Tuberculosis Guidelines Guyana 2011

GUYANA TUBERCULOSIS MANUAL
REVISED 2011
National Guidelines for the Prevention, Treatment, Care and
Control of Tuberculosis
THE MINISTRY OF HEALTH
GUYANATUBERCULOSISMANUAL2011EDITION
NATIONALGUIDELINESFORTHEPREVENTION,TREATMENT,CAREANDCONTROLOFTUBERCULOSIS
Contents
ForewordbyChiefMedicalOfficer..........................................................................................................................8
Preface....................................................................................................................................................................9
Acknowledgements...............................................................................................................................................10
ListofAbbreviations..............................................................................................................................................11
1.....................................................................................................................................................................14
INTRODUCTION...................................................................................................................................................14
TheGlobalTuberculosisSituation.........................................................................................................................14
TuberculosisinGuyana.........................................................................................................................................15
FiveYearEpidemiologicProfile8...........................................................................................................................16
2009EpidemiologicProfile...................................................................................................................................18
2.....................................................................................................................................................................25
NATIONALTUBERCULOSISPROGRAMME...................................................................................................................25
OverviewoftheNationalTBProgramme..............................................................................................................25
KeyfeaturesoftheNTP:........................................................................................................................................25
ActivitiesofTBcontrolwithinthePublicHealthSystem:......................................................................................26
StructureoftheNationalTuberculosisProgram...................................................................................................27
National................................................................................................................................................................27
GeorgetownChestClinic(GCC)............................................................................................................................29
Regional................................................................................................................................................................31
DocumentationtoolsusedatTBClinics................................................................................................................32
3.....................................................................................................................................................................35
TuberculosisTransmissionandPathogenesis...................................................................................................35
Etiology..................................................................................................................................................................35
Transmission..........................................................................................................................................................36
Pathogenesis.........................................................................................................................................................36
TuberculosisInfection..........................................................................................................................................36
Ministry of Health - Guyana, 2011 | 1
RiskFactorsforTBInfection.................................................................................................................................36
TBDisease............................................................................................................................................................37
RiskFactorsfortheDevelopmentofTBDisease..................................................................................................37
CommonSitesforTBDisease:..............................................................................................................................38
CopathogenesisofTBandHIV.............................................................................................................................39
4.....................................................................................................................................................................40
CASEFINDING.....................................................................................................................................................40
SymptomsofpulmonaryTBdiseaseinclude........................................................................................................40
5.....................................................................................................................................................................42
DIAGNOSISOFTUBERCULOSIS.................................................................................................................................42
DiagnosisofLatentTBinfection............................................................................................................................42
NB:ReactivityinadultsduetoBCGgivenininfancyisoftenlessthan10mm.(ATS/CDC)...................................43
DiagnosisofTBdisease.........................................................................................................................................44
DiagnosisofMDRTB.............................................................................................................................................49
6.....................................................................................................................................................................50
LABORATORYSERVICES.........................................................................................................................................50
NationalPublicHealthReferenceLaboratory.......................................................................................................50
TBLaboratoryLevels.............................................................................................................................................51
NationalTuberculosisLaboratoryScreeningServices...........................................................................................51
SputumCollectionProcess.....................................................................................................................................51
ProtocolforCultures/DrugSensitivityTesting(DST)............................................................................................53
QualityAssurance..................................................................................................................................................55
7.....................................................................................................................................................................58
DirectlyObservedTreatmentShortCourse(DOTS)..........................................................................................58
DefinitionofDOTS.................................................................................................................................................58
Adherence.............................................................................................................................................................59
Essentialcomponentsforcasemanagement........................................................................................................62
Healtheducation...................................................................................................................................................63
Communityparticipation.......................................................................................................................................63
ManagementofmissedAppointments............................................................................................................64
HelpfulhintsforthegradualintroductionofDOTS...............................................................................................66
8.....................................................................................................................................................................69
TBCONTACTINVESTIGATION..................................................................................................................................69
Keyelementsofcontacttracing............................................................................................................................71
DeterminetheInfectiousPeriod............................................................................................................................71
InterviewtheTBCase............................................................................................................................................71
Conductingtheinterview......................................................................................................................................71
PrioritizeContacts.................................................................................................................................................72
ChildContact.........................................................................................................................................................72
ManagementofchildcontactsofinfectiousTBcases:.........................................................................................73
ChildContactsofInfectiousMultidrugResistantTuberculosis(MDRTB)Cases...................................................74
9.....................................................................................................................................................................75
TREATMENTOFTUBERCULOSIS................................................................................................................................75
StandardizedTreatmentRegimens.......................................................................................................................76
NewCases(formerWHOcategory1and3)..........................................................................................................76
RetreatmentCases(formerWHOcategory2).....................................................................................................77
Fixeddosecombinationtablets............................................................................................................................79
IntermittentuseofTBmedication.........................................................................................................................81
TreatmentofLatentofTBinfectionorLatentTB..................................................................................................82
TreatmentofExtrapulmonaryTB(EPTB)..............................................................................................................83
Useofcorticosteroids..........................................................................................................................................84
ManagingtheSmearNegativeSuspectCase.......................................................................................................84
ManagingtheSputumSmearPositiveCases........................................................................................................85
InterruptionofTBTreatment................................................................................................................................86
10...................................................................................................................................................................89
TUBERCULOSISINCHILDREN...................................................................................................................................89
Tuberculosisinchildren.........................................................................................................................................89
ClinicalPresentationsofTBinChildren.................................................................................................................89
DiagnosingTBinChildrenwithoutHIVinfection...................................................................................................90
TuberculinSkinTest(TST)......................................................................................................................................93
BacteriologicalConfirmation.................................................................................................................................94
RelevantinvestigationsforsuspectedPTBandEPTB............................................................................................95
TreatingChildhoodTB.........................................................................................................................................100
DeterminingDrugDosage...................................................................................................................................101
AdjunctiveTreatmentwithCorticosteroids.........................................................................................................104
TreatmentAdministrationandAdherence..........................................................................................................104
ImmuneReconstitution.......................................................................................................................................108
ManagementofaBabyBorntoaMotherDiagnosedwithInfectiousPTB.........................................................108
BCGVaccinationinChildren................................................................................................................................109
11.................................................................................................................................................................110
TreatmentRegimensinSpecialPopulations..................................................................................................110
TreatmentforPregnantWomen.........................................................................................................................110
TreatmentforBreastfeedingWomen.................................................................................................................110
12.................................................................................................................................................................111
TBHIVCOMANAGEMENT..................................................................................................................................111
NaturalHistory....................................................................................................................................................112
DiagnosisofHIV/TBCoinfection........................................................................................................................113
ScreeninganddiagnosisofTBdiseaseinadolescentsandadultslivingwithHIV..............................................113
DiagnosisofextrapulmonaryTB(EPTB)inHIVinfectedpersons.......................................................................117
DiagnosisofHIVinTBcases................................................................................................................................117
TreatmentofTBHIV............................................................................................................................................117
PreventivetherapyforlatentTBinduallyinfectedpersons................................................................................117
TreatmentofactiveTBinTBHIVcoinfectedpersons........................................................................................118
INTENSIVEPHASETREATMENT.........................................................................................................................118
Immunereconstitutionsyndrome(IRIS)..............................................................................................................125
13.................................................................................................................................................................127
DRUGRESISTANTTB..........................................................................................................................................127
MDRTB................................................................................................................................................................127
MDRTBCasefinding...........................................................................................................................................127
TargetgroupsforDSTincludethefollowing:......................................................................................................128
Diagnosis.............................................................................................................................................................128
TreatmentofMDRTB.........................................................................................................................................129
Generalprinciples..............................................................................................................................................129
14.................................................................................................................................................................138
INFECTIONCONTROL..........................................................................................................................................138
DetailedInfectionControlmeasures...................................................................................................................140
Environmentalcontrols.......................................................................................................................................140
Administrativecontrols.......................................................................................................................................141
PersonalProtectiveEquipment...........................................................................................................................143
Donningpersonalprotectiveequipment.............................................................................................................144
WhenusingPPE,theapron/gownshouldbedonnedfirst,thenthemask/respiratorandthenthegloves.......144
Removalofpersonalprotectiveequipment........................................................................................................144
CareofHealthCareWorkers...............................................................................................................................145
15.................................................................................................................................................................146
Surveillance,MonitoringandEvaluation.......................................................................................................146
RecordingandReporting.....................................................................................................................................146
SurveillanceDataFlow........................................................................................................................................149
MonitoringandEvaluation..................................................................................................................................150
RecordingandEvaluatingTBTreatmentResponse.............................................................................................160
CohortAnalysisofTreatmentOutcomes.............................................................................................................160
APPENDICES..................................................................................................................................................163
REFERENCES..................................................................................................................................................212
Figure1:TBincidence(2004to2009)andmortality(2004to2008)rate................................................................16
Figure2:ProportionofnewTBcasesandnewsputumpositiveTBcasesplacedonDOTS.....................................17
Figure3:TreamentcompletionrateofTBcasesplacedonDOTS............................................................................17
Figure4:ProportionofnewTBcasestestedforHIVandHIVseroprevalenceamongTBcases..............................18
Figure5:PrevalencerateofTBineachadministrativeRegion.................................................................................19
Figure6:NewTBcasesineachadministrativeRegionin2009................................................................................19
Figure7:TBincidenceratesineachadministrativeRegionin2009........................................................................20
Figure8:NumberofTBcasesplacedonDOTSin2009byagegroup......................................................................21
Figure9:AgespecificratesofTBcasesplacedonDOTSin2009.............................................................................21
Figure10:NumberofTBcasesplacedonDOTSin2009stratifiedbygenderandagegroup................................22
Figure11:SexspecificratesofTBcasesineachagegroupwhowereplacedonDOTSin2009...........................22
Figure12:SexspecificratesofTBcasesineachadministrativeRegionwhowereplacedonDOTSin2009........24
Figure13:OrganogramoftheNationalTuberculosisProgrammeUnit.................................................................29
Figure14:OrganogramoftheGeorgetownChestClinic........................................................................................30
Figure15:OrganisationalChartofTBSitesandreportingtoNTP.........................................................................31
Figure16:Flowchartfortheinvestigationofcaseswithrespiratorysymptoms..................................................48
Figure17:ReportingstructureoftheDOTSprogramme......................................................................................67
Figure18:Concentriccircle
approach...................................................................................................................70
Table1:Interpretationofthetuberculinskintests...........................................................................................43
Table2:Indicationsanddiagnosticrequirementforsputummicroscopyandculture.......................................46
Table3:IndicationforDST................................................................................................................................49
Table4:Factorsaffectingadherenceandsuggestedinterventions2,3,12...............................................................59
Table5:EssentialantiTBdrugs.........................................................................................................................75
Table6:TreatmentregimensbyTBtreatmentcategory....................................................................................78
Table7:FixedDoseCombinations(FDC)............................................................................................................79
Table8:Exampleofthenumberoftabletstobetakendailyininitialphasebya50kgcase..............................80
Table9:FixedDoseNewCaseRegimens..........................................................................................................80
Table10:FixedDoseCombinationRegimens....................................................................................................81
Table11:RecommendedregimensfortreatmentofTBinchildren..................................................................102
Table12:SelectedregimensfortreatmentofTBmeningitisinchildren...........................................................103
Table13:HowPTBdiffersinearlyandlateHIVinfection.................................................................................113
Table14:StandardregimensfornewTBcasecases(presumedorknowntohavedrugsusceptibleTB)............118
Table15:DosingfrequencyfornewTBcases..................................................................................................119
Table16::RecommendationsformanagingHIVTBcoinfection......................................................................120
Table17:CommonARVsusedinthetreatmentHIVincomorbidcases..........................................................122
Table18:DrugcombinationsanddosemodificationinTBHIvcoinfection......................................................123
Table19:InvestigationsduringTBtreatment..................................................................................................125
Table20:ClassificationofsuspectedorprovenMDRorXDRTBcase...............................................................128
Table21:Treatmentregimenbasedonpatternofdrugresistance...................................................................131
Table22:SecondlineantiTBdrugdosage.......................................................................................................132
Table23:MonitoringMDRTBcasesontreatment...........................................................................................135
Table24:TreatmentoutcomesdefinitionsforMDR/XDRTBcases..................................................................135
Table25:Drugdosagebybodyweightofthecase2,3,11.....................................................................................136
Table26:ImpactandoutcomeindicatorsusedbytheNTP..............................................................................150
Table27:OutputindicatorsusedbytheNTP...................................................................................................159
ForewordbyChiefMedicalOfficer
GuyanahaslongsincejoinedthefightagainstTuberculosisandhasmademarkedstridesinimproving
theaccessibilitytoqualityserviceslendingtotheeffectivecare,treatmentandsupportofthoseinfected
andaffectedbythispandemic.Morespecifically,considerableprogresshasbeenmadeintheareasof
MonitoringandEvaluation,TB/HIVandlaboratoryservices,Directly ObservedTreatment Shortcourse
(DOTS) strategy, Advocacy, Communication and Social Mobilization activities and the clinical
management of TB patients with a commensurate expansion of the aforementioned services in all
regions of the country. These achievements are due largely in part to the dedication of health
professionalswhoperformtheirdutiesunreservedly.
While such progress is laudable, it is equally imperative to equip such professionals with standard
guidelines which take cognizance of international recommendations and best practices while keenly
tailoring same to the specific needs of Guyana. It is on this principle that the National Tuberculosis
Programme, in collaboration with the FranoisXavier Bagnoud Centre (FXB) and other key partners,
undertookthereviewandupdateoftheNationalGuidelinesforthePrevention,Treatment,Careand
ControlofTuberculosis.Thisresultingdocumentrepresentsthethirdversionofthismanual.
TheMinistryofHealthwishestoencourageallhealthprofessionalstoactivelyusetheseguidelinesasa
referencetoolfortheimprovedstandardizemanagementofTuberculosis.TheMinistryofHealthfirmly
believes that, though the application of these standard practices, we can all join and win the fight
againstTuberculosis.
Dr.ShamdeoPersaud,
ChiefMedicalOfficer
MinistryofHealth
Guyana
Preface
The revision of the Guyana Tuberculosis Manual is a continuous effort by the National Tuberculosis
Programme(NTP),MinistryofHealthtoprovidecontinuousandimprovedqualityofcaretothepeople
ofGuyana.Tuberculosisisaninfectiousdiseaseaffectingindividualsandthepublicatlarge.Becauseof
this the NTP generated a subtitle to this document titled National Guidelines for the Prevention,
TreatmentCareandControlofTuberculosis.Thistitleandsubtitleclearlyreflectthecontentsofthe
documentandhowitwillbeusedbyallhealthcareworkersinGuyana.Theseguidelineswillimprove
thecareandoutcomesofpatientsinfectedwithTBorHIV/TB.
The revised guidelines are based on updates from the World Health Organization (WHO) and the
Caribbean Epidemiology Centre (CAREC). As TB and HIV/TB coinfection are dynamic diseases;
additionalliteraturewasreviewedtoascertainwhethertherecommendationsareapplicabletoGuyana.
Thebestpracticesandprotocolsfromothercountrieswereincorporatedintothisrevisedmanualand
incorporatesthelatestrecommendationsandtechnologyincluding:themanagementofchildrenwith
TB, updated laboratory capabilities for TB cultures and drug sensitivity testing, timely introduction of
antiretroviral medications to HIV/TB coinfected patients, management of multiple drug resistant TB
(MDRTB), infection control for clinics and hospitals, standard operating procedures treatment and
monitoringandevaluationbytheNTPofregionalandprisonchestclinics.Theseadditionswill:
AssistphysiciansandMedextobettercareandtreatTBandHIV/TBcoinfectedpatients.
PreventthespreadofTBinclinicsandhospitalsbyinstitutingbetterinfectioncontrolpolicies
Provide updated standard guidelines for consistent care of patients with TB throughout the
country
Trainnewhealthcareprovidersintheprevention,treatment,careandcontrolofTB
ImprovecasefindinganddetectionofTBcontactsbychestclinicstaffandDOTSworkers
PreventionandearlydiagnosisofMDRTB
TheNTPhasbenefitedfromtheassistanceofourpartnersattheFranoisXavierBagnoud(FXB)Center
of the University Medical and Dentistry of New Jersey, the US Centers for Disease Control and
PreventionandthePanAmericanHealthOrganizationaswellastheGlobalFundforHIV,TBandMalaria
inthepreparationofthisdocument.Asheadofthetechnicalworkinggrouptaskedwiththerevisionof
the GuyanaTBManual,I wishtothankallwhocontributed to thisdocumentwhichisrelevanttothe
usersandthebeneficiariespatientsatallfacilitiesbothprivateandpublic.
Dr.JeetendraMohanlall,
ProgrammeManager
NationalTBProgramme,MinistryofHealth
Acknowledgements
GuyanaNationalTuberculosisWorkingGrouptorevisetheNational
TuberculosisManual
Dr.JeetendraMohanlall,ProgrammeManagerNationalTBProgramme,(NTP)
Dr.DeborahWafer,MedicalDirector,FranoisXavierBagnoudCentreGuyana(FXB)
MsYohaniChandSingh,M&ECoordinator,NTP
MsLynetteHardy.LaboratoryAdvisor,FXBGuyana
MsNicolaMelville,DOTSCoordinator,NTP
MsRomonaMorgan,HIV/TBCoordinator,NTP
Dr.RosalindaHernandez,HIVAdvisorPAHO
Dr.NadiraRamcharran,MedicalDirectorGeorgetownChestClinic(GCC)
Dr.IdelisaCartayaPersaud,MedicalOfficer,GCC
Dr.LindaDOliveiria,GeneralMedicalOfficer,GCC
Dr.CurtisLaFleur,HIV/TBadvisorCenterforDiseaseControlandPrevention,Guyana
MsCherryGeorge,HeadoftheTBDepartment,NationalPublicHealthReferenceLaboratoryMOH
Guyana
Reviewcommittee
MsNicoleJordan,CountryDirector,FXBGuyana
Dr.JeetendraMohanlall,ProgrammeManagerNTP
Dr.ShamdeoPersaud,ChiefMedicalOfficerMOHGuyana
Dr.DeborahWafer,MedicalDirectorFXBGuyana
MsYohaniChandSingh,M&ECoordinator,NTP
MsLynetteHardy,LaboratoryAdvisor,FXBGuyana
MsRomonaMorgan,HIV/TBCoordinator,NTP
MsAstridFoo,ACSMCoordinator,NTP
OtherContributors
MsVivienneLowe,ProjectCoordinator,FXB
DrBrianBaker,CDC,Atlanta
MsTowshemaHardyal,AdministrativeAssistant/Secretary,NTP
MsAnastasiaDhanraj,Pharmacist,NTP
10
ListofAbbreviations
AFBAcidfastbacilli
AIDSAcquiredimmunodeficiencysyndrome
ARTAntiretroviraltherapy
ARVAntiretroviral
BCGBacilleCalmetteGuerin
BMUBasicManagementUnit
CARECCaribbeanEpidemiologyCentre
CDCCentersforDiseaseControlandPrevention
CXRChestXray
DNADeoxyribonucleicacid
DOTDirectlyobservedtreatment
DOTSDirectlyobservedtreatment,shortcourse(globalstrategyforTBcontrol)
DSTDrugsusceptibilitytesting
EMB/EEthambutol
EPIWHOExpandedProgrammeonImmunizations
EPTBExtrapulmonarytuberculosis
HIVHumanimmunodeficiencyvirus
IGRAInterferongammareleaseassay
IMAAIIntegratedmanagementofadolescentandadultillness
INH/HIsoniazid
IPTIsoniazidpreventivetherapy
IRISImmunereconstitutioninflammatorysyndrome
ISTCInternationalStandardsforTuberculosisCare
LTBILatenttuberculosisinfection
MACMycobacteriumaviumcomplex
MAIMycobacteriumaviumintracellulare
MDRMultidrugresistant
11
M.TBMycobacteriumtuberculosis
MOHMinistryofHealth
MOTTMycobacteriaotherthantuberculosis
NAPNationalAIDSProgram
NNRTINonnucleosidereversetranscriptaseinhibitor
NTBMNonTBmycobacteria
NRTINucleoside/nucleotidereversetranscriptaseinhibitor
NTMNontuberculousmycobacteria
NTPNationalTuberculosisProgram
NTPTWGNationalTBProgrammeTechnicalWorkingGroup
PAHOPanAmericanHealthOrganization
PCRPolymerasechainreaction
PIProteaseinhibitor
PMTCTPreventionofmothertochildtransmission
PPDPurifiedproteinderivative
PPEPersonalprotectiveequipment
PTBPulmonarytuberculosis
PZA/ZPyrazinamide
QAQualityassurance
RIF/RRifampicin
RNARibonucleicacid
SStreptomycin
SOPStandardoperatingprocedure
STISexuallytransmittedinfection
TBTuberculosis
TSTTuberculinskintest(Mantoux)
UNAIDSJointUnitedNationsProgramonHIV/AIDS
USAIDUnitedStatesAgencyforInternationalDevelopment
12
VCTVoluntarycounselingandtesting
WHOWorldHealthOrganization
XDRExtensivelydrugresistant
13
1
INTRODUCTION
TheGlobalTuberculosisSituation
In2008,therewereanestimated8.99.9millionincidentcasesofTB,9.613.3millionprevalentcases
ofTB,1.11.7milliondeathsfromTBamongHIVnegativepeopleandanadditional0.450.62millionTB
deathsamongHIVpositivepeople(classifiedasHIVdeathsintheInternationalStatisticalClassification
ofDiseases),withbestestimatesof9.4million,11.1million,1.3millionand0.52million,respectively.
ThenumberofnotifiedcasesofTBin2008was5.7million,equivalentto5567%ofallincidentcases,
withabestestimateof61%(10%lessthantheGlobalPlanmilestoneofacasedetectionrateof71%in
2008). Among cases in the 2007 cohort, 87% were successfully treated; this is the first time that the
target of 85% (first set in 1991) has been exceeded at a global level. Progress in implementation of
interventionstoreducetheburdenofTBinHIVpositivepeoplehascontinued.In2008,22%ofTBcases
knewtheirHIVstatus(upfrom20%in2007)including45%ofTBcasesintheAfricanRegion;0.3million
people were placed on cotrimoxazole preventive therapy; and 0.1 million people were placed on
antiretroviraltherapy(ART).Almost30,000casesofmultidrugresistantTB(MDRTB)werenotifiedin
2008; this is 11% of the total number of cases of MDRTB estimated to exist among cases notified in
20081.DiagnosisandtreatmentofMDRTBneedstoberapidlyexpanded.
Funding for TB control has increased since 2002, and is expected to reach US$ 4.1 billion in 2010.
However,fundinggapsremain;comparedwiththeGlobalPlan,fundinggapsamounttoatleastUS$2.1
billionin2010.
Globally, incidence rates peaked at 143 (range, 136151) cases per 100, 000 population in 2004. The
worldasawholeisontracktoachieveMDGTarget6.c,asareeightofnineepidemiologicalsubregions
14
(theexceptionbeingAfricancountrieswithalowprevalenceofHIV).Fiveepidemiologicalsubregions
(CentralEurope,EasternEurope,highincomecountries,LatinAmericaandtheWesternPacific)appear
tohaveachievedtheStopTBPartnershiptargetofhalvingthe1990prevalencerateandfour(Central
Europe, highincome countries, Latin America and the Western Pacific) appear to have achieved the
Stop TB Partnership target of halving the 1990 mortality rate, in advance of the target year of 2015.
Prevalence and mortality rates are falling in all other regions with the exception of African countries
with a low prevalence of HIV, although reaching the global target appears impossible in the African
Region. Globally, the gulf between prevalence and mortality rates in 2008 and the target levels in
Africancountriesmakeitunlikelythat1990prevalenceanddeathrateswillbehalvedby2015forthe
worldasawhole1.
Reductions in disease burden achieved to date follow fourteen years of intensive efforts at global, regional and country levels to
implement the DOTS strategy (19952005) and its successor, the Stop TB Strategy (2006)1. Between 1995 and 2008, a cumulative
totalof36millionTBcasesweresuccessfullytreatedinDOTSprogrammes,andupto8milliondeathswereaverted.Toconsolidatethe
major progress in global TB control achieved in recent years; intensified efforts to plan, finance and implement the range of
interventionsandapproachesincludedintheStopTBStrategy,accordingtothetargetsestablishedintheGlobalPlantoStopTB,are
needed.
TuberculosisinGuyana
In Guyana, the tuberculosis (TB) situation has changed significantly over the last 15 years. A steady
increaseinthenumberofTBcaseswasnotedsincetheearly1990safterasubstantialdecreaseduring
the 1970s and 1980s. The case notification rate increased from 21 per 100,000 in 1992 to 83 per
100,000in2009.MoredetailedinformationontheTBtrendsinGuyanaisprovidedbelowinthefive
yearand2009epidemiologicprofiles;theserateswerecalculatedusingthepopulationdataasstatedin
theGuyanaCensus2002NationalReport.
Ministry of Health - Guyana, 2011 | Introduction
15
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
ON,TREATMENTT,CAREANDCO
ONTROLOFTUBEERCULOSIS
FiveYeaarEpidemiologicProfile
e8
AsdepicteedinFigure1
1,theinciden
ncerateofTB
Bhassteadilyyincreasedfrom76per10
00,000population
in 2004 to 93 per 100,
1
000 po
opulation in 2007. During this period the DOTS programmee was
implemen
nted increme
entally and byy 2007, was fully implem
mented in all ten Adminisstrative Regio
ons of
Guyana. There
T
was a marked decrrease in the TB incidencee rate in 200
08, perhaps attributable
a
t the
to
expansion
noftheDOTSprogrammee.Thetrend inFigure1ssuggeststhat theTBincidenceisstabilizing,
withincid
denceratesoff83per100,000populationin2008an
nd84per100
0,000populationin2009.
Figure 1 also
a
suggestss that the TB
B mortality raate is graduaally declining,, from 16 deaths per 100
0, 000
populatio
onin2004to 11deathsper100,000populationin 2008.TheTB
Bmortalityraatewascalcu
ulated
usingthe numberofp
personswhod
diedduringtthereporting period,withTBbeingtheeunderlying cause
ofdeath. ThisinformaationwasobttainedbytheMOHStatistticalUnit,fromdeathcerttificatessubm
mitted
totheGeneralRegistraarsOffice.
Figure1:TBincid
dence(2004to
o2009)andmo
ortality(2004tto2008)rate
Source:N
NTP2009Annu
ualReport
Ministry of Health - Gu
uyana, 2011 | In
ntroduction
16
6
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Figure2:Pro
oportionofne
ewTBcasesan
ndnewsputum
mpositiveTBccasesplacedonDOTS
Figure3illustratesasteadyincreasseintheproportionofTB
BcasesthatccompletedtreeatmentviaD
DOTS,
osixtyfourp
percent(64%)in2009.Ho
owever,thereewasasignificant
fromfiftyypercent(50%)in2005to
decreaseoffourperce
ent(4%)in200
08)followedbyatenperccent(10%)inccreasein2009
9.
Figure3:TreaamentcompletionrateofTB
BcasesplacedonDOTS
uyana, 2011 | In
ntroduction
17
7
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Figure4illustratesthaattheproporrtionofnew TBcasestesttedforHIVin
ncreasedfrom
mseventypeercent
(70%)in2
2005toeightyytwopercent(82%)in2006,followedbyasmalldeecreasetoeigghtypercent(80%)
in2007.H
However,in2
2008and2009
9theproporttionofnewTBcasestestedforHIVcon
ntinuedtoimprove
toeightythreepercent(83%)andeeightyninepeercent(89%)respectively.TheHIVpreevalenceamongTB
caseshasvariedovertthelastfiveyyears,decreassingfromthirrtysixpercent(36%)in2005totwentyeight
percent(2
28%)in2006followedbyasignificantreturntothirrtyfivepercent(35%)in2007.In2008there
wasanoth
herdecrease totwentyfo
ourpercent(2
24%),andagainfollowed byanincreasetotwenty eight
percent(2
28%)in20098.
Figure4:Proportionofnew
wTBcasestestedforHIVand
dHIVseroprevaalenceamongTBcases
2009EpidemiologicProfile
The2009 TBprevalenccerateinGuyyanawas148
8per100,000population.Figure5bellowillustratesthat
Regions 4, 2 and 10 have the highest prevalen
nce rates, at 23 per 10, 000
0 populatio
on, 18 per 10
0, 000
populaito
on and 15 pe
er 10, 000 population, reespectively. Regions
R
1 an
nd 3 follow at
a 12 per 10
0, 000
populatio
onand11perr10,000populationrespeectively.Thep
prevalenceraatescalculateedforRegionss5,6,
7, 8 and 9
9 may not re
eflect the true burden of TB in these Regions;
R
thuss increased case
c
detection
n and
provision of care and treatment fo
or TB cases iss needed. Reegions 1, 8 an
nd 9 pose maany challengees for
uyana, 2011 | In
ntroduction
18
8
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
casedetectionanddelliveryofserviicesduetoth
hetopographyanddisperssionofthepo
opulationsinthese
Regions.
Figure5:Pre
evalencerateofTBineachaadministrativeRegion
erateinGuyanawas84peer100,000po
opulation.AlthoughFigurre6below
The2009TBincidence
illustratessthenumberofnewactiveeTBcasesineachRegion,,Figure7belo
owmoreaccu
uratelyrefleccts
theincideenceofTBine
eachRegion8.
Figure6:Ne
ewTBcasesineachadministtrativeRegionin2009
uyana, 2011 | In
ntroduction
19
9
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Figure7:TBin
F
cidenceratesineachadmin
nistrativeRegio
onin2009
on of each Reegion,
The incidence rates depicted in figgure 7 abovee were calcullated using the populatio
hence theey are called regionspecific incidence rates. Regio
on 4 clearly has
h the highest incidence of TB
cases,evidencedbyan
nincidenceraateof15per 10,000popu
ulation.Regio
on10followsswithanincid
dence
rate of 9
9 per 10,000
0 population. Region 7 has the third highest incidence rate of 5 per 10
0, 000
populatio
on,followedb
byRegion3w
withanincideencerateof4
4per10,000population,aandRegions1
1,2,6
and 9 eacch with inciidence rates of 4 per 10, 000 population. Regions 8 and 5 each have the lo
owest
incidence rates of 1 per 10, 000
0 population..The Nation
nal TB Prograamme is wo
orking to improve
detectionandreportin
ngwithinallo
oftheregionss.
owdepictsan
normaldistrib
butionofthenumberofneewcasesofTTBdisease
AlthoughFigure8belo
wereplacedo
onTBtreatmeentandobserveddailybyahealthcaree
(disaggreggatedbyagegroup)whow
workerwhenconsumingtheirmedication(DOTSS),Figure9m
moreaccurateelyreflectsth
heincidenceo
ofTB
casesbyaagegroup.
uyana, 2011 | In
ntroduction
20
0
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Figure8:Numb
F
berofTBcasessplacedonDO
OTSin2009byyagegroup
Figure9:Age
especificratessofTBcasesplacedonDOTSSin2009
Figure9aaboveclearly illustratesth
hat3544yearoldshaveth
hehighestincidenceofTB
B,attwelve(12)in
every10, 000personsin2009.Thissgroupisclo
oselyfollowed
dby4554yeearolds,with
hanincidenceerate
ofeleven(11)ineveryy10,000perssons.Interesttingly,65+yearoldshavethenexthigh
hestincidenceerate
often(10
0)inevery10
0,000person
ns.Thisgroup
piscloselyfo
ollowedby25
534and5564yearolds,,both
with incid
dence rates of
o nine (9) in
n every 10, 000
0 persons, while 1524
4 and 014 year
y
olds havve the
uyana, 2011 | In
ntroduction
21
1
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
lowestinccidenceratess,atfour(4) andone(1)inevery10000persons,rrespectively. Theseagesp

