_________ quarter of year _________
Facility:
Date of completion of this form:
Name:
Signature:

Number of new sputum smear Sputum smear microscopy Sputum smear microscopy conversion at:
ACKNOWLEDGEMENT
microscopy positive cases registered not done at either 2 or 3

in quarter recorded above2 months 2 months 3 months
Total converted at 2 or 3 months:

Number of sputum smear Sputum smear microscopy Sputum smear microscopy conversion at:
Quarterly Report on Sputum Microscopy Conversion
microscopy positive retreatment not done at either 2 or 3

cases registered in quarter recorded months 2 months 3 months
above2
Total converted at 2 or 3 months:
1 Quarter: This form applies to patients registered (recorded in the TB Register) in the quarter that ended 3 months ago. For example, if completing this form
at the beginning of the 3rd quarter, record data on patients registered in the 1st quarter.
2 This number should match the number of new sputum smear microscopy positive cases in Block 1, Column 1, first row of the Quarterly Report on TB Case
Registration previously completed for patients registered in this quarter.
White Copy - NTP OFFICE Yellow Copy - DOTS CENTRE

_______________________________________________________________________________
3
59
57
60

Dr Iobi Batio
QUARTERLY REPORT ON TB CASE REGISTRATION
TB Guideline - Fiji
Dr Frank Underwood

Name of Division: Unit: Patients registered during1 quarter of year

Name of TB Coordinator: Signature: Date of completion of this form:
Block 1: All TB cases registered during the quarter2
Pulmonary sputum smear positive

Pulmonary Pulmonary smear Other
Previously treated not done / not
sputum smear Extrapulmonary previously Total
New cases After After negative available treated3
Relapses
failure default

ACKNOWLEDGEMENT
Block 2. Breakdown of TB cases by sex and age group

New 0–4 5–4 15 – 24 25 – 34 35 – 44 45 – 54 55 – 64 t65 Total
Quarterly Report on TB Case Registration
M
New Smear positive
F
Pulmonary smear M
negative/not done/
not available F
M
Extrapulmonary
F
Total
Block 3: Laboratory activity - direct smear4 Block 4: Quarterly report on TB/HIV activities
No. of TB suspects examined for No. of TB suspects with sputum No. tested for HIV before or
No. HIV positive
diagnosis by sputum smear microscopy smear microscopy positive result during TB treatment5
New sputum smear microscopy positive TB
All TB cases except new smear

positive, 'transferred in' and chronic cases6
1 Registration period is based on date of registration of cases in the TB register, following the start of treatment.
Q1: 1 January-31 March; Q2:1 April -30 June; Q3: 1 July-30 September ; Q4:1 October-31 December.
2 In areas routinely using culture, a quarterly report on TB case registration for unit using culture should be used. ‘Transferred in’ and chronic cases are excluded.
3 Other previously treated cases include pulmonary cases with unknown result of previous treatment, sputum smear negative pulmonary cases and extra-pulmonary cases previously treated. ‘Transferred in’ and chronic cases are excluded.
4 Data collected from the TB laboratory register related to activity performed in the unit during the quarter.
5 Documented evidence of HIV tests (and results) performed in any recognized facility before or during TB treatment should be reported here.
_______________________________________________________________________________
6 Includes smear negative, smear not done, extra-pulmonary cases and all previously treated cases. White Copy - NTP OFFICE Yellow Copy - DOTS CENTRE
TB Guideline Fiji
3
58
Quarterly Report on TB Treatment Outcomes and TB/HIV Activities
ACKNOWLEDGEMENT Ministry of Health

TUB 15
_______________________________________________________________________________
QUARTERLY REPORT ON TB TREATMENT
OUTCOMES AND TB/HIV ACTIVITIES
Patients registered during1

Name of Division: _________quarter of year_________
This Guideline was prepared by the Fiji National Tuberculosis Programme with the Date of completion of this form:
Name of TB Coordinator: Signature:
Block 1: Quarterly report on TB treatment outcomes
Total number Treatment outcomes Total number
of patients Cured Treatment Died Treatment Default Transfer evaluated for
Type of case registered completed failure 2 out outcomes (sum of
Sputum smear positive
during quarter* (1) (2) (3) (4) (5) (6) Columns 1 to 6)
their valuable Sputum

contributions
done
smear neg and not to the key technical concepts of this Guide.
Extrapulmonary
Relapses
Treatment after failure
Treatment after default
Other previously treated 3
* These numbers are transferred from the Quarterly Report on TB Case Registration for the above quarter. Of these patients,
_____________ (number) were excluded from evaluation for the following reasons: "Not TB": Other reasons:_______________________
Last but not Block

the 2:least, Quarterly the
reportcontributions
on TB/HIV activitiesand (same support
quarter analysed of asthe
Blockfollowing
1) personnel and
4
institutions is acknowledged: No. tested for HIV No. HIV positive (a)
6
No. on CPT No. on ART
6 6
New sputum smear microscopy pos. TB
Dr Iobi Batio All TB cases except new smear positive,

