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PULMONARY

TUBERCULOSIS
Santiago, Jillian Mae A.

Objectives

To discuss National TB Control Program


SPECIFIC OBJECTIVE
To identify the policies and procedures of
NTP
To know the different classification of TB
cases
To know the treatment regimen for TB and
its side effects

What is TB?

Tuberculosis (TB) is an infectious disease


caused by the bacillus Mycobacterium
tuberculosis.

It can affect the lungs (pulmonary TB) but


can also affect other sites as well such as
brain, spine and kidney (extra-pulmonary
TB)

The Philippines is among the 22 high-burdened


countries in the world according the WHO.

TB is sthe 6th leading cause of illness and the


6th leading cause of deaths among the
Filipinos.

Most TB pateints belong to the economically


productive age-group (15-54 years old)
according to the 2nd National Prevalence
Survey in 1997.

TUBERCULOSIS
Seventy-five (75) Filipinos die
of TB every day, most of them in
the prime of their life.
If untreated, a person with
tuberculosis can transmit the TB
bacteria to as many as 10 to 15
people during the course of one
year, who, in turn, may develop
the disease.

TRANSMISSION

TB is transmitted mainly by inhalation of infectious droplets


produced by persons with pulmonary or laryngeal
tuberculosis during coughing, laughing, shouting, singing or
sneezing.

Extra-pulmonary tuberculosis, other than laryngeal, is


generally not communicable

M. bovis tuberculosis results mainly from ingestion of


unpasteurized milk and dairy products.

TRANSMISSION

CASE FINDING

1. It provides a definitive diagnosis of active TB.


2. The procedure is simple.
3. It is economical.
4. A microscopy center could be organized even in remote areas.
The general objective of case finding is the early identification and
diagnosis of TB cases.

CLINICAL PRESENTATION

Presumptive TB Case
Children (<15 years old)
Patient presents at least three of the following clinical signs and symptoms:
Coughing /Wheezing of 2 weeks or more especially if unexplained
Unexplained fever of 2 weeks or more after common causes such as
Malaria or Pneumonia have been excluded
Loss of weight/failure to gain weight/ weight faltering/ loss of appetite
Failure to respond to 2 weeks of appropriate antibiotic therapy for lower
respiratory tract infection
Failure to regain previous state of health 2 weeks after a viral infection or
exanthem
Fatigue reduced playfulness or lethargy
ANY one of the above signs and symptoms (clinical criteria) in a child who
is a close contact of a known active TB case

Presumptive TB Case
Adult ( >=15 years old)
Cough for at least 2 weeks duration with or without following symptoms:

Significant & unintentional weight loss

Fever

Hemoptysis

Chest/back pain not associated with any musculoskeletal disorder

Easy Fatigability

Night sweats

Shortness of breath or difficulty of breathing


Patients with unexplained cough of any duration and are known to be:
A close contact of a known active TB disease
A member of High Risk group
A member of High Risk Population

ALL PATIENTS WITH CHEST X-RAY FINDINGS SUGGESTIVE OF PTB, WITH


OR WITHOUT SYMPTOMS, REGARDLESS OF AGE.

Classification based on history of


previous treatment
New case a patient who has never had treatment for TB or who
has taken anti-TB drugs for less than one (<1) month. Isoniazid
preventive therapy or other preventive regimens are not
considered as previous TB treatment.
Retreatment case a patient who has been previously treated with
anti-TB drugs for at least 1 month in the past.

Classification based on drugsusceptibility testing

a. Monoresistant TB resistance to one first-line anti-TB drug only.

b. Polydrug resistant TB resistance to more than one first-line anti-TB drug


(other than both isoniazid and rifampicin).

c. Multidrug resistant TB resistance to at least both isoniazid and rifampicin.

d. Extensive drug-resistant TB resistance to any fluoroquinolone and to at


least one of three second-line injectable drugs (capreomycin, kanamycin and
amikacin), in addition to multidrug resistance.

e. Rifampicin resistant TB (RR-TB) - resistance to rifampicin detected using


phenotypic or genotypic methods, with or without resistance to other anti-TB
drugs. It includes any resistance to rifampicin, whether monoresistance,
multidrug resistance, polydrug resistance or extensive drug resistance.

GUIDE TO DIAGNOSIS and


INITIATION of TREATMENT
CLINICAL

DIAGNOSIS

1. Verify information gathered on case finding


2. Verify sputum smear examination results
3. Review history of previous treatment

Direct Sputum Smear Microscopy


(DSSM)

It serves as one of the bases for categorizing TB


cases according to standard case definition.
This is also used to:
a) monitor progress of patients with TB while they
are on antiTB treatment
b) confirm cure at the end of treatment.

SPUTUM COLLECTION

SPUTUM RESULTS

SMEAR POSITIVE
Occurs if at least two sputum specimens are AFB (+)

SMEAR NEGATIVE
Occurs if none of the three specimens are AFB (+)
DOUBTFUL

when only one of the 3 sputum specimens is (+). A second set


must be collected
If at least one of the second three is (+), SMEAR POSITIVE
If all of the second three are (-), SMEAR NEGATIVE

TUBERCULIN SKIN TESTING

PURIFIED PROTEIN DERIVATIVE

a basic screening tool for TB infection among


children using purified
protein derivative (PPD) tuberculin solution to
trigger a delayed hypersensitivity reaction among
those previously infected. Also known as the PPD
test or Mantoux test, it is one of the criteria in
determining the disease activity among children.