pecific
rateswerecalculatedu
usingthepop
pulationofeaachagegroup
p.
bygenderand
dagegroupissillustratedin
nFigure10beelow,Figure11
Althoughthedistributiionofcasesb
oreaccuratelyyreflectssexspecificincid
dencerates8.
belowmo
Figure10:Nu
umberofTBcaasesplacedon
nDOTSin2009
9stratifiedbygenderandaggegroup
Figure11:SexxspecificratessofTBcasesin
neachagegroupwhowereplacedonDOTTSin2009
uyana, 2011 | In
ntroduction
22
2
Figure 11 illustrates that males are more affected by TB than females. This gap is significant in 4554
yearolds,forwhommaleincidence(18forevery10,000males)isalmostfourtimesthatoffemales(5
forevery10,000females).Among3544yearolds,maleincidence(18forevery10,000males)isjust
aboutthreetimesthatoffemales(7forevery10,000females).Among2534and65+yearolds,male
incidenceisoneandahalftimesthatoffemalesinbothagegroups.Among5564and1524yearolds,
theincidencegapismuchsmaller.Among014yearolds,maleincidenceisthreetimesthatoffemales;
however,thenumberofcasesinthisagegroupistoosmalltoidentifytrendsordrawconclusions.Thus
Figure 11 implies that more efforts are needed to sensitize males to TB screening and treatment
adherence.
Figure 12 below illustrates that in Regions 3, 4, 5 and 7 each, more males were placed on DOTS than
females; however, in Region 10 more females are on DOTS than males. In Regions 1, 2 and 6 each,
approximately the same proportion of males to females are on treatment. Again, since males are
disproportionately affected by TB in Regions 3, 4, 5 and 7, case detection as well as provision of
treatmentandadherencetotreatmentneedstobestrengthened.AlthoughTBcasesinRegions8and9
areontreatment,theyarenotbeingdirectlyobserved;hencedataonDOTSisnotavailableforthese
twoRegions.Additionally,thereisneedforgreaterengagementofcommunityhealthworkers(CHWs)in
thedeliveryofDOTSinthesetwoRegions,giventhatthetopographyanddispersionofthepopulations
thereinprecludetheassignmentofDOTSworkerstotheseareas.
Ministry of Health - Guyana, 2011 | Introduction
23
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Figure
e12:SexspecificratesofTBcasesineachadministrative
eRegionwhowereplacedo
onDOTSin200
09
uyana, 2011 | In
ntroduction
24
4
2
NATIONALTUBERCULOSISPROGRAMME
OverviewoftheNationalTBProgramme
In1994theGovernmentofGuyana(GOG)throughtheMinistryofHealth(MOH),recognizedtheneed
torevamptheNationalTuberculosisControlProgramme(NTP)basedonrecommendationsfromWorld
HealthOrganization/PanAmericanHealthOrganization(WHO/PAHO)andtheWorldHealthResolution
of1993declaringTBaglobalemergency.TheMinistryinitiatedthisprocessbyreviewingtheexisting
functionsoftheNTPandestablishingastructuretoreformthenationalTBcontrolservices.
TheaimoftheNTPistoreducetheincidenceandprevalenceofTBinGuyanasothatitnolongerposes
apublichealththreat.
TheoverallobjectiveistodecreasethemorbidityandmortalityassociatedwithTBinGuyana:
Specific targets of the NTP include: To detect 75% or more of existing cases of sputum smear
positivetuberculosisinthepopulation
Totreatandcure85%ofnewlyidentifiedsputumsmearpositivetuberculosisinthepopulation
TopreventtheemergenceofacquireddrugresistantM.tuberculosis
TB is largely a disease of the poor; thus those at lower socioeconomic levels are mainly affected.
Therefore,theNTPprovidesallTBtreatmentandessentialservicesfreeofchargetoallpersonsseeking
suchservices.
KeyfeaturesoftheNTP:
I.
Coordination
A NTP unit within the MOH Department of Disease Control, guided by a National
TuberculosisStrategicPlan
PlanofsupervisionatalllevelsoftheNTP
25
Procurementandsupplychainmanagementfordrugsanddiagnosticmaterials.
II.
Surveillance,MonitoringandEvaluation(M&E)
Standardized surveillance tools available at established TB clinics to facilitate accurate
recordingandreporting
EpidemiologicsurveillanceofTBandTB/HIVcoinfectionatallTBsitesoutlets
III.
Training
TrainingprogrammecoveringallaspectsofTBscreening,diagnosis,care,treatmentand
support
IV.
ClinicalManagement
The Guyana TB Manual, 2011 is available at all levels and across public and private
sectors of the health system. This Manual provides guidelines for the diagnosis and
treatmentofTBinfection,TBdisease,TBHIVcoinfectionandMDR/XDRsuspects.
Anationwidenetworkofmicroscopyservices,inclosecontactwithmalariamicroscopy
andprimaryhealthcare(PHC)services,whichwillbesubjecttoregularqualitycontrol
Care and treatment services within the public health system, with priority for DOTS,
administeredbyTBoutreachworkersorCHWsorvolunteers
ActivitiesofTBcontrolwithinthePublicHealthSystem:
Earlycasedetectionacrossthehealthsystem
ProvisionofTBtreatmentinaccordancewiththeNationalTBManualGuyana,2011
Stafftrainingonallaspectsofscreening,diagnosisandclinicalmanagementofTB
Healthinformation,educationandcommunicationonTB
TBlaboratoryservicesandothersupportivediagnostictesting
Contacttracingandinvestigation
DefaultertrackingandreturntoTBcareandtreatment
RecordingandreportingforsurveillanceandM&E
Provisionofover95%BCGvaccinationcoverageinentirepopulation
Enablingenvironmentforpeersupport
Ministry of Health - Guyana, 2011 | National Tuberculosis Programme
26
StructureoftheNationalTuberculosisProgram
National
TheNTPiscomprisedofanationalprogrammeunit,locatedinGeorgetownandanetworkofTBclinics,
also referred to as BMUs by the World Health Organization, distributed throughout the country. The
NTP programme unit is responsible for TB related policy development, project planning and
implementation, supervision of TB clinics/BMUs and facilitates capacity building and proficiency in TB
control throughout Guyana. The NTP programme unit is headed by a Director who has the overall
responsibilityofmanagingtheTBprogramme,andwhoreportstotheMOHDirectorofDiseaseControl.
Several coordinators work with the programme director to execute programme activities in a
coordinatedfashion.
DOTS Coordinator: Responsible for coordinating the implementation of DOTS Strategy at the
national level including training of DOTS outreach workers, community health workers and
volunteers; continuing education for DOTS personnel and volunteers ;and supervision and
developmentofbestpracticesforDOTSatthenationalandregionallevels.
Laboratory Coordinator: Ensures the proficiency of the TB laboratory and sputum microscopy
network. This coordinator works closely with heads of district and regional laboratories to
ensure availability of diagnostic testing for TB and conduct TB laboratoryrelated quality
assuranceactivities.ThiscoordinatorisduallysupervisedbytheNTPdirectoranddirectorofthe
NationalPublicHealthReferenceLaboratory(NPHRL).
M&E Supervisor: Responsible for the development and upgrade of both paperbased
and electronic data systems, supervises a team of M&E field officers and statistical
clerk to ensure a functional system of TB data collection, recording, reporting and
dissemination at regional and national levels and prepares programmatic surveillance
andM&Ereports.
TBHIVCoordinator:CoordinatestheTBHIVcollaborativeactivitiestoensureadequate
screening,diagnosis,care,treatmentandsupportofTBcasescoinfectedwithHIV
27
and ensures implementation of high quality comprehensive care and appropriate

interventionstoenhancethelivelihoodsofTBHIVcoinfectedindividuals.
Advocacy, Communication and Social Mobilization (ACSM) Coordinator: Responsible for the
followingactivities:
Raise awareness about TB for media personnel and high level officials; supports and
expandslocalnetworksofTBadvocatesandchampions.
Produce and generate information, education and communication materials for

broadcastandprintmedia.Trainscareworkersandvolunteerstocommunicatehealth
informationtoTBcasesandpeers.
Conduct educational programmes about TB aimed at destigmatizing TB, mobilize TB