'transferred in' and chronic cases 5
Block 3: Quarterly report on TB treatment outcomes of HIV-positive patients
Dr Frank Underwood
Type of case Total number of Treatment outcomes Total number
Dr Apisalome Nakolinivalu HIV positive TB Cured Completed Died Failure 7
Default Transfer evaluated for
patients out outcomes:
Fiji Red Cross Society Block 2, Column (1) (2) (3) (4) (5) (6) (sum of Columns
(a)* 1 to 6)
New sputum smear
microscopy pos. TB
Grant Management Unit
All TB cases of Fiji MOH and
except
new smear positive,
'transferred in' and
chronic cases 5
* Of these patients, _______ (number) were excluded from evaluation for the following reasons:
1. Quarter: This form applies to patients registered (recorded in the Divisional Tuberculosis Register) in the quarter that ended 12
months ago. For example, if completing this form at the beginning of the 3rd quarter, record data on patients registered in the 2nd
quarter of the previous year.
2. Include patients switched to Cat. 4 because sputum sample taken at start of treatment turned out to be MDRTB.
3. Include pulmonary cases with unknown result of previous treatment, sputum smear-negative pulmonary cases and extrapulmonary
cases previously treated.
4. Documented evidence of HIV tests (and results) performed in any recognized facility during or before TB treatment should be
reported here.
5. Includes smear negative, smear not done, extrapulmonary cases and all previously treated cases.
6. Includes TB patients tested for HIV before and during TB treatment, continuing on CPT or ART started before TB diagnosis and
those started on CPT or ART during TB treatment (till last day of TB treatment).
7. Include patients switched to Cat. 4 because sputum sample taken at start of treatment turned out to be MDRTB.
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DISCLAIMER

Fiji National Tuberculosis Programme

This Guideline was.........................................................................

Fiji Red Cross Society

Public health officials

Structure of the National Tuberculosis Programme

This Guideline was prepared Ministry

Lautoka Hospital Labasa Hospital Colonial War Memorial P J Twomey (Tamavua)

Targets of the National Tuberculosis Programme

Last but notThe theimplementation

1.1.2. Investigation of TB suspects

Two sputum specimens should be collected, using the method decribed

TB suspects whose sputum microscopy is negative should be referred to

Sputum samples eligible for Xpert MTB/RIF test:

1.1.2.3 Other investigations

a) Anatomical site of disease

Priorities in contact screening

c) TB screening among Diabetics and vice versa

e) TB screening in Prisons & Correctional Facilities

1.2 TREATMENT OF PEOPLE WITH TUBERCULOSIS

1.2.1 Registering the case and initiating treatment

Last but not 1.2.2.1

Table 4. Children between 21kg and 30kg without ethambutol

If the organism is confirmed as fully-susceptible to the standard

ACKNOWLEDGEMENTx The standard continuation phase (rifampicin,isoniazid & ethambutol)

1.2.3 Ensuring adherence

1.2.3.1 Strategies for direct observation of therapy (DOT) in the

During the continuation phase, daily regimens should be used, to implement

1.2.4 Adverse events (side-effects) & drug interactions

SIDE EFFECT ANTI-TB DRUG MANAGEMENT

Anorexia, nausea, R, Z Give drugs with small meals or last thing at

Visual impairment E Stop E

1.3.1.2 Use of N95 masks

1.3.1.3 Natural ventilation

1.3.2 BCG vaccination

1.4 Monitoring & evaluation

1.4.1 Cohort analysis

These treatment outcomes should be determined by the Divisional TBCO in

1.4.2 Recording and reporting system

1.4.2.1 TB patient register

b) The National TB Programme reports to Health Information Unit at the

1.5 PROGRAMME SUPERVISION

1.5.1 National supervision

1.5.4 Laboratory supervision and EQA

Fiji National Tuberculosis Programme

TUBERCULOSIS TRANSFER/ REFERRAL ACKNOWLEDGEMENT

Tub 1 Referral/transfer forms

Tub 4 AFB Microscopy Register

ACKNOWLEDGEMENT Ministry of Health

Fiji National Tuberculosis Programme

TUBERCULOSIS TRANSFER/ REFERRAL ACKNOWLEDGEMENT

LABORATORY REQUEST FOR SPUTUM EXAMINATION

Drug Susceptibility Test

must not go unrecognized.

Note: This form is to be used for Tuberculosis diagnosis only.

Fiji Red Cross Society

Fiji Nursing Association

Grant Management Unit of Fiji MOH and

must not go unrecognized.

Fiji Nursing Association

Public health officials

TB Guideline - Fiji TB Guideline Fiji 42

Global Fund to fight AIDS, TB and Malaria respectively.

their valuable contributions to the key technical concepts of this Guide.

Signature: _____________ Date: _

Counsellor: ____________ _

Rif/Inh 150/100 mg tabs OD ____________