Chest X-ray

used to complement bacteriologic testing in


making a diagnosis. However, it has low
specificity and does not differentiate drugsusceptible from drug-resistant disease

TB Culture and Drug susceptibility


test (DST)
solid (Ogawa or Lowenstein Jensen) or liquid
media (MGIT)

a routine diagnostic test for drug resistant TB


cases under the NTP.

for TB prevalence surveys, drug resistance


surveillance, research and other special cases.

Rapid molecular diagnostic


test

endorsed by the WHO will be utilized by the NTP

WHO-endorsed available diagnostic tests in the


country are Xpert MTB/RIF and Line-Probe Assay
(LPA)for first line drugs.

Case Holding
The procedure that ensures that patients complete
treatment
assignment

of the appropriate treatment regimen


based on diagnosis and previous history of
treatment
supervised
monitoring

drug intake with support to patients

response to treatment through follow


up sputum smear microscopy

TB Disease Registration group

New
A patient who has never had treatment for TB* or who has taken anti-TB drugs for
less than one (<1) month.

Re-treatment

Relapse
A patient previously treated for TB, who has been declared cured or treatment
completed in their most recent treatment episode, and is presently diagnosed with
bacteriologically-confirmed or clinically-diagnosed TB.

Treatment After Failure


A patient who has been previously treated for TB and whose treatment failed at the
end of their most recent course. A patient whose sputum smear or culture is positive
at 5 months or later during treatment. A clinically diagnosed patient (e.g., child or
EPTB) for whom sputum examination cannot be done and who does not show clinical
improvement anytime during treatment.

Treatment After Lost to Follow-up (TALF)


A patient who was previously treated for TB but was lost to follow-up for
two months or more in their most recent course of treatment and is
currently diagnosed with either bacteriologically confirmed or clinicallydiagnosed TB.
Previous Treatment Outcome Unknown (PTOU)
Patients who have been previously treated for TB but whose outcome after
their most recent course of treatment is unknown or undocumented
Transfer-in
A patient who has been registered in a DOTS facility adopting NTP policies
and is transferred to another DOTS facility with proper referral slip to
continue the current treatment regimen.

DOTS (Directly Observed


Treatment)

Method
developed
to
ensure
treatment
compliance
by
providing
constant
and
motivational supervision to TB patients.

Works by having a responsible person, referred to


as treatment partner, watch the TB patient take
anti-TB drugs every day during the whole course
of treatment

It is a comprehensive strategy endorsed by the World


Health Organization (WHO) and International Union
Against Tuberculosis and Lung Diseases (IUATLD) to
detect and cure TB patients.

5 Components of TB-DOTS
Program

Political or Management commitment


TB diagnosis through sputum microscopy (x-ray is
only a secondary diagnostic tool)
Availability of complete and quality anti-TB
medications
Supervised treatment (a responsible person
making sure that the patient takes the anti-TB
medication everyday)
Recording and reporting of cases and outcomes

Treatment Regimen for


PTB

Treatment Regimen for


PTB

Treatment Regimen for PTB


Category I
- New pulmonary TB (bacteriologically-confirmed or clinicallydiagnosed)
-New extra-pulmonary TB (bacteriologically-confirmed or
clinically-diagnosed), except CNS/ bones or joints

Initial Phase - 2HRZE

Continuation Phase 4HR or 4HRE

Category Ia
- New extra-pulmonary TB (CNS/ bones or joints)

Initial Phase 2 HRZE

Continuation phase - 10 HR
3

Treatment Regimen for


PTB
Category II
- Pulmonary or extra-pulmonary, previously treated drugsusceptible TB (whether bacteriologically-confirmed or clinicallydiagnosed), except CNS/ bones or joints RelapseTreatment After
FailureTreatment After Lost to Follow-up (TALF) Previous Treatment
Outcome Unknown (PTOU)

Initial Phase 2 HRZES and 1 HRZE


Continuation Phase 5 HRE

Category IIa
- Extra-pulmonary (CNS / bones or joints), previously treated, drug
susceptible TB ( whether bacteriologically-confirmed or clinicallydiagnosed)

Initial Phase 2 HRZES and 1 HRZE


Continuation Phase 9 HRE

Treatment Regimen for


PTB

Drug Resistant TB

- Standard Regimen Drug-Resistant (SRDR):


rifampicin resistant TB or multi- drug resistant TB
- Individualized based on previous treatment
courses and drug sensitivity testing

Algorithm for Management of


Initial Phase Treatment
Interruptions

Algorithm for Management of


Continuation Phase Treatment
Interruptions

GUIDE IN MANAGING DRUGS SIDE


EFFECTS

GUIDE IN MANAGING DRUGS SIDE


EFFECTS

Treatment Outcomes
1. Cured
Was registered as pulmonary smear-positive
completed treatment
becomes smear-negative in the last month of treatment
on at least one previous occasion in the continuation phase.
2 .Completed treatment
registered smear-positive
completed treatment but without DSSM follow-up during the
treatment, or with only 1 negative DSSM during the treatment or
without DSSM in the last month of treatment.
Was registered as pulmonary smear-negative and has completed
treatment.
3. Died
Was known to have died for any reason during the course of
treatment Treatment outcomes

Treatment Outcomes
4. Failed
registered as pulmonary smear-positive, but still smear-positive at 5
months or later during the treatment
registered as smear-negative but becomes smear-positive during the
treatment.
5. Defaulted
Has interrupted treatment for 2 consecutive months or more, and
remained unretrieved.
6. Transferred out
transferred to another health facility for continuation of treatment
with proper referral slip and whose treatment outcome is not
known.

Prevention

depends largely on preventing exposure and


infection

young children (i.e., 0-4 years old) and people


living with HIV (PLHIV) who are already exposed
or infected, the aim is preventing progression to
TB disease

Prevention of TB can be achieved through the


following: TB infection control (TB IC), universal
use of BCG