controladvocatesandpeereducators;andfacilitatethedevelopmentofcaseTBsocial
(peer)supportgroups.
28
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
ChielMedical
Officer
Directorof
DiseeaseControl
HeadofC
ChestClinic
(PrincipalTB
BOfficer)
M&
&E
Supervisor
ACSM
Coordinator
M&E
Field
O
Officers
Ad
dministrative
DirectorofN
NTP
(ProgrammeMaanager)
Support
DOTS
TB/HIV
Coordinator
C
Lab
Coordinator
Supervisorss
ACSMRegional
DOT/HAART
DO
OTS
Lab
Superviisor(s)
Supervisor
Supervisors
Supervisorrs
Data
Sociial
Entry
Workkers
DOTS
Sputu
um
Workers
Microscopist
Clerks
Figgure13:Organ
nogramoftheNationalTube
erculosisProgrrammeUnit
Georgeto
ownChestC
Clinic(GCC)
TheGCCisthenationalcentreofexcellenceeforthecareeandtreatm
mentofTBcaases,TBsuspects
ory diseases. It is manaaged by a medical dirrector (a meedical officeer by
and otheer respirato
training) who reportts to the Diirector of th
he NTP. Thee head of th
he Georgeto
own Chest Clinic
C
macist, nursseinchargee and seveeral medical officers. The pharm
macist
supervisees a pharm
supervisees a Medexx/dispenser and pharm
macy assistant; the phaarmacist alsso preparess and
submits reportsonTTBdrugman
nagementandconsump
ptiontotheNTPDirector.Thenurssein
nforhighly activeantireetroviraltheerapy
chargesupervisesa teamofnurses,direct observation
(DOTHA
AART)SupervvisorsandDOTSsupervisors.TheDO
OTSsupervissormanagessateamofD
DOTS
uyana, 2011 | National Tuberculosis Programme
e
29
9
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
workers. Several me
edical officers clinically manage TB,, TBHIV coinfected and other casses of
es; they are also involvved in training health personnel
p
on
n TB and TB
BHIV
lung relaated illnesse
managem
ment; and conduct ch
hest clinics and regional physiciaan supervission on TB and
respirato
ory diseasess. The Georrgetown Chest Clinic directly
d
overrsees all clinical TB co
ontrol
activitiessinRegion4
4.ThephyssiciansattheGCCalso providehigh
hlevelconsultationwiththe
providerssoftheche
estclinicswithinthereggions.Theorganizational chartofthe GCCisdepicttedin
figure14.
ChiefMed
dicalOfficer
Director(Programme
M
Manager),
NationaalTuberculosis
Pro
ogramme
HeadofCheestClinics
(PrincipalTBOfficer)
Pharmacist
NurseinCharge
MedicalOfficers
Medex/Dispenser
Nurses
DOTSSSupervisors
DOTHAARTSSupervisor
PharmacyAssistaant
DO
OTSWorkers
Figure14
4:Organogram
moftheGeorge
etownChestC
Clinic
e
30
0
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Regionall
Regionalh
healthofficerrs(RHO)supeerviseTBconttrolactivitiessattheregion
nalanddistrictlevels,including
theoperaationofTBcllinics/BMUsaand TBsatelliteclinics,an
ndsupervisionofregionalland district staff.
TheRHOssliaisewithttheNTPprogrammeunitttoensurethaatpoliciesandguidelines areadhered toby
regionalTTBclinics/BMUs.TBclinics/BMUsareheadedbyam
medicalofficer.Anurseincchargeormedexis
responsib
ble for the daytoday op
perations of the
t clinics; and
a ensures that
t
medical care for TB
B is in
keepingw
withtheNatio
onalTBManu
ualGuyana, 2011andthatTBsurveilllanceactivitieesareconsisttently
conducted
dinorderto meetreportingneedsof theNTP.Theenursesinch
hargeorMed
dexalsosupervises
clinicnursses,DOTSwo
orkersandottheralliedhealthworkers..Thereareso
omeregionallDOTSsupervvisors
who overrsee the delivvery of high quality DOTSS and superviises the activvities of DOTSS workers. In
n high
volumereegionsotherw
wisethenurseeinchargeofftheclinicsittesupervisestheDOTswo
orkers.
Director, N
NTP
(Progrramme Man
nager, NTP)
DOTSS
Coordinator
Laboraatory
Coordin
nator
M&E
Coordin
nator
Figure15:OrgganisationalChartofTBSite
esandreportin
ngtoNTP
e
31
1
DocumentationtoolsusedatTBClinics
The following documentation tools are used by the TB clinics/BMUs to record and monitor
appointments,clinicalmanagement,requestlaboratorytestsandmedicalsupplies,recordeducational
sessionsandotherclinicactivities:
Appointment Card (Appendix I): Utilised to provide dates of appointments to the patient TB
case.Itisissuedandupdatedbythenurseinchargeateachfollowupvisit.Thecolourofthe
cardindicateswhattypeoftreatmentaTBcaseison:
Blue:Caseisonprophylaxis
Green:CaseisbeingtreatedforTBdisease
Yellow: Off treatment TB case has completed treatment and is being monitored during
followupperiod
White: Outcase TB case has completed both treatment and followup period but can re
visitcliniciftheneedarises
AdifferentcliniccardisissuedtoaTBcaseifthetreatmentregimenchanges.TheletterC
iswrittenonthecliniccardofaTBHIVcoinfectedpersons.
DomiciliaryorAmbulatoryCaseTreatmentSheet(Appendix2):Usedtorecordthedateandall
TB treatment prescribed to a TB case. The physician updates this treatment sheet upon
assessmentofaTBcaseateachclinicvisit.
TreatmentCard(Appendix3):UsedbytheTBoutreachworkerstorecorddailyDOTStreatment
providedtopatientTBcase.
Laboratory Request for Mycobacterium Tuberculosis Investigation (Appendix 4): Utilised to
requestsputummicroscopyinvestigationforeachTBcase.
InvestigationRequisitionForm(Appendix5):Utilisedbymedicalofficerstorequestadditional
investigations(biochemistry,haematology,urine,etc).
32
Chest XRay Examination Request Card (Appendix 6): Utilised by medical officers to request
chestXrays.
Combined Requisition and Issue Voucher (Appendix 7): Utilised by designated clinic staff to
requisitionmedicalsuppliesfromtheMOHMaterialsManagementUnit.
DiseaseNotificationForm(Appendix8):ThisformislegallymandatedunderthePublicHealth
OrdinanceNo.15of1934andrequiresreportingofallcasesofinfectiousdiseasestotheMOH
DiseaseControlDepartment.Hence,allnewandretreatmentTBcasesneedtobereportedthe
MOHnationalepidemiologist,upondetection.
TBHIV Educational/Sensitization Session Form (Appendix 9): Utilized to record all
educational/sensitizationsessionsconductedbyaTBcliniconoroffsite(e.g.atschools,work
places,placesofworship.etc),andisattachedtotheBMUMonthlyClinicReportforsubmission.
TBMedicalRecord/TBPatientChart(Appendix10):isinitiallycompletedatthefirstclinicvisit
after the patient is assessed physically and diagnostic tests are performed. The TB case is
monitoredthroughouttreatmentandahealthassessmentisconductedateachclinicvisitand
recordedonthefollowupsheets.
Active TB Case Report (Appendix 11): is used to notify the NTP of each active TB case that is
placed on treatment, it is filled in duplicate. Sections 15 of the original form (white page) is
submittedtotheNTP(attachedtotheBMUMonthlyClinicReport)whenthecaseisplacedon
treatment,section6oftheduplicatecopy(bluepage)iscompletedafterthesixmonthperiod
to record the treatment outcome and this copy is also submitted to the NTP attached to the
BMUMonthlyClinicReport.
Basic Management Unit (BMU) Monthly Clinic Report (Appendix 12): is a detailed summary
reportofallthecasesmanagedattheClinicforthatmonth.Itisfilledinduplicate,theoriginalis
submitted tothe NTPandthe duplicatecopyisretainedat TB Clinic/BMUforrecordkeeping.
The BMU Monthly Clinic Report also facilitates ease of compilation of data when preparing
33
many other types of management reports e.g. for planning, resource allocation, prevention
activities,etc.
Registers: are used at the TB clinics/BMUs (and prisons) to record and monitor patients
diagnosisandtreatment.Registersalsofacilitateeaseofextractionofdatawhencompilingthe
BMUMonthlyClinicReport.
Note:moredetaileddescriptionofthevariousregistersisprovidedinChapter15:Surveillance,
MonitoringandEvaluation.
34
3
TUBERCULOSISTRANSMISSIONANDPATHOGENESIS
Etiology
Mycobacterium tuberculosis (M. tuberculosis) is the organism responsible for most TB infection and
disease seen in Guyana and the Caribbean. M. tuberculosis organisms are rodshaped bacilli of
approximately0.20.5micronsindiameterand24micronsinlength.Thereareseveralotherspecies
and subspecies that are included in the M. tuberculosis complex because of their close genetic
relationship to tuberculosis. These include Mycobacterium bovis, Mycobacterium africanum, microti,
Mycobacteriumcanettii, Mycobacteriumcaprae,andMycobacteriumpinnipedii.With the exceptionof
Mycobacteriumpinnipedii, allofthespeciesintheM.tuberculosiscomplexhavebeenshowntocause
diseaseinhumans;however,M.tuberculosisisbyfarthemostprevalent.
Themycobacteriathatcausetuberculosisareaerobic,nonsporeforming,nonmotile,andmultiplyvery
slowly(onceevery1824hours).M.tuberculosisorganismshaveathicklipidcellwallwhichretainsdye
andresistsdecolourisationwhenwashedwithacidoralcohol,andtherebyarereferredtoasacidfast
bacilliorAFB2,3.
Mycobacteriacommonlyfoundintheenvironmentrarelycausediseaseinhumansandarenotableto
be spread from person to person. The mycobacteriums other than tuberculosis (MOTT) most often
causediseaseinindividualswithweakenedimmunesystems.
MycobacteriumaviumandMycobacteriumintracellulaearethemorecommonoftheMOTTsometimes
seen in TB cases coinfected with HIV. Because of their close association with each other,
Mycobacteriumavium and Mycobacterium intracellulae is sometimes referred to as Mycobacterium
aviumcomplex(MAC)oravium/intracellulae(MAI).
35
Transmission
Transmission is the spread of organisms, such as M. tuberculosis, from one person to another. The
primarymodeoftransmissionforTBisthroughinhalationofinfectiousparticles.WhenapersonwithTB
disease of the lungs or larynx coughs, sneezes or sings, droplets or particles called droplet nuclei
containing the TB bacilli are expelled into the air. These droplet nuclei are about 1 to 5 microns in
diameterlessthan1/5000ofaninch.Dropletnucleicanremainsuspendedintheairforseveralhours,
depending on the environment. Transmission occurs when droplet nuclei are breathed in through the
airwayandreachtheterminalairspacesofthelungs(alveoli).
Pathogenesis
TuberculosisInfection
TBinfectionmeansthattuberclebacilliareinthebodybuttheintactimmunesystemiskeepingthem
undercontrol.Thepulmonarymacrophagesactasscavengersandengulfthebacilli.Somearewalledoff
withinthemacrophageandlivethereformanyyears.Iftheimmunesystemiscompromised,thenthe
bacillimultiplyandspreadtoothersitesinthebody.
PeoplewhohaveTBinfection,sometimesreferredtoaslatentTBinfection(LTBI)butnotTBdiseasedo
nothavesymptomsoftheirinfection,andtheycannotspreadtheinfectiontootherpeople.Itisvery
importanttorememberthatTBinfectionisnotconsideredacaseofTB.
RiskFactorsforTBInfection
TheWHOestimatesthatapproximatelyonethirdofthepopulationworldwidehasTBinfection.Certain
populationshowever,haveagreaterriskforexposuretoTBandarethereforemorelikelytohavebeen
infected.
ConditionsthatincreasetheriskforTBinfectioninclude:
KnownexposuretoapersonwithTBdisease;and
Personswholiveorspendtimeincertaincongregateorinstitutionalizedsettingssuchas:
Prisons,jails,andcorrectionalfacilities
Ministry of Health - Guyana,

Pathogenesis
2011 | Tuberculosis Transmission and
36
Grouphomesorfacilitiesfortheelderly
Sheltersforhomelesspersons
Acuteinpatientandoutpatientcarefacilities
Overcrowdedhabitation
LivingorworkinginaTBhighprevalencecountry
TBDisease
TB disease develops when the immune system cannot keep the tubercle bacilli under control and the
bacilli begin to multiply unchecked. TB disease can develop very soon after infection (primary TB) or
many years after infection (reactivation or postprimary TB). In individuals without HIV coinfection,
about5%ofpeoplewhohavebeenrecentlyinfectedwithM.tuberculosiswilldevelopTBdiseaseinthe
firstyearortwoafterinfection.
Another5%willdevelopdiseaselaterintheirlives.Therefore,10%ofallpeoplewhohaveTBinfection
willdevelopdiseaseatsomepointintheirlives.Theremaining90%willstayinfectedbutfreeofdisease
fortherestoftheirlives.
RiskFactorsfortheDevelopmentofTBDisease
SomeconditionsappeartoincreasetherelativeriskthatlatentTBinfectionwillprogresstoTBdisease.
Theriskmaybe1.7timeshigher(aswithdiabetes)tomorethan10timeshigher(aswithHIVinfection)
forpeoplewhohavetheseconditionsthanforthosewhodonot.
ConditionsthatincreasetheriskforTBinfectionprogressingtodiseaseinclude2,3:
CoinfectionwithHIV
History of prior active TB or chest Xray finding suggestive of prior untreated or inadequately
treatedTB
RecentTBinfection(withinthepast2years)
Substanceabuse(e.g.,injectiondrugs,alcohol)
Extremesofage(particularlychildren<5yearsofage)andtheelderly.
Certainmedicalconditionssuchas:

Pathogenesis
37
Silicosis
Diabetesmellitus
Chronicrenalfailureoronhemodialysis
Solidorgantransplantation
Gastrectomyorjejunoilealbypass
Certaintypesofcancer(e.g.,leukemia,Hodgkinsdisease,orcancerofthehead
andneck)
Underweightormalnourished(i.e.,bodymassindex10%ormorebelowideal)
Useofimmunosuppressiveagents,suchas:
Prolongedcorticosteroidtherapy(15mgdailyforover4weeks)
Certaincancerchemotherapyagents
Antirejectiondrugsfororgantransplant
Tumournecrosisfactoralphaantagonists
CommonSitesforTBDisease:
Followinginfection,tuberclebacillicantravelfromtheoriginalsiteofinfectiontoothersitesinthebody
throughthelymphaticandcirculatorysystems.TBdiseasecanoccurinalmostanyorganofthebody:
PulmonaryTB(PTB)occursinthelungsandaccountsforthemajorityofTBcases
ExtrapulmonaryTB(EPTB)occursinplacesotherthanthelungs.
CommonformsofEPTB:
TBofthecentralnervoussystem(CNS),includesTBmeningitisandbraintuberculoma
TBofthespine(Pottsdisease)
TBofthecervicallymphnodes(scrofula)
TBpleuraleffusion
TBpericarditis
DisseminatedTB,includingmiliarytuberculosis
GenitourinaryTB

Pathogenesis
38
CopathogenesisofTBandHIV
HIVinfectionaltersthepathogenesisofTBbycompromisingthecellmediatedimmuneresponseofthe
host, and therefore, the hosts ability to contain the tubercle bacilli. For person with M. tuberculosis
infection,thepresenceofHIVincreasestheirriskfordevelopingTBdisease,from10%to50%overthe
courseoftheirlifetime.Whentheimmunesystemisweakened,thebodybecomeslessabletocontrol
themultiplicationandspreadoftuberclebacilli.Forthisreason,peoplewhoareinfectedwithbothM.
tuberculosisandHIVaremuchmorelikelytodevelopTBdiseasethanpeoplewhoareinfectedonlywith
M.tuberculosis.
TBdiseasecandevelopatanystageinthecourseofHIVdiseaseprogressionalthoughtheriskincreases
with advancing immunesuppression and decreases in persons receiving effective ART. In an HIV
infectedperson,TBdiseasecandevelopineitheroftwoways:
ApersonwhohasTBinfectioncanbecomeinfectedwithHIVandthendevelopTBdiseaseas
theimmunesystemisweakened.
A person who has HIV infection can become infected with M. tuberculosis and then rapidly
developTBdisease.
Additionally,insomeonewithHIV,thepresenceofotherinfections,includingTB,activatestheimmune
system,resultinginincreasedHIVreplicationandsubsequentacceleratedprogressionofHIVdisease.
Ministry of Health - Guyana, 2011 |
39
4
CASEFINDING
Finding TB cases is one of the hallmarks of a strong TB programme. Case finding involves identifying
persons in the community who are sputum smear positive and placing them on effective treatment.
Fromapublichealthperspective,sputumpositiveTBcasesaremoreimportantinthetransmissionof
the disease in the community. Finding these cases ensures that the transmission cycle of TB in the
communityisinterruptedandimprovesthelikelihoodofsuccessfultreatment.
TBcasescanbefoundamongthree maingroups ofpersons:contactsofTBcases,TBcasesattending
healthcarefacilities(inpatientandoutpatientscentresincludingHIVservices),andpersonsindetention
facilities. Therefore,tofindinfectiouscaseshealthcareworkersarerequired toensurethatactiveTB
cases name their contacts, and that these contacts are investigated for TB. In health facilities, health
careworkersmustbeparticularlyvigilantaboutidentifyingpersonswithsymptomssuggestiveofTBand
provide TB screening. Physicians must consider TB as a differential diagnosis in any person with
abnormalchestXrayswithorwithoutrespiratorysymptoms,whoareunresponsivetobroadspectrum
antibiotics.
Indetentionfacilitiesandothercongregationalsettingssuchassheltersforthehomeless,homesforthe
elderly and drug rehabilitation centres, health care workers must ensure that inmates and clients are
regularly screened for TB symptoms and investigated for active TB disease whenever necessary. Thus
maintainingaregisterofpersonswithrespiratorysymptomsisimportantforidentifyingpersonseligible
forTBscreeninginthesesettings.
SymptomsofpulmonaryTBdiseaseinclude:
Persistent,productivecoughfor2weeksormoreandsometimes;
Chestpainwhencoughingorbreathing;and
Bloodstainedsputumorhaemoptysis
40
ThegeneralsymptomsofTBdisease(pulmonaryorextrapulmonary)include:
Weightloss;
Malaise;
Fatigue;
Fever;
Nightsweats;and
Lossofappetite.
ThesymptomsofEPTBdiseasedependonthepartofthebodythatisaffectedbythedisease.
AnyonewithsymptomsofTBmustbeinvestigatedforactivedisease.TBcasefindinghastraditionally
beendescribedasactivecasefindingandpassivecasefinding.
InthepastactivecasefindingwasconductedbymassminiaturechestXraysofhighriskgroups.Thisis
a costly exercise and not presently recommended. Active case finding has a role in the screening of
contactsofTBcases,HIVinfectedpersonsandtheidentificationofpersonswithsymptomssuggestive
ofTBforscreening.Passivecasefindingisbasedonselfreferralofsymptomaticindividualswhoseek
treatmentatacarefacility.
TheNTPusesacombinationofactiveandpassivecasefindingtoidentifyinfectiouscases.Closelinkages
betweenprimarycarecentresandTBclinics/BMUarecrucialtoimprovedcasefinding.
41
5
DIAGNOSISOFTUBERCULOSIS
DiagnosisofLatentTBinfection
TBinfectionisatermusedtodescribepersonswhohaveviable tuberclebacilliintheirbodiesthatare
undetectablebyconventionallaboratorymethodsandcanonlybeestablishedbyimmunologicalmeans.
BydefinitionthesepersonsarehealthybutareatincreasedriskofdevelopingactiveTBdiseaselater.
TheTuberculinSkinTest(TST)alsoreferredtoasMantouxorPurifiedProteinDerivative(PPD)testhas
traditionally been utilized to diagnose TB infection. TST measures the inflammatory reaction that
develops after the injection of pure protein derivative (a mixture of antigens obtained by the
precipitation of the supernatant fluid of pure M. tuberculosis cultures) intradermally. TST cannot
distinguishbetweenactiveTBdiseaseandTBinfection;assuch,itcannotbeusedasadiagnostictool
foractivedisease.TSTisnotaspecificantigenforM.tuberculosisasmanyoftheseantigensareshared
withothermycobacteria.TheTSTmaygivefalsepositivereactionsinpersonsvaccinatedwithBCGand
those infected with nonTB mycobacterium. BCG vaccines are given shortly after birth, as part of the
Expanded Programme on Immunization (EPI) in Guyana. If BCG is given in infancy, a reaction of more
than 10 mm is rare after the age 5 years. In persons who are vaccinated at an older age, such as in
primaryschool,1525%willremainpositiveforaslongas2025years.
TargetedTSTisaneffectiveTBpreventionandcontrolstrategy.Itshouldbeutilizedamongpersonsat
highriskofdevelopingTBsuchashealthcareworkers,contactsofTBcases,andHIVinfectedpersons.
TSTisnotrecommendedforroutinescreeningofpersonsatlowriskofTB.Sincetheinterpretationof
theTSTresultisinfluencedbythepersonsHIVstatus,allindividualswhorequireaTSTshouldalsohave
anHIVtestdone.
Ifusedininitialdiagnosis,theTSTshouldbegivenatthesametimeastheotherTBdiagnostictestingis
initiated,andtheresultsmustbeinterpretedbasedonanindividualsHIVstatus,BCGvaccinationand
42
contacthistory.Apositivereaction,accordingtoWHOguidelines,meansthatapersonisinfectedwith
theTBbacteria.
TBinfectionisestablishedwhenanindividualhasareactiveTSTandactivediseasehasbeenexcludedby
microbiologicalandradiographicalmethods.
Recentlynewertechniquessuchastheinterferongammareleasingassays(IGRAs)havebeendeveloped
todiagnoseTBinfection.ThesetestsmeasurethereleaseofinterferongammabyTlymphocytesafter
stimulationwithM.tuberculosisspecificantigens.IGRAsarenotpresentlyavailableinGuyana.
Table1:Interpretationofthetuberculinskintests
SIZEOFINDURATION
0mm
INTERPRETATION
Uninfected
Anergy
5mm
Positivein:
HIVinfectedindividuals
PersonswithfibroticchangesonchestXraysconsistentwithpriorTB
Recipients
of
organ
transplants
and
those
on
chronic
immunosuppressivetherapy
10mm
Positivein:
Residents and workers of high risk settings including health care
workers,laboratorypersonnelandinmatesofdetentionfacilities
Drugusers
Children<5yearsofage
Children,adolescentsandadultsexposedtoaninfectiousadultTBcase
15mm
Positiveinapersonwithnohistoryofcontact
NB:ReactivityinadultsduetoBCGgivenininfancyisoftenlessthan10mm.(ATS/CDC)
Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis
43
DiagnosisofTBdisease
There are several steps to diagnosing TB disease, including obtaining the TB cases history, and
conductingaphysicalexamination,mycobacteriologicalassessmentandradiographicexamination.
Comprehensivehistory
This is important in ascertaining the level of risk a person has for TB as well as identifying symptoms
compatible with TB disease. It includes social, family, medical and occupational information on the
person.Inaddition,thepersonshistoryshouldincludethefollowing:
ExposuretoapersonwhohasinfectiousTB
ChroniccoughorothersymptomsofTBdisease
PastTBinfectionorTBdisease
HIVstatus
AnyriskfactorsforTBinfectionanddevelopingTBdisease
HistoryofBCGvaccine
Physicalexamination
Aphysicalexaminationhelpstoelicitsignsofthediseasesuchastachypnea,presenceofadventitious
sounds on auscultation, weight loss and enlargement of lymphnodes. These signs are not
pathopneumonic of TB but are present in cases with significant respiratory diseases. As active TB is a
clinical, laboratory and/or radiographic diagnosis, many practitioners omit conducting a thorough
physicalexaminationandmayfailtonoticesignsofcomorbidconditions.
Mycobacteriologicalexamination
In most cases the laboratory diagnosis of TB requires identifying M. tuberculosis in clinical specimens
either by microscopy, cultures or molecular methods. Clinical specimens commonly used for TB
diagnosis includes sputum, aspirates from TB lesions, cerebrospinal fluid (CSF), blood, urine,
bronchoalveolarlavageandgastricaspirates.MicroscopicexaminationofsputumforAFBisbyfarthe
mostcommonlaboratorymethodusedtodiagnoseTB.WhilesputummicroscopycannotdistinguishM.
tuberculosisfromotherAFB,thepresenceofAFBinasymptomaticpersonisstillastrongindicationthat
44
M.tuberculosismightbethecauseofthepersonscondition.CaremustbeexercisedwithTBHIVco
infected persons as they are quite likely to have nonTB mycobacteria (NTBM). TB culture helps to
distinguishM.tuberculosisfromNTBMs.ItisnotrecommendedforallcasesbutonlythosewhoareAFB
smearnegative,HIVinfectedandforcaseswhomayneeddrugsusceptibilitytesting.
AllcasessuspectedofhavingTBshouldhaveatleast2sputumsmearsformicroscopy.Mostoftenthree
sputum smears are requested: two spot and an early morning specimen are taken. Cases must be
properly instructed to produce good sputum specimens. Health care workers must also examine the
specimentoensurethatitisofgoodqualitybeforesendingittothelab.Thishelpstopreventrejection
ofspecimenbythelaboratory.
InGuyanaatleastonepositivesputumsmearbymicroscopyissufficienttoestablishthediagnosisofTB
andinitiatetreatment.Thesensitivityofsputummicroscopydependsontheloadoftuberclebacilliin
thesputum.Somecaseshaverelativelysmallamountsoftuberclebacilliintheirsputumandhencemay
have negative smears. In these cases the presence of clinical manifestations and radiological signs
suggestiveofTBhelptoestablishadiagnosisofsputumsmearnegativeTB.ThesecasesshouldhaveTB
culturesdone,whichmaybepositive.Everyeffortshouldbemadetoensurethatanetiologicdiagnosis
ofTBisestablishedinthesecases.
45
Table2:Indicationsanddiagnosticrequirementforsputummicroscopyandculture
Test
Indication
Sputummicroscopy Allcaseswithcough>2weeksdurationwithor
withoutothersymptomsofTB
Allcaseswithprolongedcoughthatis
unresponsivetobroadspectrumantibiotics
HIVinfectedpersonswithanycough
unresponsivetotreatment
TBculture
SputumsmearnegativeforTB
TBdefaulters
DiagnosticRequirement
Atleast3sputum
sampleson
consecutivedays
AFBdetectedinat
least1sputum
sample
Atleast1sputum
sampleforculture
TBtreatmentfailures,relapse
PersonsexposedtoMDR/XDRTBcases
Radiographicexamination
Chest radiography is not diagnostic of TB. Several studies have shown that there are no radiographic
patternsthatarepathogenicofTBlungdisease.Manydiseasesofthelungshowasimilarradiographic
appearance and can easily mimic TB. Similarly, the lesions of PTB can take almost any form on a
radiographicpicture.
Comorbidity with HIV infection and TB further diminishes the reliability of chest radiography for the
diagnosis of PTB. HIVinfected persons especially those with low CD4 count may have atypical
radiographic patterns of PTB: Hilar or mediastinaladenopathy, middle or lower lung field infiltrates.
AbsenceofpulmonaryinfiltratesandcavitiesarealsocommoninHIVinfectedpersons.TheirchestX
raysmaybenormalorhaveminimalchanges.ThusinGuyana,thephysicianorMedexneedstohavea
highindexofsuspicionforTBinthecaseofHIVinfectedpersons.
Chestradiographyisutilizedintheinitialdiagnosistohelpto:
LocalizeandcharacterizetheextentoflunginvolvementinTBcases
46
IdentifycasesforinvestigationofTB
DiagnosesputumsmearnegativemiliaryandpulmonaryTBinchildren
AllcasessuspectedofhavingTBorthosediagnosedwithTBshouldhaveaposterioranterior(PA)chest
radiographdoneifpossible.
For cases already on treatment chest Xrays serve to monitor the evolution of pulmonary lesions and
should be repeated at the time of treatment reduction (completion of the initial phase of treatment)
andwhentreatmentconcludes.Additionally,chestXraysareslowtoreflectchange;thusacasemust
bemonitoredclinicallyandwithsputumforAFBmicroscopyifwarranted.
47
PatientPresentat
HealthFacility
(Respiratory
Symptomatic)
Sputumsmear+veTB
StartTBTreatment
Conductphysicalexamination
Requestsputummicroscopy
RequestChestXRay
RequestHIVtest
Sputum+veTB/HIVcoinfected
RequestsputumcultureforID
StartTBTreatment
PrepareforART
SputumsmearveTB/HIV+/
RequestsputumcultureforID
StartTBTreatment
PrepareforART
Figure16:Flowchartfortheinvestigationofcaseswithrespiratorysymptoms
48
DiagnosisofMDRTB
MDR TB is a term used to describe M.Tuberculosis (M.TB) isolates that are resistant to both isoniazid
and rifampicin. Cases who have failed a regimen containing rifampicin and isoniazid or who have
relapsed while completing a full course of antiTB therapy are at high risk of having MDR TB. Drug
susceptibilitytesting(DST)shouldbeperformedforallcasesforretreatment:relapse,treatmentfailure,
treatmentafterdefaultandMDRTBsuspect(sputumpositivePTBaftersupervisedretreatment)cases.
ThereisnoevidenceatthisstagetorecommendedDSTtoallTBHIVcoinfectedpersons2,3,11.
DrugsusceptibilitytestinginGuyanaisperformedeitherbyconventionalmethodsinvolvingtheuseof
solidculturesorbymoleculardiagnosis(theHainTest2,3)directlyfromclinicalmaterialofAFBsputum
positive cases. The latter is a rapid method, which is now available in Guyana, and can give a result
within48hours.
Table3:IndicationforDST
Sputumpositive:
Relapsecases
Treatmentfailure
Treatmentafterdefault
Aftersupervisedretreatment
ContactsofinfectiousMDRcaseswithrespiratorysymptoms
49
6
LABORATORYSERVICES
NationalPublicHealthReferenceLaboratory
TheNationalPublicHealthReferenceLaboratory(NPHRL)isGuyanasispremierelaboratoryandserves
asthecoreofthenationalpublichealthlaboratorysystemwithdiseasepreventionandcontrolasatop
priority.TheNPHRLremainssteadfastinprovidingscientific,analytic,anddemographicinformationthat
is crucial to the identification of infectious microorganisms responsible for disease outbreaks. The
NPHRLexecutesthefollowingactivities:
Servesasthenucleusofthenationallaboratoryservices;
Conductsadvancedlaboratorytesting;
Hasthecapacitytoconductqualityassuranceandproficiencytestingforperipherallaboratories,
and
Serves as a reference facility for haematology, chemical pathology, parasitology, microbiology
andmolecularbiology.
TheNPHRLconsistsofthefollowingdepartments:
Microbiology
Mycobacteriology(TB)
MolecularBiology
ImmunologyandClinicalChemistry
Haematology
EmergencyPreparednessandResponse
QualityAssuranceSafetyandTraining
Administration
50
TBLaboratoryLevels
Level1laboratory:Suitableforsmearmicroscopyonly,includingallmicrocopysites,andperipheraland
regionallaboratories.
Level 2 laboratory: Performs AFB smears and cultures with identification of M.tuberculosis. It differs
fromLevel1withregardtothefollowingspecifications:
Laboratory personnel have specific training in handling pathogenic agents and are directed by
competentscientists
Accesstothelaboratoryislimitedwhenworkisbeingconducted
Certain procedures in which infectious aerosols or splashes may be created are conducted in
biologicalsafetycabinetsorotherphysicalcontainmentequipment
TheNPHRLiscategorizedasalevel2laboratory.
NationalTuberculosisLaboratoryScreeningServices
LaboratoryscreeningservicesforthedetectionofTBareconductedatallcategoriesofthelaboratory
systemwithinGuyana.Sputummicroscopyisconductedathealthcentres,andatdistrict,regionaland
thecentral(NPHRL)laboratories.Additionally,culturesandDSTareperformedattheNPHRL.Caseswho
receive positive sputum for AFB microscopy result are referred to the nearest chest clinic in the
respective administrative region. Medical officers at regional TB treatment sites can send sputum
samples to the NPHRL for culture and DST. All laboratories that perform TB microscopy and culture
servicesarerequiredtosubmitmonthlyreportsoftheiractivitiestotheNTPprogrammemanagervia
theTBLaboratoryCoordinator.
SputumCollectionProcess
Laboratory examination of sputum must be performed on all individuals where PTB and/or EPTB are
suspected. Other specimens such as CSF, urine, tissues and aspirates may be submitted as required.
SwabsarenotsuitableforTBtesting.
Ministry of Health - Guyana, 2011 | Laboratory Services
51
An initial sputum specimen should be collected before administration of antiTB therapy. Sputum
collectionshouldtakeplaceintheopenair(orwellventilatedroomusedonlyforthispurpose)taking
intoconsiderationtheneedforprivacy.Aclean,leakproof,screwcappedplastic,disposablecontainer
(do not use wax container) should be utilised for sputum collection. A specimen collected under
supervision of a trained health care worker is likely to yield better results than a specimen collected
withoutsupervision.
Three sputum specimens should be collected (within 24 hours where possible using the spot/early
morning/spotsystem):
1stspecimenshouldbeobtainedonthespot,followingtheinitialinterview.Thecollectionofthis
1stspecimenmustbeunderthesupervisionofahealthcareworker
2ndspecimenshouldbeobtainedwithin24hours.TheTBsuspectisprovidedwithacontainer
forcollectionofanearlymorningspecimenathome,thattheythenbringtotheTBtreatment
site
3rdspecimenisanotherspotspecimenobtainedfromtheTBsuspectataTBtreatmentsite.
Generalproceduresforsputumcollection:
ExplaintothesuspectedTBcasethereasonsforsputumcollection
Complete the Laboratory Request for Mycobacterium Tuberculosis Investigation form
(Appendix4) withalltherequiredinformation.Placelabelontheside(notonthecover)of
the sputum container. The label must have the same name and identification number and
specimendateaswrittenontheform
Ensurenooneisstandinginfrontofthepersonwhencollectingasputumsample
Explaintothepersonthatspitorsalivaisnotsuitableandtoavoidcontaminatingtheoutsideof
the container with sputum (if outside the container is contaminated, discard and repeat
procedureusingafreshsputumcontainer)
Priortocollectingasputumsample,casesshouldberequested tofirstrinse theirmouthsout
withwateriftheyhavebeeneatingfoodimmediatelypriortocollection
52
Askcasetocoughdeeply(demonstration,ifpossible),clearthebackofthethroatandspitout
sputuminthecontainer;repeatthisprocedureuntilabout510mlofsputumisobtained
Youmayassistthecasetoproduceanadequatesamplebytappinglightlyonthebackfromthe
lowerchesttotheshoulderswhilethecasecoughs.Ensurethatthecaseknowshowtosecure
thelidofthesputumcontainer
Sputumpostcollectionprecautions:
Placelidonsputumcontainerandclosefirmly
Washhandswithsoapandwater
Specimensthatwillnotreachthelaboratorywithinonehourofcollectionmustberefrigerated
(240C);theycanberefrigeratedupto24hourspriortobeingtransportedtothelaboratory
EachspecimenmustbeaccompaniedbyacompletedLaboratoryRequestforMycobacterium
TuberculosisInvestigationform.
Transportationofsputumspecimens
Sputumsamplesfromthefieldtothelaboratorymustbeplacedinsecureplasticbags.Laboratoryforms
(seeAppendix4)shouldbekeptseparately.Thesecontainersshouldbekeptinanuprightpositionin
sturdytransportcarrierscontainingicepacks.Thesamplesshouldnotbeexposedtosunlight.The
preparationofsamplesfortransportisimportantfordiagnosisforpatientsandsafetyofhealthcare
workers.
ProtocolforCultures/DrugSensitivityTesting(DST)
The requisition accompanying the specimen for culture should be clearly state Culture is being
requested.
Possiblereasonsforcultureincludethefollowing:
HIVcase;
Treatmentfailure;
Relapse;
53
Defaulter;
Children;
Sputumnegative;
MDRsuspect;
MDRcontact;and
MedicalStaff
PossiblereasonsforDSTincludethefollowing:
Treatmentfailure;
Relapse;
Defaulter;and
SuspectMDRTB
All specimens for culture will be inoculated on Lowenstein Jensen (LJ) media and tested using the
NitrateReductaseAssay,whileonlysmearpositivespecimenswillbetestedusingtheHainLineProbe
Assay.Onlyonespecimenpercasewillbecultured.
Turnaroundtime:
Smearresultsareavailablewithin24hoursofspecimenreceiptinthelaboratory
Cultureresultsareavailablewithinapproximately8weeks
SmearpositiveLineProbeAssaywillbebatchedandconductedonceperweek(urgentrequest
forthisassaycanbefacilitatedandshouldberequestedthroughtheHeadofTBDepartmentat
theNPHRL)
SampleRejectionCriteria:
SamplesthatarereceivedbytheNPHRLandregionallaboratorieswillberejectedbasedonthe
followingcriteria:
Labellingerror:
Unlabelled
54
Mislabelled
Improper/incorrectcontainer
Leakingorspilledspecimen
Requisitionerror:
Lackofrequisitionform
Incorrectcaserequisitionorname
Insufficientquantityofspecimen
Overfilledcontainer
Improperstorageofspecimen
Inordinatedelayinspecimentransport
Salivanotsputumcollected(somecasesareunabletoproducesputum;inthiscaseanoteon
therequisitionformshouldindicatesuch)
Contaminatedspecimen(foodparticlespresentinspecimen)
QualityAssurance
Quality assurance is an essential component of the TB control programme. Laboratory quality
programmes are designed to assure clinicians of accurate reporting for case management, and to
guaranteereliabilityofpublichealthdataforepidemiologyanddiseasecontrolprogrammes.Because
opportunisticAFBlungdiseaseisanindirectmeasureofHIVprevalence,thesestatisticswillalsoaidin
monitoringprevalenceofadvancedHIVinfection.
The NPHRL is responsible for employing a quality management approach to TB diagnostic testing
through participation in internal and external quality management programmes supervised by a
laboratory professional. In the absence of a laboratory physician, this responsibility is delegated to a
seniortechnologistunderthesupervisionofaTBControlphysician.
55
ThequalityprogrammewillincludeproficiencytestingforAFBtechnologistsandregionalMicroscopists
through external proficiency testing schemes. External programmes will be supplemented by internal
proficiencytestingasrequired.
TheNPHRL willalsocomplywithTBtestingstandardsoftheWHO/PAHOforlevel2serviceincluding
targetedturnaroundtimesforsmearandculturereports.
An accredited reference laboratory (Health Canada or college of American Pathologist) will provide
proficiency testing samples for antimicrobial susceptibility testing and, identification of TB
mycobacteriumandnonTBmycobacterium.
TheNPHRLwillconductthefollowingQAactivities:
EnsurethataQAprogrammeisincludedintheNPHRLlaboratoryproceduremanual
EnsurethattheNPHRLmaintainscompliancewithqualitypolicies
Ensurethatregionallaboratoriesinexternalproficiencytestingprogrammes
Ensure that all regional microscopists participate at least twice annually in external proficiency
testingprogrammes
Ensure that all laboratories health centers and health posts complies with international biosafety
proceduresandobserveuniversalprecautionsatalltimes
Ensure that all laboratories health centers and health posts observe safe disposal practices of
hazardouswaste
Conduct regular inspection of all TB laboratory related sites and provide comprehensive report to
the Director of Laboratory Services and National TB Programme Director (NTP Programme
Manager).
Coordinate/conducttrainingprogrammesandcontinuingeducationalsessions
Theregionallaboratoriesandhealthcentres/healthpostswillconductthefollowingQAactivities:
Compliancewithstandardprocedures
56
Compliancewithinternationalbiosafetyprocedures
Controlandmaintainofqualitycontrolrecords
Observesafedisposalpracticesofhazardouswaste
Participateinexternalandinternalproficiencytestingprogrammes
Participateincontinuingeducationsessions
DocumentandsubmitoperationalreportstotheDirectorofLaboratoryServicesandNationalTB
ProgrammeDirector(NTPProgrammeManager).
57
7
DIRECTLYOBSERVEDTREATMENTSHORTCOURSE(DOTS)
TheNationalTBDOTSprogrammecomplieswiththeWorldHealthOrganization(WHO)standardsasa
prescribed, costeffective strategy to detect, treat and cure TB.DOTS is the most costeffective
programmeforpreventingdeathsfromTBdiseaseinthedevelopingworld.
TherearefiveessentialelementsofaneffectiveDOTSstrategy:
Politicalcommitmentandfunding;
IdentificationofallinfectiouscasesofTBusingsputummicroscopy;
ProvisionofastandardcourseofmultidrugtreatmentforallTBcases;
Observation ofallsputumpositivecases/casestakingtheentirecourseofallantiTBmedications
untilTBiscured;and
Standard recording, reporting and cohort analysis so that all TB cases can be monitored during
treatment.
DefinitionofDOTS
Observationbyahealthcareproviderorotherresponsiblepersonasthediseasedorinfectedindividual
ingestseachdoseofantiTBmedication.
DOTS is a method used to ensure adherence of TB cases to antiTB treatment. It is necessitated
worldwide due to the high number of TB cases who defaulting from appropriate treatment.
ImplementationofaDOTSprogrammedecreasesthecourseoftheillness,preventsthespreadoftheTB
diseasetootherorgansinthediseasedpersonandtothoseincontactwiththediseasedperson,andin
someinstances,preventstheemergenceofmultidrugresistantstrainsofM.tuberculosis.
DOTS requires that an individual treatment supporter observe a TB case intake of the right antiTB
drugs,attherightdoses,andattherightintervals.DOTSalsorequiresregularsupervisionandsupport
which helps to maintain frequent communication between the case and a health care worker or
58
treatmentobserver.ThisprovidesmoreopportunitiesforTBeducation,identificationandresolutionof
obstacles to treatment, and early identification of nonadherenceultimately allowing health care
workers to employ interventions to return the case to the prescribed treatment. Regular supervision
alsoallowsthepromptdetectionandmanagementofadversedrugreactionsandclinicalworseningof
TB.
Adherence
Table4:Factorsaffectingadherenceandsuggestedinterventions2,3,12
Factors
Constraints
InterventionstoImprove
Adherence
Socioeconomic
Limitedsocialsupport
Assessmentofsocio
fromfamilymembersand
economicneed:availabilityof
thecommunity
socialsupportsystem,
unstableliving
housing,food,andlegal
measures:Written
circumstances
Culturalandlaybeliefs
policies/legislationtoguide
HealthCareWorkers)
aboutillnessand
treatment(stigma)
Provisionoftransportationor
Ethnicity,gender,andage
moneytotraveltotreatment
Highcostoftransportation
settings
totraveltotreatment
Encouragepeerassistance
setting
Mobilizationoffamily,and
Sellingandpurchasing
illicitdrugs
communitysupport
optimizingthecooperation
betweenservices
Educationofthecommunity
andhealthcareworkersto
reducestigma
Ministry of Health - Guyana, 2011 | Directly Observed Treatment ShortCourse (DOTS)
59
Healthcare
()Poorlydeveloped
infrastructure
healthservices
Inadequaterelationship
betweenhealthcare
workerandcase
Healthcareproviderswho
Uninterrupted,ready
availabilityofhealth
information
implementationof
managementprocesses
aimedatimprovingtheway
areuntrained,
healthcareworkerscarefor
overworked,inadequately
caseTBcases
supervisedor
Onsitepeersupportcase
unsupervised
organizations/groups
Inabilitytopredict
Managementandtreatment
potentiallynonadherent
ofTBdiseaseinconjunction
cases
withcaseTBcases
Multidisciplinaryapproach
toTBcare
Intensivestaffsupervision
andtraininginadherence
monitoringanduseofDOT
Physicalandmental
Asymptomaticcases
SupportivecounsellingS
status
UseofIllicitdrugs,alcohol
Referraltotreatmentfor
substanceandalcoholabuse
ortobacco

Depressionandother
Provisionofinformation
aboutTB,antiTB
psychological
medicationsandtheneedto
manifestationsincluding
adheretotreatment
60
stress
Relationshipbetweenthe
Forgetfulness
clientandtheworkerthat
willaffectchangeintheclient
Mutualgoalsetting
Memoryaids,reminders
(letters,telephonecallsor
homevisitsforcaseswho
default),incentivesand/or
reinforcements
Treatment
Complextreatment
Educationonuseof
regimen
medicationsandadverse
Adverseeffectsof
treatment
Toxicity
effectsofmedications
Adherenceeducation
Useoffixeddose
combinationpreparations
Tailortreatmentsupportto
needsofcasesatriskofnon
adherence
WrittenContractagreement
(toreturnforclinic
appointmentortreatment
Continuousmonitoringand
reassessment
61
Consequencesofnonadherence
NonadherencetoantiTBmedicationregimenscanresultinthefollowing:
Deteriorationofcasephysicalcondition
Increaseinmorbidityandmortality
EmergenceofdrugresistanceTB(MDRTB)
DecreaseinTBcurerates
Increaseindurationoftreatment(defaulting)
Continuedspreadofthediseasewithinthecommunity
All phases of treatment must be supervised, whether or not the initial or continuation phase of
treatmentisconductedinhospitalorathomeunderthesupervisionofaDOTSworker.Dailysupervision
oftreatmentadherencecanbeprovidedbythefollowingpersons:
TBoutreachworker(DOTSworker)
Otherhealthcareworker(medicalofficer,nurse,technologist,orhealthsupportworker)
Familymember
Friendandothercloseassociate
Memberofasupportgroupfromtheclinicorcommunity
Volunteer
Essentialcomponentsforcasemanagement
ItisimportanttonotethatinordertosuccessfullycarryoutDOTS,twobasicskillsareneeded:
Good communication is essential, since a lapse in communication can have serious
consequencesandcanleadtoincompleteorinadequatetreatmentresultingin:
AdditionalpersonsexposedtoTB
HospitalizationwithseriouscomplicationsofTB
DevelopmentofMDRTB
CollaborationisnecessaryforconductinggoodTBsurveillanceandcasemanagement:
AnuninterruptedsupplyofantiTBdrugs
62
EducatethecaseaboutthebenefitsoftakingtheantiTBdrugs
Explainthedurationoftreatmentandthereasonforcompletingtreatment
Ensurethecaseisnottakingthetabletsonanemptystomach
Havedrinkingwaterorjuice/liquidsreadytofacilitateswallowingofthetablets
Observethecaseswallowthetabletsasprescribed
ThemainadvantageofDOTSisthatantiTBtreatmentiscarriedoutentirelyunderdirectsupervision.
Thisprovidesbothagreaterassurancethattheprescribedmedicationshaveactuallybeeningestedand
an opportunity to assess whether the case is clinically improving. Because there is regular contact
between the case and the treatment supporter, adverse drug effects and other complications can be
identified quickly and managed appropriately. Moreover, such case management can also serve to
identifyandassistinaddressingthecountlessotherissuesexperiencedbypersonswithTBdisease,such
aspoornutritionandinadequatehousing.
Healtheducation
HealthcareworkersmustbediligentaboutinstructingandeducatingTBcasesandtheircontacts.This
shouldincludethefollowing:
WhatisTB
HowTBdiseaseisspread
WhatcanbedonetolimitthespreadofTBdisease
CurabilityofTBdisease
Whatmedicationsareusedandforhowlong
Howtreatmentistobefollowed
Expectedsideeffectsofmedications
Communityparticipation
Incommunitybasedcare,aTBtreatmentsupportersharestheresponsibilityforsuccessfulcompletion
oftreatmentwiththecase.Heorsheprovidessupervisedtreatmentaswellassocialandpsychological
63
support. Communitybased care can help to expand access to TB care but requires a strong reporting
system, access to laboratory facilities, and a secure drug supply. Treatment supporters need regular
contactwithNTPstafftoensurethatmotivationandsuccessfuloutcomesaremaintained.
Effectivecommunitybasedcarerequiresthefullengagementofhealthcareworkers,linkagesbetween
publicandprivatesectorsofthehealthsystem,anduniversalaccesstohealthservices.
ManagementofmissedAppointments
ThefollowingprocessismanagedbythenurseinchargeandguidesthemanagementofTBcaseswho
missedanappointment:

Appointments
2011 | Management of missed
64
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
NB:Acaseeisconsideredlosttofollowupifnocontacctwasmadeaf
afterthreeatteempts(viatelep
phonecallsand
d/or
visits).
MissedAppointmentFFollowupFo
orm(seeAppeendix14)

Appointments
2
2011
| Manag
gement of misssed
65
5
HelpfulhintsforthegradualintroductionofDOTS
Health care workers and programme managers can organize the gradual introduction of DOTS by
followingsomehelpfulhints:
Learn as much as possible about your cases beliefs and attitudes about TB and TBHIV co
infection and the barriers to treatment (his is an important aspect of assessment in order to
determineeducationalneeds/formulateatreatmentplan)
Berespectfulofyourcaseandtheirculture
Knowyourcaseshistory
Becreativeandflexibleindetermininghowyourcasescanbestbebroughtintoplanningtheir
treatment
Recognizethecasesroleinmakingdecisionsabouttreatment
Involvethecaseinproblemsolving
Do everything possible to educate, support, influence and persuade the case to take the
prescribedmedicationtocompletetreatment
Provide support for case and outreach workers from the healthcare team and non
governmentalorganizations
ClarifyinstructionstothepersonwhowillprovidetheantiTBdrugsincludinghow,whenand
wherethedrugsaretobeaccessed
Outlineclearinstructionstothecaseaboutcontinuingthetreatmenteitherbyvisitingahealth
centre for DOTS, or through a caregiver/DOT worker who will administer DOTS at the cases
home
ThehealthcareworkerwhomonitorsDOTSwillalsoarrangeforfollowuptesting,i.e.,sputum
collectionandtransporttothecentrallaboratory.
N.B.:Onlyrecommendeddrugcombinationsmustbeused.Itisimportanttoeducatethecasethatthe
fullcoursemustbecompleted.

Appointments
2011 | Management of missed
66
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
ChiefM
MedicalOfficer,
MinisstryofHealth
Dirrector(Pro
ogrammeManager)),
NationalTube
erculosisP
Programm
me
HeaadofChesstClinics((PrincipalTB
Officer)
Regions
GeorgettownChesstClinic
RegionalD
DOTSSupervisors
DOTTSSupervisors
DOTSWorrkers(TBO
D
Outreach
Wo
orkers),TreatmentSSupporterrs
DOTSWorkers(TBOutreach
Workers)
Figure17
7:Reportingsttructureofthe
eDOTSprogram
mme
Atthenattionallevelth
heDirectorofftheNTPoveerseestheimp
plementation
nandsustainaabilityoftheDOTS
strategyh
howeverthe DOTSCoordinatorisdirecctlyinvolved intheimplem
mentationan
ndsustainabilityof
theDOTSstrategyand
dupdatestheeNTPDirecto
orregularly.TTheDOTSCoo
ordinatormo
onitors,guideesand
providesssupporttotheRegionalDO
OTSSupervisorsandGeorgetownChesstClinicDOTSSSupervisors.
AttheGeorgetownCh
hestClinictheeDOTSSuperrvisorsdirectlysupervise,m
monitor,guid
deandsupportthe
DOTSWo
orkers(TBOuttreachWorkeers).DOTSwo
orkers,DOTS Supervisors andRegionalDOTSSupervvisors

Appointments
2
2011
| Manag
gement of misssed
67
7
alsoreporttotheHeadoftheTBChestClinic/BMU.TheRegionalDOTSSupervisorswillalsoreportto
theRHOsasnecessary.
Attheregionallevel,theRegionalDOTSSupervisorsdirectlysupervise,monitor,guideandsupportthe
TB Field Outreach Workers (DOTS Workers) in their specific areas.. However, it is not feasible for an
Outreach Worker to manage more than one patient in any of the hinterland regions due to the
topographyanddistributionofsparsepopulation.TheCommunityapproachisapplicabletobeutilized
especiallyinthehinterlandandoutlyingareas.ThismodelentailstheinvolvementofCommunityHealth
Workers,Volunteers,Familymembers,CommunityLeaderstotaketheroleofTreatmentSupporterin
their community. This model will shift some of the daily observation of treatment from a specially
employed health worker to a responsible person at the community level. These individuals will be
managedbyRegionalSupervisorsattachedtoTBtreatmentsites.
68
8
TBCONTACTINVESTIGATION
ThereisahighlikelihoodthatapersonwithsmearpositivepulmonaryTBwilltransmitTB.Therefore,
promptandthoroughcontactinvestigationisessentialforthecontrolofTB.
EveryTBindexcaseincludingchildrenrequirescontactinvestigation(seeChapter4:CaseFinding)and
HIVtesting.OncetheTBindexcaseisidentifiedallcontactsshouldbetestedforTB.
Contacts should be given a TST. Contacts with a positive skin test result (10mm) in healthy nonHIV
infectedadultsandchildren.SignsorsymptomsofTBdiseaseshouldbeevaluatedcarefullytoruleout
activediseasebeforeinitiatingpreventivetherapy.
If skin testing of close contacts reveals a rate of positive skin test results (the infection level) in this
groupexceedsthatexpectedforthe general population,theinvestigationshould proceedto thenext
circleofcontacts(thosewhocomeincontactwiththecase,butlessfrequentlythantheclosecontacts).
Thismayincludefrequenthouseholdvisitors,closerelatives,andfriends.Theinvestigationshouldstop
whentherateofskintestpositivityinthetestedgroupisnohigherthanthatexpectedforthegeneral
populationinthecommunity.Ingeneral,contactswhomayposeagreaterrisktoothers(e.g.,teachers,
hospital nursery workers, other health care workers) or who are at greater risk themselves (e.g., HIV
infectedpersons)shouldbetestedeventhoughtheymaynotnecessarilybeclosecontacts2,3,12.
ConcentricCircleApproach
Household/Residence
Environment
69
IndexCase
Household/Residence
Environment
Leisure/Recreation
Environment
Work/School
Environment
IndexCase
CloseContacts(HighRisk)
CasualContacts(MediumRisk)
Figure18:Concentriccircleapproach
Ministry of Health - Guyana, 2011 | TB Contact Investigation
70
Keyelementsofcontacttracing
DeterminetheInfectiousPeriod
Establishinganinfectiousperiodhelpstofocustheinvestigationonpersonsmostlikelytohavebeen
exposed and infected. Published guidelines on estimating onset of infectious period are essentially
based on expert opinion, but give some parameters for NTPs to consider when establishing country
specificguidelines.
TheinfectiousperiodonsetisestimatedbasedonTBcasefactors,whichinclude:
DatewhenTBsymptomsbegan;
DateoffirstdiagnostictestconsistentwithTB(e.g.,sputumforAFBorchestXray)
TheinfectiousperiodisgenerallyconsideredclosedwhentheTBcase:
Has3consecutivesputumsmearsthatarenegative;
HasbeenonappropriateTBtreatmentfor2weeks;and
Isshowingclinicalresponsetotreatment,withsymptomsdiminishing.
InterviewtheTBCase
The purpose of the interview is to obtain information from the case related to onset of symptoms in
ordertohelpestablishthepotentialinfectiousperiodaswellastoidentifypersonsandplaceswhere
the TB case spent time prior to diagnosis. Generally, several interviews will be needed to obtain this
information.
Conductingtheinterview:
Explainthepurposeoftheinterviewtotheindexcase;
Explainconfidentiality;
Establishindexcasescurrentunderstandingofhis/herTBdiagnosis;
ClarifyanymisinformationandprovidecaseinformationaboutTB,howitistransmittedandthe
importanceoftakingtreatmentasprescribedforthefullduration;
71
DeterminecasesTBsymptomhistory;
Identifytheplaceswheretheindexcasespenttimeduringtheperiodhe/shewassymptomatic;
and
Identifynamesandlocatinginformationofpersonswhospenttimewithindexcaseduringthe
periodthatshe/hewassymptomatic(contacts).
PrioritizeContacts
Highprioritycontactsincludethosemostlikelytohavebecomeinfectedduetothequalityofexposure
or those most likely to progress to TB disease once infected (see list on pages 1718). These are the
individualstotargetforevaluationwhentheNTPimplementscontactinvestigation.
In general, contacts who may pose a greater risk to others (e.g., teachers, hospital nursery workers,
otherhealthcareworkers)orwhoareatgreaterriskthemselves(e.g.,HIVinfectedpersonsandchildren
<5yearsofage)shouldbeprioritizedfortestingeventhoughtheymaynothavehadclosecontact.
Forlargersettinginvestigations(e.g.,schoolandworksites),itisadvisabletogivepriorityclassifications
ofhigh,mediumandlow,withcriteriaforeachclassificationclearlydefined.ThiswillenabletheNTPto
keepthefocusonthosewithahighpriorityclassification4
ChildContact
HighpriorityshouldbegiventoexaminingcontactswhoarechildrenorwhoareHIVinfected.Newly
infected children are at high risk for miliary TB and possibly TB meningitis, which can develop within
weeksunlessthechildisgivenpreventivetherapy.InHIVinfectedpersons,TBinfectionmayprogress
rapidlytoTBdisease.Insomeinstances,theintervalbetweenexposureandthedevelopmentofdisease
hasbeenasshortas20days.Therefore,contactswhoarechildrenorwhoareHIVinfectedshouldbe
givenpreventivetherapyregardlessofskintestresults12.
IfachildisdiagnosedwithTB,thechildsfamilymustbeexaminedtoidentifythesourcecase,orwho
mayhaveinfectedthechild.Thesourcecasemaybeaparent,agrandparent,orsomeoneelseinclose
72
contact with the child who may have infectious TB. Additionally, the investigation should attempt to
identifyotherswhomayhavebeeninfectedbythesourcecase.
ManagementofchildcontactsofinfectiousTBcases:
I.Tuberculinpositivechildren:
Ifwell,offerpreventivetherapyfor6months;
Ifunwell,furtherevaluateforpossibleorprobabledisease,includingadetailedhistoryand
chestXrayifpossible;and
ProvidetreatmentforTBdiseaseifconfirmedorthereisahighindexofsuspicion.
II.Tuberculinnegativechildren:
Ifwell,offerpreventivetherapyfor2monthsandrepeatthetuberculintest
Ifpositiveattwomonths,continuepreventivetherapyforatotalof6months
Ifnegativeattwomonths,discontinuepreventivetherapy
Ifunwell,furtherevaluateforpossibleorprobabledisease,includingadetailedhistoryand
chestXrayifpossible
ProvidetreatmentforTBdiseaseifconfirmed.
III.Whenthetuberculintestisnotpossible:
ifwell,educatethecaregivertoreturnwiththechildshouldthechildbecomeill
suggestaroutinefollowupin1month
ifunwell,obtainahistoryandexaminationforTBandincludeachestXrayifpossible
TreatforTBforsix(6)monthsifdiseaseisconfirmed.
AllprovidersofcareforcaseswithTBshouldensurethathighriskpersons(especiallychildren<5yrsold
andchildrenandadultswithHIVinfection)whoareinclosecontactwithcaseswhohaveinfectiousTB
are evaluated and managed in line with national guidelines. Children <5 yrs old and persons with HIV
infection who have been in contact with an infectious case should be evaluated for both latent and
activeTB.AllHIVpositivepersonsregardlessofage;apositiveTSTisdefinedbyWHOas5mm.
73
ChildContactsofInfectiousMultidrugResistantTuberculosis(MDRTB)Cases
SincebydefinitionMDRTBisresistanttobothisoniazidandrifampicin,itisunlikelythatusingthemto
treat latent infection caused by an MDRTB strain will prevent the development of active TB disease.
ClosecontactsofMDRTBcasesshouldreceivecarefulclinicalfollowupforatleasttwoyears.Ifactive
disease develops, prompt initiation of treatment with a regimen designed to treat MDRTB is
recommended.Onthebasisofthecurrentlyavailableevidence,theWHOdoesnotrecommendsecond
linedrugsforchemoprophylaxisinMDRTBcontacts.
74
9
TREATMENTOFTUBERCULOSIS
Themaininterventionstopreventthe spreadofTBinthecommunityarethedetection ofcaseswith

infectious TB and providing them with effective treatment to ensure a rapid and lasting cure.
Consequently,treatmentforTBisnotonlyamatterofindividualhealth(asisthecasewith,forexample,
treatmentofhypertensionordiabetesmellitus);itisalsoamatterofpublichealth.
TheaimsofTBtreatmentincludethefollowing:
TocurethecaseofTB
TopreventdeathfromactiveTBoritscomplications
TopreventrelapseofTB
TodecreasetransmissionofTBtoothers
TopreventthedevelopmentofacquiredresistancetoantiTBdrugs
Table5:EssentialantiTBdrugs
DRUGS
MODEOFACTION
RECOMMENDEDDOSES(MG/KG)
Daily
3X/Week
Isoniazid(H)
Bactericidal
5(46)
10(812)
Rifampicin(R)
Bactericidal
10(812)
10(812)
Pyrazinamide(Z)
Bactericidal
25(2030)
35(3040)
Bacteriostatic
15(1520)
30(2035)
Bactericidal
15(1218)
15(1218)
Ethambutol(E)
Streptomycin(S)
75
StandardizedTreatmentRegimens
WHOhaseliminateditsoldercategoriesof14andnowusesthefollowingfourtypesofstandard
treatmentregimens2,3,11:
NewTBcasetreatment:PersonhasneverbeendiagnosedortreatedforTBdisease
Retreatmentregimens
TBcasehasdefaulted(nomedicationsforatleasttwomonths)
TBcasehascompletedtreatmentbuthasarelapse(>6months)
TBcasemaintainsapositivesputummicroscopyat56monthsoftreatment
SuspectedorprovencasesofMDRorXDRTB
Transferin:ATBcasewhohasbeentransferredfromanotherTBregistertocontinue
treatmentinadifferentregisterarea.
NewCases(formerWHOcategory1and3)
Treatmentregimenshaveaninitial(intensive)phaselasting2monthsandacontinuationphaseusually
lasting 46 months. The initial phase usually consists of INH, RIF, PZA and EMB, where there is rapid
killingoftuberclebacilli.Withtreatment,infectiousTBcasesbecomenoninfectiouswithin2to3weeks.
SymptomsimproveandmostcaseswithsputumsmearpositiveTBbecomesputumsmearnegativefor
TB within 2 months. The continuation phase consists of INH, RIF. The sterilizing effect of these drugs
eliminatestheremainingtuberclebacilliandpreventsubsequentrelapse.
TB cases with a large bacillary load (smearpositive PTB and many HIVinfected cases with smear
negative PTB) have an increased risk of selecting resistant bacilli because a large population of bacilli
developsspontaneousresistancetoasingledrug.Shortcoursechemotherapyregimensconsistingof4
drugs during the initial phase and 2 drugs during the continuation phase reduce this risk of selecting
resistantbacilli.Thesenewcasetreatmentregimensarehighlyeffectiveincaseswithsusceptiblebacilli,
andalmostaseffectiveincaseswithinitiallyINHresistantorganisms(SeeTable6forasummaryofthe
treatmentregimensforeachdiagnosticcategory).
Ministry of Health - Guyana, 2011 | Treatment of Tuberculosis
76
CasesnegativeforHIVwithsmearnegativePTBorEPTBthatisfullydrugsusceptiblehavelittleriskof
selecting resistant bacilli because their lesions generally harbour fewer bacilli. However, since initial
resistancetoINHiscommoninmanycases,itisnowrecommendedthatEMBbeincludedasafourth
drugduringtheinitialphaseoftreatmentforcasesasthiswasnotincludedinpreviousCat3.
RetreatmentCases(formerWHOcategory2)
PreviouslytreatedTBcasesincludethosecaseswhohavereceivedonemonthormoreofantiTBdrugs
in the past. They may be smearnegative or positive and may have disease at any anatomical site.
Retreatmentcasesincludetreatmentfailure,relapse,andtreatmentdefault.Retreatmentcaseshavea
higher likelihood of drug resistance, which may have been acquired through inadequate prior
chemotherapy.AnadherentcasewhofailstheretreatmentregimenisathighriskfordevelopingMDR
TB.
Definitionsofretreatmentcasesincludethefollowing2:
Relapse:AcasepreviouslytreatedforTBwhohasbeendeclaredcuredortreatmentcompleted,
and is diagnosed with bacteriologicalpositive (smear, culture or other newer means of
identifyingM.tuberculosis)TB.
Failure: A case who is started on a retreatment regimen after having failed previous TB
treatment
Default:Acasewhoreturnstotreatmentandisbacteriologicalpositivefollowinginterruption
of treatment for one month or more. Its important to note that while WHO and the Guyana
NationalTBProgrammedefinedefaultasaninterruptionintreatmentfor2months2,thePan
American Health Organization considers an interruption of 1 month to represent default for
practicalreasons3.
Thestandardretreatmentregimen(seeTable6)consistsoftwomonthsof5drugs,thenonemonthof
4 drugs in the initial phase, and five months of 3 drugs in the continuation phase. This standardized
regimen can cure cases excreting bacilli still fully sensitive to the drugs and those excreting bacilli
77
resistant to INH and/or streptomycin. Under proper case management conditions, MDRTB cases are
mostlikelytooccurifthesepatientsfailtheretreatmentregime..
Table6:TreatmentregimensbyTBtreatmentcategory
CASECLINICAL
TBTREATMENTCATEGORY
TREATMENTREGIMENS
PRESENTATION
InitialPhase
New(formerWHO
Newsmear PTB;
category1&3)
ContinuationPhase
2HRZE
4HR
4H3R3
Newsmear withextensive
6HE
lunginvolvement,severe
EPTB
Retreatment(formerWHO
category2)
Smear PTB:relapse,Rx
2HRZES/1HRZE
5H3R3E3
5HRE
failure,Rxafterdefault
Confirmedorsuspected
MDR(formerWHO
category4)
Smear aftersupervisedRx
Individualizedregimencontainingsecond
asaretreatmentcase;
linedrugs
provenorsuspectedMDR
TB
Key:E=ethambutol;H=isoniazid;R=rifampicin;S=streptomycin;Z=pyrazinamide;
NB:Numbersprecedingregimensindicatelengthoftreatment(months).Subscriptsfollowingregimensindicate
frequencyofadministration(daysperweek).Whennosubscriptsaregiven,theregimenisdaily.Directobservation
ofdrugintakeisalwaysrequiredwhentreatmentisgivenintermittentlythreetimesperweek.Fixeddose
78
combinationtabletsarehighlyrecommendedforuseinboththeinitialandcontinuationphasesof
treatment.DrugsusceptibilitytestingisrecommendedforcasesthatarecontactsofMDRTBcases.
DosageformulationofDrugs:
INH100,300mgtabs
Rifampin150,300mgtabsorcapsules
PZA400mg,500mgtabs
Ethambutol100,400mgtabs
Streptomycin1gmpowderforinjectioninvial
Fixeddosecombinationtablets
TheWHOstronglyrecommendstheuseoffixeddosecombinationtabletsfortreatmentofTB,
citingthefollowingadvantages:Reducesprescriptionerrorsbecausedosagerecommendations
aremorestraightforward,andadjustmentofdosageaccordingtoweightiseasier
Thenumberoftabletstoingestissmallerandmaypositivelyimpactcaseadherence
DecreaseschanceofacquireddrugresistanceduetocaseselfselectionofdrugwhenDOTisnot
used. Fixeddose combination tablets may not fit the needs of all NTPs and will not suit all
treatmentsituations.
Itwillbenecessarytohavesomestocksupplyofindividualdrugsforcasesituationswherethecasemay
experiencedrugtoxicity,drugintoleranceorwhendrugresistanceisidentified.
Table7:FixedDoseCombinations(FDC)
DRUG
STRENGTHFORDAILYUSE
STRENGTHFORUSE3TIMES
HRZE
75+150+400+275
HRE
75+150+400
150+150+400
30+60+150
HR
75+150,150+300,
150+150
79
HE
30+60
60+60
150+400
Table8:Exampleofthenumberoftabletstobetakendailyininitialphasebya50kgcase
SINGLEDRUGTABLETS
R150mg
H300mg(100mg)
NO.OFTABS
FDC
NO.OFTABS
HRZE
1(3)
Z400mg
E400(100mg)
Total
3
2
April
9(17)
Total3
Table9:FixedDoseNewCaseRegimens
WEIGHT
REGIMEN
InitialPhase
ContinuationPhase
2(HRZE)
4(RH)3
40doses
48doses
H75+R150+Z400+E275
R150+H150
3039kg
4054kg
5570kg
80
>70kg
Table10:FixedDoseCombinationRegimens
WEIGHT
REGIMEN
InitialPhase(3months)
ContinuationPhase(5Months)
2(HRZE)S/1(HRZE)
5(RHE)3
5(RHE)
60HRZEdoses+
60doses
140doses
40STMdoses
H75+R150+Z400+E275
Streptomycin
(R150+H150+E400)
(R150+H150+E400)
tablets
grams
tablets
tablets
2months
3039kg
0.5
2+2
2+1.5
4054kg
0.75
3+4
3+2
5570kg
4+6
4+3
>70kg
5+6
5+3
Question
IntermittentuseofTBmedication
Isoniazid,rifampicin,pyrazinamide,andstreptomycinareallasefficaciouswhengivenintermittently(3
timesperweek)aswhengivendaily.Thriceweeklydrugintakehasthefollowingbenefits:
Facilitatesobservation(DOTisrequiredforintermittentregimens);
Reducescostandinconvenienceforthecasebecausefewerclinicvisitsarenecessary;and
Freesstaffforotherprogrammeactivities.
TheWHOdoesnotgenerallyrecommendtwiceweeklyregimens,asamisseddosewouldrepresenta
largerfractionofthetotalnumberoftreatmentdoses,andthereforeincreasedriskoftreatmentfailure
thanifthecasewerereceivingathriceweeklyordailyregimen.TheGuyanaNTPrecommendsthatall
81
HIVandTBcoinfectedcasesreceivedailytreatmentfornewandretreatmentcasesduringtheinitial
phaseoftreatment,underDOTSsupervision.
TreatmentofLatentofTBinfectionorLatentTB
Treating TB infection can significantly reduce the number of persons who might go on to active TB
disease.Inhealthyadultswithoutriskfactors,10%cangoontodevelopactiveTB.Itisimportantto
ensurethatthecasedoesnothaveactiveTB.
ThoseatriskforrapidTBinfectionprogressionincludethefollowing:
Children
Children and adults with compromised immune systems including those who are HIVpositive
regardlessoftheirCD4count,Diabetes
TherearetwotypesofcasesforwhomTBinfectionprophylaxisisused:
Those who are exposed to a known person (index case) with active TB and are susceptible to
progressingfromTBinfectiontoactiveTB,i.e.,immunosuppressedpersonsandyoungchildren.
PersonswithapositiveTSTorapositivebloodassayformycobacteriumTB.
INHcombinedwithvitaminB6istheregimenofchoicetotreatTBinfection.ThevitaminB6isusedto
preventperipheralneuropathy.IfINHisnottoleratedoriftheindexcaseisINHresistant,Rifampicin
dailyforfourmonthsistheregimenofchoice.
TreatmentofTBInfection
DRUG
DOSAGE
Adults
DURATION
Children
Isoniazid(INH)H
300mgdaily
5mg/kg
6monthsHIVnegative
82
9monthsHIVpositive
VitaminB6
2550mgdaily
10mg/kg(max.300mg)
6monthsHIVnegative
9monthsHIVpositive
Rifampicin(R)
600mgdaily
15mg/kgdaily(max.600mg)
(ifINHnot
2
tolerated)
4months
6months(childrenand
immunosuppressedpersons)
Isoniazid and Rifampicin are both recommended and tolerated during pregnancy and breastfeeding.
HoweversomeexpertsrecommenddelayingINHforpregnantwomenwithalowriskofprogressionto
activeTBuntilafterdelivery.
TreatmentofExtrapulmonaryTB(EPTB)
Fromapublichealthperspective,EPTBisnotofgreatimportance,becausecaseswiththisformofTB
diseasearenotinfectiousasthereisnopulmonaryinvolvement.Additionally,EPTBismoredifficultthan
PTB to diagnose, often requiring invasive procedures to obtain diagnostic specimens and more
sophisticatedlaboratorytechniquesthansputummicroscopy.
In general, EPTB is treated the same as PTB. However, streptomycin replaces EMB when treating TB
involving the central nervous system. Some experts recommend extending the duration of therapy in
caseswithmeningealTBandbone/jointTBtotwelvemonths.Corticosteroidsareusefulinsomeforms
ofEPTB.Thereareminimaldifferencesbetweenthetreatmentofpulmonaryandextrapulmonarysites
ofTB.Thereisextensivepublishedevidenceonthemosteffectivetreatmentregimensforpulmonary
sites;however,thereisnotmuchevidenceonthetreatmentofextrapulmonarysites.
83
SurgeryplaysaroleinthetreatmentofEPTB.Suchisreservedformanagementoflatecomplicationsof
EPTB such as hydrocephalus, obstructive uropathy, constrictive pericarditis, and neurological
involvement,orseverekyphosisfromPottsdisease(spinalTB).
Useofcorticosteroids
TheuseofcorticosteroidshassuccessfullybeenusedtotreatthefollowingTBinfections
Meningitis
Pericarditisthereislessneedforpericardectomy
Pleurisypleuralfluidresolvesmorequickly
LifethreateningdisseminatedTB
TBcausingadrenalInsufficiency
Dosageofcorticosteroidsforadults
Prednisone3060mg/dayfor48weeks2,3thentaper(optimaltimeanddurationisunknown).
Dosageofcorticosteroids(usuallyPrednisone)forchildren
Thedoseis2mg/kg/day(maximumdoseof60mg/day)forfourweekswithaslowtaperingof
prednisoneover23weeks2,3.
ManagingtheSmearNegativeSuspectCase
Thefollowingdescriptionassumesthattheinitialsetofthreesputumspecimensforsmearmicroscopy
wereallnegative.
ForanyseverelyillorHIVpositivecasewithchestsymptomstypicalofTB,butwhosesputumsmears
(3)arenegative:
Obtainadetailedhistoryandphysical,includingalistofcontacts
ExaminethechestXrayforpresentationssuggestiveofactivePTBsuchasupperlobe
pneumonia,unresolvingpneumonia,cavitarylesion,lunginfiltrates,pleuraleffusionor
intrathoracicadenopathy
Ruleoutpneumocysticjiroveci(PCP)pneumoniainanHIVpositivecase
84
SendsputumspecimenforAFBcultureanddrugsensitivitytesting(DST)
ExerciseclinicaljudgmenttotreatforactiveTBandmonitorclinicalprogress
FollowTBtreatmentguidelineandappropriatestandardoperatingprocedures(seeAppendix
15)
ForacasewhoisnotillandwhoisHIVnegative:
>ObtainachestXRayifthereisaninfiltrate
Startantibiotictreatmentforpneumonia(excludingfluoroquinolones)
Followupintwoweeks
Ifthere iscompleteimprovement,activeTBisunlikely.Ifnoimprovementorpartialimprovementis
observed:
RepeatchestXrayandstartantiTBtreatment;
Examine3ormoresputaforAFB;and
Ifsputaareallnegative,repeatchestXrayin1month:
Iftheshadowshavecompletelyclearedandthecaseisnowwell,stopTBtreatment.
Ifthereispartialimprovement,thisisconsistentwithresponsetotherapyforTB,and
treatmentshouldbecontinued.
Ifthereisradiologicdeterioration,considerdrugresistance,nonadherence,oranother
causeoflungabnormality.
ManagingtheSputumSmearPositiveCases
Newcases:
TreatforactiveTB
ObtainsputumforAFBattheendofinitialphase(endof2ndmonth)
Ifsputumisnegativebegincontinuationphase
Ifsputumispositive:
a. Extendinitialphaseoftreatmentwithfourdrugsbyanothermonth.
85
b. ObtainsputumforAFBattheendof3rdmonth.
If sputum is still positive, send sputum for culture as well as DST and initiate
continuationphase.
c)
ObtainsputumforAFBattheendof5thmonth
Ifsputumsmearnegative:continuesecond/continuationphaseoftherapy.
Ifsputumsmearpositive:stoptreatmentandstartretreatmenttherapyandlabel
astreatmentfailure.AlsoobtainsputumforAFBcultureandDST.
CasesonRetreatmentTherapy(previouslytreatedsputumsmearpositivePTBcaseswithoutarecent
cultureandDST):
ObtainsputumforAFBcultureandDST
ObtainsputumforAFBattheendof2ndmonth,ifpositiverepeatattheendof3rdmonth.
Obtain sputum for AFB during the continuation phase (2nd month after started continuation
phase).
ObtainsputumforAFBattheendoftreatment.
IfsputumforAFBispositiveattheendof3rdmonth,obtainsputumforcultureandDST:
a. Extendinitialphaseoftreatmentwith5drugsbyanothermonth.
o
If still sputumpositive at the end of 4 months; obtain sputum for culture and
DST,andstartcontinuationphase.
IfDSTshowsresistanceto2ofthe3drugsemployedinthecontinuationphase,
refercaseforspecializedtreatment,i.e.,MDRsuspect.
If there are no facilities for DST, continue treatment until the end of re
treatmentregimen.
Apositivesputumsmearattheendof5thmonthisindicativeoffailureofthere
treatmentregimenandsuspectedMDR.Refercaseforspecializedtreatment.
InterruptionofTBTreatment
Interruptionoftreatmentisdefinedascasewhodefaultsfromtreatmentfortwoormoremonths.
86
Interruptionforlessthan1month:
Tracecase.
Addressthereason(s)fortheinterruption.
Continuetreatmentandprolongittocompensateformisseddoses.
Interruptionfor12months:
Tracecase.
Addressthereason(s)fortheinterruption.
ObtainthreesputumspecimensforAFBandcontinuetreatmentwhilewaitingforresults.
If sputumnegative or EPTB, continue treatment and prolong it to compensate for missed

doses.
Ifoneormoresputumpositive,suspectMDRTBandobtainsputumforcultureandDST.
NB:Seechapter13fortreatmentofMultipleDrugResistanceTB
ClinicalEvaluation
This entails obtaining a thorough history and conducting a thorough physical examination. The
physician/Medex needs to pay close attention to a history and family history of TB, HIV, diabetes
mellitus,asthma,tobaccouse,alcoholanddrugusage,herbalmedication(includingtea)andmedication
reactions.
PatientMonitoring
(a) Evaluationofmedicationtoxicity:
Symptomsandsignsofhepatitis(yellowingofskinandeyes)
Visualacuityandcolourvisionforcasesonhighdoseofethambutolandcaseswithrenal
impairment
Blood tests are done as baseline (CBC, platelet count, LFT, RFT, blood glucose) or are
repeated frequently for cases with baseline abnormalities, cases at increased risk of
hepatotoxicity(HBVandHCVinfection,alcoholabuse)andsymptomaticcases.
87
(b)Bacteriologictests:
ThreesputumsmearsforAFBifpossible,docultureifsputumisnegativeinHIVpositive.
DST:fortreatmentfailureorsuspecteddrugresistance
Ifthecasehasothersymptomsworkuporrefertomedicalclinicortheirfamilyphysician
withacompletereferral.
(c)Radiographicevaluation
ChestXray:baseline,at2months,thenattheendoftreatment
CaseMonitoring
Monthlyfollowupvisitsinclusiveofvitalsignmeasurements,i.e.,temperature,respiratoryrate,
blood pressure, weight and height (height and weight yearly for adults, and every visit for
childrenandadolescents).
Responsetotreatment:signsandsymptoms,appetiteandweightchangesdocumentedateach
visit.
Adherencetotreatment.
Assessforadverseeffectsofthemedication.
88
10
TUBERCULOSISINCHILDREN
Tuberculosisinchildren
TheWHOestimatesthateachyear,approximatelyonemillioncasesofTBoccurinchildren<15yearsof
age,accountingfor11%oftheannualburdenofcasesdiagnosedworldwide.Childrencanpresentwith
TBatanyage.ThefrequencyofchildhoodTBisinfluencedbytheintensityoftheTBepidemiclocally,
the age structure of the population, the availability of diagnostic tools, and whether contact
investigationisroutinelyconducted10.
TransmissionofTBtoachildusuallyresultsfromexposuretoaninfectiousadultoradolescentinher/his
closeenvironment,oftenwithinthehousehold.OnacquiringTBinfection,childrenfrequentlydevelopa
primaryparenchymallesionoraGhonfocusinthelungs,withsubsequentspreadtotheregionallymph
nodes.Thecellmediatedimmuneresponsehaltsfurtherprogressioninmostsituations;however,very
youngchildren(<5yearsofage)andthosewithweakenedimmunesystemsareatgreatriskfordisease
progression.Forinfants,thetimespanbetweeninfectionanddiseasecanbeasshortasseveralweeks.
ClinicalPresentationsofTBinChildren
Most children with TB have PTB; however, PTB is more difficult to recognize because many children
presentwithprimaryratherthanreactivation(cavitary)PTB.Additionally,themajorityofchildrenwith
TBaretooyoungtoproducesputumforsmearmicroscopy.TheWHOnotesthattheratioofreported
PTB:EPTBinchildrenisusuallyaround1:3;however,theratiovariesdependingonfactorssuchasage,
ability to conduct contact investigations, and also possibly genetic factors. The most common type of
EPTBseeninchildrenisintrathoracic.OtherformsofEPTBfrequentlyseeninchildreninclude10:
TBlymphadenopathy
TBmeningitis
MiliaryTB
TBeffusions(pleural,pericardial,andperitoneal)
89
SpinalTB
PrimaryTBDisease
Oftenunilaterallymphadenopathy,hilarormediastinal,withoutradiographicabnormalitiesin
thelung(noobviousparenchymalinvolvement).ThisisthemostfrequentpresentationofTBin
children(7080%)andshouldbeclassifiedasEPTBandtreatedasnewTBcase(formerWHO
CategoryIII;1,10and
Sometimestypicalprimarycomplexcombininghilarandmediastina/lymphnodesonchestX
ray.
DiagnosingTBinChildrenwithoutHIVinfection
DiagnosingTBinchildrenisparticularlyproblematic.Children<5yearsofagerarelyexpectoratesputum
for evaluation, and even when specimens are obtained, they are rarely smearpositive for AFB on
routine microscopy. In very young children, gastric aspirate specimens can be collected; however, the
yieldofpositivesmearisalsofairlylow(lessthan20%)andtheprocedureisoftennotpracticaloutside
ofurbancentres.
The diagnosis of intrathoracic (i.e., pulmonary, pleural, and mediastinal or hilar lymph node) TB in
symptomatic children with negative sputum smears should be based on the finding of chest
radiographicabnormalitiesconsistentwithTB,andeitherahistoryofexposuretoaninfectiouscaseor
evidenceofTBinfection(positiveTSTorinterferongammareleaseassay).Forsuchcases,iffacilitiesfor
culture are available, sputum specimens should be obtained (by expectoration, gastric washings, or
inducedsputum)forculture.
RecommendedApproachtoDiagnosingTBinChildrenwithoutHIVinfection
TodiagnoseTBinchildrenthefollowingfactsshouldbeconsidered:
DiagnosisofPTBmaybedifficultinchildren<68yearsofage
DiagnosticTBworkupinachildshouldincludeallofthefollowing:
Symptomandcontacthistory;
Clinicalexam(includinggrowthassessment);
Ministry of Health - Guyana, 2011 | Tuberculosis in Children
90
TST(MantouxorPPD)result;
Bacteriologicalexam(wheneverpossible);
Chestradiograph;and
Other specific evaluation indicated by disease site including investigations for EPTB or
comorbidity(e.g.,HIVrisk).
CarefulHistory(includinghistoryofTBcontactandsymptomsconsistentwithTB)
Contact:Aclosecontactisdefinedaslivinginthesamehouseholdorinfrequentcontactwithasource
case(e.g.,caregiver)withsputumsmearpositiveTB.Sourcecaseswhoaresputumsmearnegativebut
culturepositivearealsoinfectious,buttoamuchlesserdegree.
Thefollowingpointsconcerningcontactareofimportance:
Children(especiallythose<5yearsofage)whohavebeeninclosecontactwithacaseofsmear
positiveTBmustbescreenedforTB(seeChapter8:TBContactInvestigation);and
After TB is diagnosed in a child or adolescent, an effort should be made to detect the adult
source case(s), especially within the household. If a child presents with infectious TB, then
childhood contacts must be sought and screened as you would a smearpositive source case.
Children should be regarded as infectious if they are sputum smearpositive or have a cavity
visibleonchestXray.
Symptoms:Childrenwithsymptomaticdiseasedevelopchronicsymptomsinmostcases.
Themostfrequentsymptomsarechronicandunremittingcough,fever,andweightloss.Thespecificity
ofsymptomsforthediagnosisofTBdependsonhowstrictthedefinitionsofthesymptomsare:
Chroniccough:anunremittingcoughthatisnotimprovingandhasbeenpresentfor21days(3
weeks).
Fever: of 38C for 14 days after common causes such as malaria or pneumonia have been
excluded.
Weightlossorfailuretothrive:alwaysaskaboutweightlossorfailuretothriveandreviewthe
childsgrowthchartforstuntingandpoorweightgain.
91
ClinicalExamination(includinggrowthassessment)
Therearenospecificfeaturesonclinicalexaminationthatcanconfirmthatthepresentingillnessisdue
to PTB. Some signs, although uncommon, are highly suggestive of EPTB and the physicians index of
suspicionshouldbehighthatthechildhasactiveTB.
PhysicalsignshighlysuggestiveofEPTB:
Gibbus,especiallyofrecentonset(vertebralTB)
Nonpainfulenlargedcervicallymphadenopathywithfistulaformation
PhysicalsignsrequiringinvestigationtoexcludeEPTB:
Meningitis not responding to antibiotic treatment, with a subacute onset or raised

intracranialpressure
Pleuraleffusion
Pericardialeffusion
Distendedabdomenwithascites
Nonpainfulenlargedlymphnodeswithoutfistulaformation
Nonpainfulenlargedjoint
Signsoftuberculinhypersensitivity:phlyctenularkeratoconjunctivitis,erythemanodosum.
Documentedweightlossorfailuretogainweight,especiallyafternutritionalrehabilitation,isa
goodindicatorofchronicdiseaseinchildren,andTBmaybethecause10.
AnapproachtothediagnosisofTBinchildrenwithoutHIVinfection
TheriskofTBisincreasedwhenthereisanactivecase(infectious,smearpositiveTB)inthesamehouse
orwhenthechildismalnourished,isHIVinfected,orhashadmeaslesinthepastfewmonths.Consider
TBinanychildwith:
SignsandsymptomsofTBinchildren
92
HISTORYOF:Symptoms
Unexplainedweightlossorfailureto
ONEXAMINATION:Signs
Fluid on one side of the chest (reduced air
grownormally
Unexplainedfever,especiallywhenit
entry,stonydullnesstopercussion)
Enlargednontenderlymphnodesoralymph
continuesformorethantwoweeks
Chroniccough
nodeabscess,especiallyintheneck
Signsofmeningitis,especiallywhenthese
Exposuretoanadultwithprobableor
developoverseveraldaysandthespinalfluid
containsmostlylymphocytesandelevated
definitepulmonaryinfectiousTB
protein
Abdominalswelling,withorwithoutpalpable
lumps
Progressive swelling or deformity in the bone
orajoint,includingthespine
TuberculinSkinTest(TST)
A positive TST occurs when a child is infected with M. tuberculosis. However, in children, the TST can
alsobeusedinconjunctionwithsignsandsymptomsofTBandotherdiagnostictestsasanadjunctin
diagnosing TB disease. There are a number of TSTs available (e.g., Mantoux, multipuncture, Tine and
Heaf).InGuyana,MantouxistherecommendedTST.
Usingthetest:TheTSTshouldbestandardizedforeachcountry,usingeither5TU(tuberculinunits)of
tuberculinpurifiedproteinderivativeS(PPDS)or2TUoftuberculinPPDRT23.Astheybothgivesimilar
reactions in infected children. All health care workers working in TB control must be trained to
administerandreadaTSTinaccordancewiththeTSTguidelines6.
ATSTshouldberegardedaspositivewhen:
Highriskchildren:TST5mminduration(highriskincludesHIVinfectedchildren,closecontacts
to active PTB, children whose chest Xrays are consistent with TB, and severely malnourished
children,i.e.,thosewithclinicalevidenceofmarasmusorkwashiorkor;and
93
Allotherchildren:TST10mmindurationisregardedaspositive(whetherornottheyhavebeen
BCGvaccinated).
Value of the test: A positive TST indicates that the child has been infected with TB but does not
necessarily indicate disease. However, when used in a child with symptoms and other evidence of TB
disease(suchasanabnormalchestXray),itisausefultoolinmakingthediagnosisofTBinachild.TST
can be used to screen children exposed to TB (i.e., through a household contact with TB), although
children can still receive chemoprophylaxis even if TST is not available (see Chapter 8: TB Contact
Investigation).
TheTSTisalsousefulinidentifyingHIVinfectedchildrenwithTB,althoughfewerHIVinfectedchildren
will have a positive TST. This occurs because a normal immune response is required to produce a
positiveTSTandmanyHIVinfectedchildrenhaveimmunesuppression.AllHIVpositivechildrenshould
receiveanannualTST.
TherecanbefalsepositiveaswellasfalsenegativeTSTresults.ItissometimesusefultorepeattheTST
inchildrenoncetheirmalnutritionhasbeenaddressedortheirsevereillness(includingTB)hasresolved,
astheymaybeinitiallyTSTnegative,butpositiveafter23monthsonantiTBtreatment.
NB:AnegativeTSTneverrulesoutadiagnosisofTB.
BacteriologicalConfirmation(wheneverpossible)
ItisalwayspreferabletomakeabacteriologicaldiagnosisofTBinachildusingwhateverspecimensand
laboratory methods are available, including sputum, gastric aspirate and other material (e.g., lymph
nodebiopsyoranyothermaterialthatisbiopsied)specimens.Fineneedleaspiration(FNA)ofenlarged
lymphglandsforbothhistologyandstainingforAFBhasbeenshowntobeausefulprocedurethathasa
high bacteriological yield. All specimens obtained should be sent for mycobacterial culture whenever
possible.Thiswillimprovetheyieldofthetest(i.e.,itismoresensitive),butitisalsotheonlywayto
differentiateMtuberculosisfromothernonTBmycobacterium.
94
Abacteriologicaldiagnosisisespeciallyimportantforchildrenwhohaveoneormoreofthefollowing:
Suspecteddrugresistance
HIVinfection
Complicatedorseverecasesofdisease
Anuncertaindiagnosis
Morecommonwaysofobtainingsputumformicroscopyinclude:
Expectoration:Sputumforsmearmicroscopyisausefultestandshouldalwaysbeobtainedin
adultsandchildren10yearsofagewhoarePTBsuspects.Amongyoungerchildren,especially
children <5 years of age, sputum is difficult to obtain and most children are sputum smear
negative.However,inchildrenwhoareabletoproduceaspecimen,itisworthsendingsuchfor
AFB smear microscopy (and culture if available). Bacteriological yields are higher in older
children(>5yearsofage)includingadolescents,andinchildrenofallageswithseveredisease.
AswithadultTBsuspects,threesputumspecimensshouldbeobtained:spotspecimen(atinitial
evaluation),earlymorning,andspotspecimen(atfollowupvisit).
Gastricaspirates:Gastricaspirationusinganasogastricfeedingtubecanbeperformedinyoung
children who are unable or unwilling to expectorate sputum. If performed, gastric aspirates
shouldbesentforAFBsmearmicroscopyandmycobacteriumculture.
Sputuminduction:Severalrecentstudieshavefoundthatsputuminductioncanbeperformed
safelyandeffectivelyinchildrenofallages,andthebacteriologicalyieldisasgoodasorbetter
thanforgastricaspirates.However,trainingandspecializedequipmentarerequiredtoperform
thistestproperly.
RelevantinvestigationsforsuspectedPTBandEPTB:
95
SuspectedpulmonaryandintrathoracicTB:Inthemajorityofcases,childrenwithpulmonaryor
intrathoracicTBhavechestXraychangessuggestiveofTB.Themostcommonpictureisthatof
persistentopacificationinthelung,togetherwithenlargedhilarorsubcarinallymphglands.A
miliarypatternofopacificationinnonHIVinfectedchildrenishighlysuggestiveofTB.Persons
with persistent opacification that does not improve after a course of antibiotics should be
investigatedforTB.AdolescentswithTBhavechestXraychangessimilartoadultswithTB,with
largepleuraleffusionsandapicalinfiltrateswithcavityformationbeingthemostcommonforms
of presentation. Adolescents may also develop primary disease, with hilaradenopathy and
collapsedlesionsvisibleonchestXray.ChestradiographyisquiteusefulinthediagnosisofTB
in children. A lateral view may be helpful in situations where the frontal view is difficult to
interpretandinveryyoungchildren(e.g.,<5yearsofage).ThechestXraypreferablyshouldbe
read by a radiologist or other health care worker trained to read chest Xrays. Good quality
chestXraysareessentialforproperevaluation.
Suspected extra pulmonary TB: In most of these cases, TB will be suspected from the clinical
pictureandconfirmedbyhistologyorotherspecialinvestigations.
Othertests:
Serologicalandnucleicacidamplification(e.g.,polymerasechainreaction[PCR])testsarenot
currently recommended for the routine diagnosis of childhood TB, as they have been
inadequatelystudiedinchildrenandyieldpoorresultsinthefewstudiesthathavebeendone.
However, this is anarea that requires further research, as they may prove to be useful in the
future10.
Lumbar puncture: Miliary or haematogenously disseminated TB has a high risk (6070%) of

meningeal involvement and should therefore be managed similarly to TB meningitis. For this
reason,manyexpertsrecommendthatallchildrenwithMTB(orsuspectedofhavingmiliaryTB)
shouldundergolumbarpuncturetoevaluatethepresenceofmeningitis.
96
NB: Other specialised tests, such as computerised chest tomography and bronchoscopy, are not
recommendedfortheroutinediagnosisofTBinchildren.
HIVTesting:InareaswithahighprevalenceofHIVinfectioninthegeneralpopulation(whereTB
andHIVinfectionarelikelytocoexist),HIVcounsellingandtestingisindicatedforallTBcases
as part of their routine management. In areas with lower HIV prevalence, HIV counseling and
testingisindicatedforTBcaseswithsymptomsand/orsignsofHIVrelatedconditions,andinTB
caseswithahistorysuggestiveofhighriskofHIVexposure.
ScreeningandDiagnosisofTBinChildrenwithHIV
ThenaturalhistoryofTBinachildwithHIVdependsonthestageofHIVdisease.InearlyHIVinfection,
thesignsofTBaresimilartothoseofanHIVuninfectedchild.AsHIVinfectionprogresses,dissemination
ofTBbecomesmorecommon(i.e.,meningitis,militaryTBandwidespreadTBlymphadenopathy).Older
HIVinfectedchildrenwithTBmayhaveclinicalpresentationssimilartothatseeninHIVinfectedadults.
AsisthecaseamongadultswithHIV,thereisstrongandconsistentevidencethattheresponsetoTB
treatmentandoutcomearepoorerforHIVinfectedchildrenascomparedtoHIVuninfectedchildren;a
substantial proportion of deaths in children with TB/HIV occur in the first two months following
commencementofTBtreatment.
It is essential to have a high index of suspicion for TB disease in children living with HIV (CLHIV).
Intensified case finding (ICF) for TB disease among children living with HIV offers the opportunity to
identifyTBdiseaseearly,initiateappropriateTBtherapyquickly,andalsoprovideisoniazidpreventive
therapy(IPT)forthosewhodonothavesymptomsandsignsofTBdisease.AllchildrenlivingwithHIV,
wherever they receive care, should be regularly screened for TB disease using a clinical algorithm at
everyvisittoahealthfacilityorcontactwithahealthworker.Thosewhodonothavepoorweightgain,
fever or current cough and do not have a history of contact with a TB case are unlikely to have TB
diseaseandshouldbeassessedforIPTeligibility.
97
ScreeningforTBdiseaseamongCLHIV
ThefollowingquestionsshouldbeaddressedforallchildrenlivingwithHIVateveryvisittoa
healthfacility:
Doesthechildhaveanyofthefollowingsymptoms?
1. Currentcough?
2. Fever?
3. Poorweightgain?
and/or
4. HistoryofcontactwithaTBcase?
Poorweightgainisdefinedasreportedweightloss,orverylowweight(weightforagelessthan3zscore),or
underweight(weightforagelessthan2zscore),orconfirmedweightloss(>5%)sincethelastvisit,orgrowth
curveflattening.
AmongchildrenlivingwithHIVwhoarelessthan12monthsofage,onlythosewhohadcontactwitha
TBcaseandwhoareevaluatedforTB(usinginvestigations)shouldreceiveIPTiftheevaluationshows
noTBdisease.Therecommendeddoseofisoniazid(INH)forpreventivetherapyis10mg/kg/dailyfor6
months(maximum300mg/day).CLHIVwhodohaveanyoneofthefollowingsymptomspoorweight
gain, fever, current cough and/or history of contact with a TB case might have TB and should be
evaluatedforTBandotherconditions.
98
AlgorithmforTBscreeninginchildrenlivingwithHIV
Children*livingwithHIV
ScreenforTBdisease:
Doesthechildhaveanyofthefollowing?
Currentcough
Fever
Poorweightgain**
HistoryofcontactwithaTBcase
No
Yes
Assessforcontraindications***toIPT
InvestigateforTBandotherdiseases
No
Considerfor
IPT*
Yes
Other
diagnosis
NotTB
TB
DeferIPT
Giveappropriate
treatmentand
considerforIPT*
Followupand
considerIPT*
TreatforTBand
ensureearly
initiationof
ART*****
99
AswiththenonHIVinfectedchild,therecommendedapproachtodiagnosisofTBinachildlivingwith
HIVshouldincludethefollowing:
1. Carefulhistory,includinghistoryofcontactwithaTBpatient
2. CarefulhistoryofsymptomsconsistentwithTB
3. Clinicalexaminationincludinggrowthassessment
4. Tuberculinskintesting
5. InvestigationsrelevantforsuspectedpulmonaryTBandsuspectedextrapulmonaryTB
6. Bacteriologicalconfirmationwheneverpossible
Bacterial confirmation of diagnosis of TB disease requires isolation of M. tuberculosis. Appropriate

specimens for the suspected sites of involvement should be obtained for microscopy and, where
facilitiesareavailable,forculture.Appropriateclinicalsamplesinclude:
Sputumbyexpectorationorsputuminductionorbygastricaspiration(highestyieldspecimens
areobtainedintheearlymorningafterfastofatleast4hoursforchildren[3hoursforinfants])
Bronchoalveolarlavagefluid
Fineneedleaspirateofperipherallymphnode
Biopsy/samplingofothertissueorfluiddependingonsuspectedsiteofinvolvement
Diagnostic yield is greater for culture than microscopy. Current recommendations advise gastric
aspiration only when culture is available as smearpositivity on microscopy is low and the gastric
aspiration procedure causes distress to the child. However, CLHIV may be diagnosed with TB disease
baseduponclinicalsuspicionalone,evenintheabsenceofbacterialconfirmation.
TreatingChildhoodTB
Therecommendedtreatmentregimenforbothchildrenandadultsisbasedonthediagnosticcategory
assigned. The WHO recommends that regimens and dosages be the same for adults and children in
ordertoreduceconfusionandimproveoverallcompliance.However,recommendeddosagesarebased
on research in adults, and metabolism of drugs varies with age. This manual presents current WHO
100
recommendedoptionsfordrugregimenanddosagebutalsoacknowledgessomeoftheotherbroadly
adoptedapproaches(e.g.,AmericanThoracicSociety):
MostchildrenwithTBhaveuncomplicated(smearnegative)pulmonary/intrathoracicTBornon
severeformsofEPTB,andthereforecategorisedasNewCase;
Children with smearpositive PTB, extensive pulmonary involvement or severe forms of EPTB
(e.g.,meningealormiliaryTB)arealsocategorisedasNewCase.
Note: Children with TB meningitis should receive streptomycin in place of ethambutol in the
CategoryIregimen,asethambutoldoesnotcrossthebloodbrainbarrier.Seealsotables12and
13forrecommendedregimensforthetreatmentofTBmeningitis;
PreviouslytreatedcasesarecategorisedasRetreatmentorsuspectedMDRTB);and
TheprinciplesforTBtreatmentarethesameintheHIVinfectedasintheHIVuninfectedchild.
Modified treatment durations, schedules and medications are recommended for specific
instances(seealsoChapter12:TBHIVComanagement).
DeterminingDrugDosage
There is limited data on the pharmacokinetics of antituberculosis drugs in children resulting in
variations in the recommended drug doses for children (e.g., the American Thoracic Society
recommends1015mg/kgINHdailyascomparedtoWHOrecommendationof5mg/kgdaily)amongst
NTPs. In general, the drug dosage per kilogram is the same for both children and adults, with the
exception of ethambutol (see also table 12: Doses of firstline antituberculosis drugs in children for
ethambutol, the daily dose is higher in children (20 mg/kg) than in adults (15 mg/kg) because peak
serumethambutolconcentrationsarelowerinchildrenthaninadultsreceivingthesamedose1,2,10.
Weight and height should be monitored regularly throughout treatment for all children and dosage
shouldbeadjustedaccordinglyasthechildgainsweight.
101
Table11:RecommendedregimensfortreatmentofTBinchildren
TBDIAGNOSTICCATEGORY
NewCase
CLINICALPRESENTATION
REGIMEN
InitialPhase
ContinuationPhase
2HRZE
4HRor6HEc
NewsmearpositivePTB
NewsmearnegativePTBwith
extensiveparenchymal
involvement
SevereformsofEPTB(other
thanTBmeningitisseebelow)
SevereconcomitantHIV
disease
TBmeningitis
2HRZS(daily)
4HR
2HRZES/1HRZE
5HRE
RetreatmentCase
Previouslytreatedsmear
positivePTB:
Relapse
TreatmentafterDefault
Treatmentfailure
SuspectedMDRCase
ChronicandMDRTB
Speciallydesignedstandardizedor
individualizedregimens
(recommendconsultationwitha
clinicianexperiencedinMDRTB
management)
Key:TB=tuberculosis;H=isoniazid;R=rifampicin;Z=pyrazinamide;E=ethambutol;PTB=pulmonaryTB;EPTB=
extrapulmonaryTB;HIV=humanimmunodeficiencyvirus;S=streptomycin;MDRTB=multidrugresistant
tuberculosis
102
Direct observation of drug administration is recommended during the initial treatment phase and whenever the
continuationphasecontainsR.IncomparisonwiththetreatmentregimenforTBcasesindiagnosticcategoryI,E
maybeomittedduringtheinitialphaseoftreatmentforTBcaseswithnoncavitary,smearnegativepulmonaryTB
who are known to be HIVnegative, TB cases known to be infected with fully drugsusceptible bacilli and young
childrenwithprimaryTB.Thisregimen(2HRZE/6HE)maybeassociatedwithahigherrateoftreatmentfailureand
relapsecomparedwiththe6monthregimenwithRinthecontinuationphase.Incomparisonwiththetreatment
regimenforTBcasesindiagnosticcategoryNewPatient,SreplacesEinthetreatmentofTBmeningitis.
Table12:SelectedregimensfortreatmentofTBmeningitisinchildren
INTENSIVEPHASE
CONTINUATIONPHASE
2HRZS
4HR
2HRZ(SorEth)
710HR
REFERENCE
WHO(Treatmentguidelines
AmericanAcademyofPediatrics
Key:TB=tuberculosis;H=isoniazid;R=rifampicin;Z=pyrazinamide;S=streptomycin;Eth=ethionamide;WHO=
WorldHealthOrganization.
Table13:DosesoffirstlineantiTBdrugsinchildren
DRUG
DOSAGE(MG/KG)
Isoniazide(INH),H)
10(1015)maximumdose300mg/day
Rifampicin(RIF,R)
15mg/kg(1020mg)maximumdose600mg/day
Pyrazinamide(PZA,Z)
Ethambutal(EMB,E)
Streptomicin(SM,S)
15mg/kg(1218mg)maximumdose1000mg/dayIM
NB:
a.
Daily dose recommendations for children as determined following review of existing pharmacokinetic
studiesandinconsultationwithpediatricpharmacologyandTBexperts
b.
RIFdosagesatthehigherrangesmaybepreferableforchildrenunder10kilograms,andchildrenwithHIV
infectionormalnutrition
103
c.
TherecommendeddailydoseofEishigherinchildrenthaninadults,becausethepharmacokineticsare
different(peakserumEconcentrationsarelowerinchildrenthaninadultsreceivingthesamemg/kgdose)
d.
Streptomycin should be avoided when possible in children because the injections are painful and
irreversibleauditorynervedamagemayoccur.Theuseofstreptomycininchildrenismainlyreservedfor
the first 2 months of treatment of TB meningitis. Streptomycin should also be avoided in TB cases with
renal failure because of increased risk of nephrotoxicity and ototoxicity. If streptomycin must be used,
decreasefrequencytotwoorthreetimesperweek,andmonitorserumlevelsofthedrug.Somesources
recommendreductionofstreptomycindoseto10mg/kg/day(max.750mg/day)inTBcases>59yearsof
age.TBcasesweighinglessthan50kgmaynottoleratedosesabove500750mgdaily
AdjunctiveTreatmentwithCorticosteroids
Corticosteroids may be used for the management of some complicated forms of TB (e.g., tuberculous
meningitis, the complications of airway obstruction by TB lymph glands, and TB pericarditis). In
advanced TB meningitis cases, corticosteroids have been shown to improve survival and reduce
morbidity and are thus recommended in all cases of TB meningitis. The drug most frequently used is
prednisone,inadosageof2mg/kg/day(maximumdosage60mg/day)for4weeks.Ifthereisrebound
inflammationorIRISthedoseshouldbeslowlytaperedovera23weekperiodoftime.
TreatmentAdministrationandAdherence
Children, their parents, other family members and other caregivers should be educated about TB and
the importance of completing antiTB treatment. The support of the childs parents and immediate
familyisvitaltoensuringasatisfactorytreatmentoutcome.Preferablysomeoneotherthanthechilds
parentorimmediatefamilyshouldobserveoradministertreatment.Fixeddosecombinationsshouldbe
used whenever possible to improve simplicity and adherence to antiTB treatment. Utilization of
treatmentcardsisrecommendedfordocumentingtreatmentadherence.
Where possible, children with severe forms of TB should be hospitalized for intensive management.
Conditionsthatmerithospitalisationinclude2,3,10:
TBmeningitisandmiliaryTB,preferablyforthefirst2months;
Anychildwithrespiratorydistress;
SpinalTB;and
104
Severeadverseevents,suchasclinicalsignsofhepatotoxicity(e.g.,jaundice).
MonitoringthroughoutTreatment
Ideally, each child should be assessed by the National Tuberculosis Programme (NTP) (or those
designated by the NTP to provide treatment) at least2 weeks after treatment initiation and then
monthlythereafter.
Theassessmentshouldinclude,ataminimum:
Asymptomassessment;
Anassessmentofadherence;
Enquiryaboutanyadverseevents;
Weightmeasurementwithmedicationdosagesadjustedtoaccountforweightgain;
Adherenceincludingreviewingthetreatmentcard;and
CollectionofafollowupsputumspecimenforAFBsmearmicroscopyat2and5monthsforany
childwhowassputumsmearpositiveatdiagnosis.
Followup chest radiographs are not routinely required in children, particularly as many children will
haveaslowradiologicalresponsetotreatment.AchildwhoisnotrespondingtoTBtreatmentshouldbe
referred for further assessment and management. These children may have drugresistant TB, an
unusualcomplicationofPTB,othercausesoflungdisease,orproblemswithtreatmentadherence.
TheNTPisresponsiblefororganizingtreatmentinaccordancewithWHOGuidelines,andensuringthat
TBcasesandtheiroutcomesarerecordedandreported.Goodcommunicationisnecessarybetweenthe
NTP and health care workers treating children with TB. Adverse events noted by health care workers
shouldbereportedtotheNTP.
AntiTBdrugregimensinHIVinfectedchildren
RecommendationsforTBtreatmentinHIVinfectedchildrenorchildrenwithTBlivinginanHIVendemic
setting, irrespective of HIV status, have recently been revised from those listed in the 2006 WHO
105
Guidancedocument.ThenewpatientregimenforallHIVinfectedchildrenwithallformsofpulmonary
and extrapulmonary TB has four drugs in the intensive phase (2HRZE). The continuation phase of the
new patient regimen remains 4HR for all HIVinfected children except those with TB meningitis or
osteoarticulartuberculosis.A10monthcontinuationphaseisnowrecommendedforTBmeningitisand
osteoarticular TB. Streptomycin is no longer recommended in any firstline treatment regimens for
children. Children with TB/HIV are more likely to have severe disease with extensive parenchymal
involvementandcavitarydiseaseandsorequiretheadditionofethambutoltotheintensivephase.TB
treatment in HIVinfected children should be given daily (7 days per week) during the intensive and
continuationphasesoftherapy.Drugdosagesdependonthebodyweightofthechild,roundedoffinto
weightbands,andneedtobeincreasedasthechildgainsweight.Ifthereispoorresponsetotherapy
(noweightgain,persistentsymptoms)childrenshouldbereferredtothenextlevelofcareforurgent
assessment.Specimensforcultureanddrugsusceptibilitytesting(DST)shouldbecollectedinchildren
whorespondpoorlytotreatment.
106
RecommendedtreatmentregimensforHIVinfectedchildren
AntiTBdrugregimens
TBcasesanddiagnosticcategory
Intensive
phase
Continuation
phase
NewPatientRegimen
SmearpositivePTB
SmearnegativePTBwithorwithoutextensiveparenchymal
2HRZE
4HR
2HRZE
10HR
involvement
AllformsofEPTBexceptTBmeningitisandosteoarticularTB
NewPatientRegimen
TBmeningitisandosteoarticularTB
MDRRegimen
MDRTBIndividualizedregimens
HIVinfected children who require treatment for a second episode of TB, due to reactivation or re
infection disease, need careful consideration of what treatment regimen should apply. There are new
guidelinesforthetreatmentofadultswithTB,andtherecommendationswithintheseguidelinesneed
tobeconsideredforchildrenwithpreviouslytreatedTB.AnychildwithactiveTBdiseaseshouldbegin
107
TB treatment immediately, and start ART as soon as tolerated in the first 8 weeks of TB therapy,
irrespectiveofCD4countandclinicalstage.
ImmuneReconstitution
Sometimes referred to as a paradoxical reaction, this temporary exacerbation of symptoms, signs, or
radiographic manifestations sometimes occurs after beginning antiTB treatment. This can simulate
worsening disease, with fever and increased size of lymph nodes or tuberculomas. Immune
reconstitution can be brought about by improved nutritional status or by the antiTB treatment itself.
Clinical deterioration due to immune reconstitution can occur after initiation of antiretroviral therapy
(ART) in HIVinfected children with TB, and is known as the immune reconstitution inflammatory
syndrome (IRIS). AntiTB treatment should be continued, although in some cases the addition of
corticosteroids might be useful. If in doubt, contact a specialist at the NTP or the Georgetown Chest
Clinic(centreofexcellenceforTBandTBHIVcare)foradditionaladvice.
ManagementofaBabyBorntoaMotherDiagnosedwithInfectiousPTB
Once a pregnant woman has been on treatment for at least 23 weeks, she is generally no longer
infectious.IfapregnantwomanwithTBhasbeenontreatmentforTBforseveralweeksbeforedelivery,
itislesslikelythatthebabywillbecomeinfected.Theriskishighestifapregnantwomanisdiagnosedat
the time of delivery or shortly thereafter. If a pregnant woman is found to have PTB shortly before
delivery,thenthebaby,andifpossibletheplacenta,shouldbeinvestigatedforevidenceofcongenital
TBinfectionand,iffound,thebabyshouldbetreated.
AbreastfeedinginfanthasahighriskofinfectionfromamotherwithsmearpositivePTB,aswellasa
high risk of developing TB. The infant should receive 6 months of IPT, followed by BCG vaccination.
Breastfeedingcanbecontinuedsafelyduringthisperiod.Analternativepolicyistogive3monthsofIPT,
thenperformaTST.Ifthetestisnegative,INHshouldbestoppedandBCGvaccinegiven.Ifthetestis
positive,INHshouldbecontinuedforanother3to6months,afterwhichitshouldbestoppedandBCG
vaccinegiven.
108
BCGVaccinationinChildren
BacilleCalmetteGurin(BCG)isaliveattenuatedvaccinederivedfromMycobacteriumbovis.TheWHO
Expanded Programme on Immunisation (EPI) recommends BCG vaccination as soon as possible after
birth in countries with a high TB prevalence, unless the child is an HIV Exposed Infant (mother is HIV
positive).ThisissupportedbytheGuyanaMinistryofHealthMaternalandChildHealthDepartment.
HIVexposedandHIVinfectedChildren:
AlthoughtherehavebeenseveralreportsofdisseminatedBCGinfectioninHIVinfectedindividuals,BCG
appears to be safe in the vast majority of cases. There is a wide range of reported BCG efficacy in
published studies to date (080%); however, it is generally accepted that BCG vaccination provides
children with protection against the more severe types of TB such as miliary TB and tuberculous
meningitis,andevendeath.Therefore,incountrieswithahighTBprevalence(irrespectiveoftheHIV
prevalence),thebenefitsofBCGvaccinationoutweightherisksandtheWHOrecommendsapolicyof
routine BCG immunization (single dose) for all neonates unless there is known primary (e.g.,
congenital)immunodeficiency2,3,10.
WHOdoesnotrecommendBCGvaccinationfor2,3,and10:
ChildrenwithsymptomaticHIVinfectionlivingincountrieswithlowHIVprevalence
HIVpositivechildrenwhoareatminimalriskforinfectionwithM.tuberculosis
Childrenwithknownprimary(e.g.,congenital)immunodeficiency:
ChildrenborntoaTBinfectedmother
Underweightandsickchildren
InGuyana,BCGisrecommendedasfollows:
HIVexposedinfantshouldnotreceiveBCGuntiltheirHIVstatusisknown.Ifthebabytests
HIVnegative,thenthebabycanreceiveBCGvaccine7.
HIVinfected infantshould not receive BCG vaccine, regardless of the physical status of the
baby(symptomaticorasymptomatic)7.
109
11
TREATMENTREGIMENSINSPECIALPOPULATIONS
TreatmentforPregnantWomen
TherisktoapregnantwomanandherfoetusisfargreaterfromuntreatedTBthanfromantiTBdrugs.
Isoniazid, rifampicin, and ethambutol have been well studied and are known to be safe for
administration during pregnancy. Although the teratogenicity data is not complete, pyrazinamide is
probablyalsosafe.Streptomycinisnotrecommendedbecauseofototoxicitytothefetus.
ItisimportanttoexplaintoapregnantwomanthatsuccessfultreatmentofTBwiththerecommended
regimenisimportantforahealthyoutcomeofpregnancy.
Duringpregnancy,TBdiseasemaydevelopespeciallyifthemotherisalsocoinfectedwithHIVorhas
other risk factors for TB such as diabetes, poor nutrition, and contact of TB patients. All pregnant
womenshouldbescreenedforHIV.OncetheyareidentifiedasHIVpositive,thesewomenalongwith
their close contacts should be screened for TB. When TB disease is detected, treatment must be
initiatedpromptly.PregnantwomenfoundtobeinfectedwithTB(TST>10mm)shouldbeofferedIPT.
Thiscancommenceandbecontinuedthroughoutthecourseofpregnancy.
TreatmentforBreastfeedingWomen
AwomanwhoisbreastfeedingandhasTBshouldreceiveafullcourseofantiTBtreatment.Timelyand
properlyadministeredchemotherapyisthebestwaytopreventtransmissionoftuberclebacillitoher
baby. All the antiTB first line drugs are compatible with breastfeeding, and as such, a woman taking
themcansafelybreastfeedinthenormalway;however,thenewbornshouldbegivenprophylacticINH
foratleastthreemonthsbeyondthetimethemotherisconsideredtobenoninfectious.Additionally,
BCGvaccinationofthenewbornisonlyrecommendedoncethebabycompletesINHprophylaxis.
110
12
TBHIVCOMANAGEMENT
ThissectionwilldiscussthefollowinginaccordancewithnationalguidelinesandwithreferencetoWHO
recommendations:
HIVtestingandcounselingofallpersonsknownorsuspectedtohaveTB
HIVpreventionforTBinfectedcases
TreatmentofTBforpeoplelivingwithHIV
ProvidingcotrimoxazolepreventivetherapytoallpatientswithTB/HIV
ProvidingARTtoallpatientswithTB/HIV
WhentostartARTandwhatantiretroviralagentstouse
Drugsusceptibilitytestingandcasemonitoring
EnsuringcomprehensiveHIVcareandsupportservices
Intensifiedcasefinding(ICF)ofallpersonslivingwithHIV
ScreeningforlatentTBinfectionamongallPLHIV
ProvisionofIPTtoalleligiblePLHIV
IncreasedcollaborationbetweenTBandHIV/AIDSprogrammesatalllevelsisrecommendedinorderto
mitigatethe burdenofHIVinpersonsdiagnosedwithTB,aswellastheburdenofTBinpeopleliving
withHIV.
WHOrecommendsemployingtheThreeIstoreducetheburdenofTBinpersonslivingwithHIV2,3,12:
Intensifiedcasefinding(ICF),;
Isoniazidpreventivetherapy(IPT);and
TBInfectioncontrol(IC).
The HIV epidemic has increased the burden of TB globally, especially in populations where the
prevalence of TB infection is high among young adults. In Guyana the TBHIV coinfection rate is
estimated to be 28%. TB is one of the most commonly occurring opportunistic infections among HIV
111
infectedpersonsinGuyana.HIVisthemostpowerfulfactorknowntoincreasetheriskofprogression
fromTBinfectiontoTBdisease;forapersonduallyinfectedwithHIVandM.tuberculosis,thelifetime
riskofdevelopingTBisabout50%.
NaturalHistory
TBcanoccuratanytimeinHIVinfectedpersons.MostofcasesofTBinTBHIVduallyinfectedindividuals
may be due to a reactivation of latent TB infection. People living with HIV are more likely to present
with extra pulmonary or sputum smearnegative TB, especially as immunesuppression advances. This
can result in misdiagnosis or delays in diagnosis and in turn, higher morbidity and mortality for this
population.TheclinicalpresentationsofTBinHIVinfectedpersonsdependonthedegreeofimmuno
suppression, as evidenced by the CD4 count. The higher the CD4 count the more typical the TB
presentation.PulmonaryTBisbyfarthemostcommonpresentationofTBinHIVinfectedpersons.At
highCD4countsHIVinfectedpersonspresentwithtypicalpostprimaryPTBtheyaresputumsmear
positiveandhavecavitiesintheirlungs.AtlowerCD4counts,laterinthecourseofHIVinfection,the
presentation is usually that of primary PTBsputum smears are often negative and chest Xrays may
show more infiltrates than cavities. Extra pulmonary TB is a frequent occurrence at low CD4 counts.
Pleuraleffusion,TBlymphadenopathy,pericardialdisease,miliaryTBandTBmeningitisareamongthe
morecommonformsofEPTB.
The WHO has developed a staging system for HIV infection which reflects the natural history of that
infection,rangingfromStages1through4.Stageonecorrespondstotheasymptomatic(latentstageof
HIVinfection)whileStage4isclassifiedasclinicalAIDS.DuallyinfectedpersonsareclassifiedasStage3.
OnceafamilymemberisidentifiedasHIVinfected,healthcareworkersshouldencourageandactively
facilitateHIVtestingforotherfamilymembers.
Ministry of Health - Guyana, 2011 | TB-HIV Co-management
112
Table13:HowPTBdiffersinearlyandlateHIVinfection
FEATURESOFPTB
STAGESOFHIVINFECTION
Early
Late
Clinicalpicture
Oftenresemblespostprimary
OftenresemblesprimaryPTB
PTB
Sputumsmearresult
Oftenpositive
Oftennegative
ChestXrayappearance
Oftencavities
Ofteninfiltrateswithoutcavities
DiagnosisofHIV/TBCoinfection
ScreeninganddiagnosisofTBdiseaseinadolescentsandadultslivingwithHIV
HIV is the strongest risk factor for developing TB disease in those with latent or new Mycobacterium
tuberculosisinfection.TheriskofdevelopingTBdiseaseisbetween2134timesgreaterinpeopleliving
withHIV(PLHIV)thanamongthosewhodonothaveHIVinfection.Globally,TBdiseaseisresponsible
formorethanonefifthofalldeathsamongPLHIV.
Previously undiagnosed TB disease is common among PLHIV. Intensified TB case finding (ICF) and
treatmentofTBdiseaseamongPLHIVinterruptsdiseasetransmissionbyinfectiouscasesandreducesTB
relatedmorbidityandmortality.ActivescreeningforTBdiseaseamongPLHIVofferstheopportunityto
identifyTBdiseaseearly,initiateappropriateTBtherapyquickly,andalsoprovideisoniazidpreventive
therapy (IPT) for those who do not have symptoms and signs of TB disease. (See section Isoniazid
PreventiveTherapyforPLHIV.)
All PLHIV, wherever they receive care, should be regularly screened for TB disease using a clinical
algorithm at every visit to a health facility or contact with a health worker. Those who do not have
currentcough,fever,weightlossornightsweatsareunlikelytohaveTBdiseaseandareeligibleforIPT.
ThisrecommendationisapplicableforPLHIVirrespectiveofthedegreeofimmunosuppression(e.g.,CD4
count),andforthoseonantiretroviraltherapy(ART).
113
SymptomscreeningforTBdiseaseamongPLHIV
ThefollowingquestionsshouldbeaskedofallPLHIVateveryvisittoahealthfacility:
Doyouhaveanyofthefollowingsymptoms?
1. Currentcough?
2. Fever?
3. Weightloss?
4. NightSweats?
AdultsandadolescentslivingwithHIVwhoreportanyoneofthefoursymptoms(currentcough,fever,
weightlossornightsweats)mighthaveTBdiseaseandshouldbeevaluated.Thisevaluationshould
includesputumcollectionforacidfastbacilli(AFB)smearexamination,chestradiograph,andpossibly
cultureofsputum.PatientswithHIVandTBmightpresentinwaysthatareclinicallydifferentthan
patientswithoutHIV.Forexample,PLHIVwithTBdiseasemighthavenormalchestradiographs,
absenceofcavitarydisease,andsputathatuponexaminationbysmearmicroscopyarenegativefor
AFB.Therefore,providersmustmaintainahighindexofsuspicionofTBdiseaseinPLHIVevenwhen
thesetestsarenotconclusive.CultureisamoresensitivediagnostictoolforPLHIVandshouldbe
consideredforpatientswithpositivesymptomscreens,normalchestradiographs,andnegativesputum
smearmicroscopyresults.Tuberculinskintests(TSTs)shouldnotbeapartoftheevaluationforTB
diseaseinPLHIVinadultsandadolescents,asanonreactiveTST(<5mm)doesnotimplytheabsenceof
TBdiseaseduetoimmunosuppressionamongPLHIV.
114
DiagnosisoflatentTBinfectioninadultsandadolescentslivingwithHIV
As mentioned in the previous section, all people living with HIV (PLHIV) should be screened for TB
disease using a clinical algorithm at every visit. Patients responding that they do not have any of the
four screening symptoms (current cough, fever, weight loss, or night sweats) are unlikely to have TB
disease,andshouldbescreenedforlatentTBinfectionwithatuberculinskintest(TST).TheTSTisused
to identify persons with infection, and for PLHIV, the individuals most likely to benefit from IPT. TST
screeningshouldoccuratenrolmentandannuallythereafter.Remindersinpatientchartsandinclinic
areas should be used to promote annual TST screening. PLHIV with a history of TB disease or a
previously positive TST should not undergo TST screening. Instead, they should have an annual chest
radiograph to look for TB disease, in addition to the symptom screening performed at each visit. For
PLHIV,aTSTresultinginaninduration5mmisconsideredreactive.ManyPLHIVmaybeanergicand
have a negative TST. Thus a twostage TST may be done four weeks apart, at the discretion of the
provider.
TuberculinskintestingforPLHIVandprovisionofIPT.
PLHIVwhoare
unlikelytohave
TBdisease
(nosymptoms)
TST5mm
ProvideIPT
TST<5mm
RepeatTSTannually
PlacementofTST
atenrollment
intoHIVcare
115
AlgorithmforTBscreeninginadultsandadolescentslivingwithHIV
AdultsandadolescentslivingwithHIV
ScreenforTBdisease:
Doesthepatienthaveanyoneofthefollowingsymptoms?
Currentcough
Fever
Weightloss
Nightsweats
No
Yes
AssessforcontraindicationstoIPT
InvestigateforTBandotherdiseases
No
Evaluate
forIPT*
Yes
DeferIPT
Other
diagnosis
Giveappropriate
treatmentand
evaluateforIPT*
NotTB
TB
Followupand TreatTB**and
ensureearly
evaluatefor
initationofART
IPT*
ScreenforTBregularlyateachencounterwithahealthworkerorvisittoahealthfacility
*PatientsshouldbeevaluatedforIPTwithatuberculinskintesttodetermineeligibilityforIPT.
**AnypatientwithactiveTBdiseaseshouldbeginTBtreatmentimmediately,andstartARTassoonastolerated
inthefirst8weeksofTBtherapy,irrespectiveofCD4countandclinicalstage
116
DiagnosisofextrapulmonaryTB(EPTB)inHIVinfectedpersons
The definitive diagnosis of EPTB in dually infected persons is a difficult one. Diagnosis may be
presumptive, provided other conditions can be excluded. Persons usually present with constitutional
features (fever, night sweats, weight loss) and localized features (related to the site of disease). The
degreeofcertaintyof diagnosisdependsontheavailabilityofdiagnostic tools,e.g.specialized Xrays,
ultrasound,biopsy.
DiagnosisofHIVinTBcases
HIVtestingmustbedoneaspartoftheroutinediagnosticevaluationofTBcases.WhileHIVtestingin
Guyanaisvoluntarywithinformedconsent,TBcasesmustbeawareoftheimportanceofknowingtheir
HIVstatusinthecontextofTBtreatment.HIVtestingforTBcasesshouldbeofferedonanoptoutbasis.
Provider initiated testing and counselling (by a physician, nurse, medex or other trained health care
worker)canbeprovidedtotheTBcaseifanHIVcounsellor/testerisnotavailable.
TreatmentofTBHIV
PreventivetherapyforlatentTBinduallyinfectedpersons
AdultsandadolescentswhoarelivingwithHIV,haveapositiveTST(5mm)andareunlikelytohaveTB
disease(accordingtoastandardizedTBsymptomscreen)shouldreceiveIPTatadosageof5mg/kg(not
exceeding300mg)dailyforaminimumofninemonths.FiftymilligramsofvitaminB6shouldalsobe
prescribedtopreventthepossibilityofisoniazidinducedneuropathy.IPTshouldbegiventoPLHIVfor
whom TB has been excluded (e.g., negative symptom screen) irrespective of the degree of
immunosuppression (e.g., CD4 count), and also to those on ART. Providing IPT to PLHIV does not
increasetheriskofdevelopingisoniazidresistantTB.Therefore,concernsregardingthedevelopmentof
isoniazidresistantTBshouldnotbeabarriertoprovidingIPT.Amonghouseholdcontacts,peopleliving
withHIV(regardlessoftheirARTstatusorCD4count),andchildren(regardlessoftheirHIVstatus)who
donothaveTBdiseasearecandidatesforIPT.
117
TreatmentofactiveTBinTBHIVcoinfectedpersons
Case Death rates for treated TB cases are higher in HIVpositive than in HIVnegative persons. Case
fatality is higher in people living with HIV with smearnegative pulmonary and extrapulmonary TB, as
these persons are generally more immunosuppressed than those with smearpositive TB. The case
fatalityrateisreducedinpersonswhoreceiveconcurrentART.
The management of TB in HIVinfected persons is the same as in seronegative persons, with the
exception that thiacetazone should never be used. The first priority for HIVpositive TB cases is to
initiate antiTB treatment and cotrimoxazole therapy, followed by ART. New TB casesliving with HIV
shouldbetreatedwiththeregimensbelow.
Table14:StandardregimensfornewTBcases
CONTINUATIONPHASE
INTENSIVEPHASETREATMENT
2monthsofHRZE
4monthsofHR
Dailydosing
Dailydosing(ifnotpossible)thenDOTS(weekdayobservation
byaDOTworkerandweekendobservationbyafriendor
familymember)
Key:H=isoniazid,R=rifampicin,Z=pyrazinamide,E=ethambutol,S=streptomycin
NB:WHOnolongerrecommendsomissionofethambutolduringtheintensivephaseoftreatmentfor
caseswithnoncavitary,smearnegativePTBorEPTBwhoareknowntobeHIVnegative.Intuberculous
meningitis,ethambutolshouldbereplacedbystreptomycin.
118
Table15:DosingfrequencyfornewTBcases
Daily
OptimalforanyTBcasesreceivingDOTS
Threetimeperweek
AcceptablealternativeprovidedthattheTBcaseisreceiving
DOTSandisnotHIVinfected
NB:
a.
NewTBcasesarethosewhohavehadnopriorTBtreatmentorwhohavebeenreceivingTBtreatmentfor
lessthan1month.
b.
TB cases who are living with HIV should receive at least the same duration of TB treatment as HIV
negativeTBcases(Strong/Highgradeofevidence).
c. HIVpositive TB cases who have been previously treated for TB should receive the same retreatment
regimensasHIVnegativeTBcases.
Persons dually infected with HIV and TB can be treated for both conditions at the same time. The
priorityhowevershouldalwaysbetotreatTBfirstespeciallyifcasesputumsmearpositive.Thedecision
ofwhentostartARTisguidedbytheCD4count(see
Table1616below).WHOrecommendsthatallTB/HIVpatientsstartARTassoonaspossibleregardless
ofCD4count.AllpatientswithTBandHIVshouldbestartedonARTby8weeks(attheverylatest)after
TBtreatmentinitiation.
119
Table16:RecommendationsformanagingHIVTBcoinfection
CD4lymphocytecount
Generalrecommendation
AllTB/HIVcoinfected
patients
Offercotrimoxazoletoall960mgsoncedaily(adultsandchildren
withweight>25kgs).Forchildren4mgs/kgoncedaily.
<200cells/mm3
TreatTBfor2weeksandtheninitiateonHAART*
200500cells/mm
TreatTBfor24weeksandtheninitiateHAART
>500cells/mm3
TreatTBfor48weeksandtheninitiateonHAART
*InitiationofHAARTat2weeksaftertreatingTBcansometimesbedifficultduetoanumberoffactors
includingsideeffectsandpoortolerabilityofmedications.Inthesesituationsclinicaljudgmentis
requiredonacasebycasebasis.
An HIVinfected person who is already receiving ART and is diagnosed with active TB should be
continued on ART and started on TB treatment immediately. However, the ART regimen for these
personsmayneedto be changed.Certainantiretroviraldrugs(ARVs)interactwithTBdrugsand may
produce the same side effects (hepatotoxicity and reduction of availability of some drug classes);
therefore,itisimportanttomonitorpersonsondualtreatment.
Rifampicin is a powerful enzyme inducer of CYP450 (a well known group of human enzymes that
metabolizedrugsinthebody)andhaseffectsonseveralmetabolicpathways.Rifampicininteractswith
proteaseinhibitors,NNRTIs,CCR5inhibitors,andantimicrobialssuchasfluconazole.Rifabutin,although
intheclassofdrugsasrifampicin,isalesspotentinducerofCYP450andmaybeusedasanalternative
toovercomesomeofthesedifficulties.
120
RifampicininducescertainliverenzymesthatmetabolizeNevirapineandproteaseinhibitors(PIs).This
reduces the bioavailability of these drugs and facilitates the emergence of resistant strains of HIV.
NevirapineandmostPIsshouldthereforenotbeusedtotreatHIVinfectedpersonswithactiveTBona
Rifampicinbased regimen. Efavirenz with dual nucleotide reverse transcriptase inhibitors (NRTIs) is
the HAART regimen of choice for HIVTB coinfected persons on a Rifampicinbased TB regimen.
Nevirapine should only be used when there is no alternative drug, and capacity for close clinical and
virologic monitoring is available. Liver function should be carefully monitored as both nevirapine and
rifampicin cause hepatotoxicity. Lopinavir/ritonavir may be used with rifampicin under special
circumstances, with ritonavir for additional boosting; however there is an increased risk of
hepatotoxicityandincreaseddiarrheaasthedoseoflopinivir/ritonivir(Alluvia)isdoubledto4tablets
twice daily. In the absence of efavirenz, or when efavirenz toxicity or another contraindication is
present,atripleNRTIregimenincludingabacavirmaybeused(pleaseconsulttheNationalGuidelines
forManagementofHIVInfectedandHIVExposedAdultsandChildren7).Whentreatinganypersonco
infectedwithHIVandTB,theadviceofanexperiencedphysicianshouldbesought.
121
Table17:CommonARVsusedinthetreatmentHIVincomorbidcases
ARV
DOSE
DIETARY
RESTRICTION
ADVERSEEFFECTS
NNRTI
Efavirenz(EFV)
600mgoncedaily,
Donottakewithhigh Centralnervoussystem
preferablyatnight
fatmeals
300mgtwicedaily
None
effects,rash
NRTIs
Zidovudine(AZT)
Anaemia,Neutropoenia
Tenofovir(TDF)
300mgoncedaily
None
Renaltoxicity
Lamivudine(3TC)
150mgtwicedaily
None
Peripheralneuropathy,
lacticacidosis(rare)
Emtricitabine
200mgoncedaily
None
Lopinavir+
200mg/50mg[2tablets]
None
Ritonavir
twicedaily
Skindiscolouration
(FTC)
PIs
Metabolicchanges
(LPV/r)Aluvia
Truvada(Tenofovir(TDF)andEmtricitabineFTCandEfavirenzarethefirstlineARVSinHIVpositive
patients.
122
Table18:DrugcombinationsanddosemodificationinTBHIVcoinfection
DRUGCOMBINATION
Rifampicin+Efavirenz
DOSEMODIFICATION
Useefavirenz600mg/day
Rifampicin+Nevirapine
Notrecommended
Rifabutin+Efavirenz
Rifabutin+Nevirapine
Rifampicin+unboostedPI
Rifampicin+boostedPI
Increaserifabutinto450mgdaily
Notrecommended
Donotuse
Notrecommendedbecauseofpoorpharmacokineticsand
highratesofhepatotoxicityinhealthyvolunteers
Rifabutin+boostedPI
Reducerifabutinto150mgthreetimesperweek
Rifampicin
Rifampicin,acornerstoneofTBtreatment,inducescytochromeP450intheliver,thereby
alteringlevelsofmanymedicationsincludingantiretrovirals.Thisresultsinrapidclearanceof
antiretroviralsleadingtosubtherapeuticdruglevelsandultimatelyHIVdrugresistance.
Duetothisfact,HIVpatientsonsecondlineHAARTincludingLopinavi/ritonavir(LPV/rAlluvia
orKaletra)useRifabutininsteadofRifampicin.
123
Rifabutin
Rifabutin(RFB)isprimarilybactericidalantibioticdrugusedtotreattuberculosis.Itseffecton
bacteriaisbasedonDNAdependentRNApolymeraseblockingdrugrifamycinS.,asemi
syntheticderivative,efficientforexample,inhighlyresistantmycobacteria,theGrampositive
andsomeareeffectiveagainstGramnegativebacteria,butalsoagainstMycobacterium
tuberculosis,M.lepraeandM.aviumintracellulare.
Rifabutinisusedinthetreatmentofmycobacteriumaviumcomplexdisease,abacterial
infectionmostcommonlyencounteredinlatestageAIDSpatients.
RifabutiniswelltoleratedinpatientswithHIVrelatedtuberculosis(TB),butpatientswithlow
CD4cellcountshaveahighriskoftreatmentfailureorrelapseduetoacquiredrifamycin
resistance,anewstudyfound.
SincepatientscoinfectedwithTBandHIV/AIDSarelikelytogetTBtreatedfirst,doctorsand
patientsshouldbeawareofapossiblerifamycinresistanceissue,iftheCD4issosuppressedat
Dose
Adult:300mgorallythreetimesweekly
Children:5mg/kgorallythreetimesweekly
Sideeffects
Themostcommonsideeffectisfromthegastrointestinalsystem.
Nauseaandvomiting
Diarrhoea
Changesintaste
Browndiscolorationtoskin,urine,sweat,saliva,ortears.Thiseffectisharmlessandwill
disappearwhenthemedicationisstopped.However,denturesandcontactlensesmay
bepermanentlystained.
Rarebutserioussideeffectsoccur:easybleeding/bruising,signsofanewinfection
(suchasfever,persistentsorethroat/cough),muscleweakness/pain,joint
pain/swelling,eye
124
pain/redness,visionproblems,chestpain/pressure,unusualweakness/tiredness
Rarelycauseasevereintestinalcondition(Clostridiumdifficileassociateddiarrhea)due
toatypeofresistantbacteria.
Seriousallergicreaction,including:rash,itching/swelling(especiallyofthe
face/tongue/throat),severedizziness,troublebreathing
Themostcommonsideeffectsareassociatedwiththegastrointestinalsystemwhichimproves
withantiemetics.Therecommendeddrugispromethazine.Promethazineisaphenothiazinein
thesamedrugclassaschlorpromazine(Thorazine/Largactil)andtrifluoperazine(Stelazine).
However,unliketheotherdrugsinthisclass,promethazineisnotusedasanantipsychotic.It
usedasanantihistamine,sedative,andantiemetic(antinausea).
Nauseaandvomitingmaybemanagedwith12.525mgadministeredevery46hoursas
needed.
Table19:InvestigationsduringTBtreatment
INVESTIGATIONSBaselineinvestigations:
CD4countandpercentage;
LFTsincludingbilirubin
serumcreatinineandBUN
CBCwithplateletcount;
hepatitisBandCserology;
Glucoseandlipidpanel
Priortoethambutol:testingofvisualacuitywithSnellenchartandcolourvisionwithIshiharaplates
Immunereconstitutionsyndrome(IRIS)
Occasionally,personswithHIVrelatedTBmayexperienceatemporaryexacerbationofsymptoms,signs
orradiographicmanifestationsofTBafterbeginningantiTBtreatment.ThisparadoxicalreactioninHIV
infectedpersonswithTBisthoughttobearesultofimmunereconstitution,astheCD4countincreases.
Thisreactionoccursusuallyduringthefirst112weeksafterbeginningHAART.Thisoccursfrequentlyin
125
persons who are treated simultaneously for HIV and TB and have a very low CD4 count (<200
cells/mm3).Symptomsandsignsmayincludehighfever,lymphadenopathy,expandingcentralnervous
system lesions and worsening of chest Xray findings. A thorough evaluation is necessary to exclude
other causes, particularly TB treatment failure, before diagnosing a paradoxical reaction. Do not stop
HAARTorTBmedication.Forsevereparadoxicalreactions,prednisone(12mg/kgfor12weeks,then
graduallydecreasingdoses)mayhelp.
DirectobservedtherapyforHAART(DOTHAART)alongwithTBmedicationshouldbeencouragedasa
treatmentenforcementoptionforHIV_TBcoinfectedpersons.
126
13
DRUGRESISTANTTB
MDRTB
Suspected or proven (former WHO Category IV TB cases) include those that remain sputum positive
aftercompletingaretreatmentregimen,andsuspectedorlaboratoryconfirmedMDRTBcases.Drug
resistant TB is a naturally occurring phenomenon caused by the mutation of the TB bacillus which
reducesitssusceptibilitytoantiTBdrugs.TBbacillimayberesistanttoasinglefirstlineTBdrug(mono
resistantTB)ortwoormorefirstlineTBdrugs(polyresistantTB).MDRTBreferstoTBbacillithatare
resistant to the two most potent antiTB drugs isoniazid and rifampicin. MDRTB strains that are also
resistanttoatleastonefluoroquinoloneandasecondlineinjectabledrugaredescribedasextensively
drugresistant(XDRTB).DrugresistantTBmaybeprimaryifthecasewasinfectedwithadrugresistant
TB strain, or acquired in cases with previously pansusceptible MTB that became resistant during
treatment.
MDRTB and XDRTB are manmade, resulting from the selection of M. TB strains resistant to INH and
rifampicin, and also to secondline drugs due to insufficient drug levels in TB cases. Various factors
contribute towards the emergence of resistant strains of the TB bacilli and may be grouped as
programmatic factors (the absence of or nonadherence to TB guidelines, poor training and poor
monitoringoftreatment),inadequatesupplyorqualityofantiTBdrugsandnonadherenceofTBcases
totreatmentregimens2,3,and11.
MDRTBCasefinding
Resistant strains of MTB are transmitted similarly to susceptible strains. Persons at increase risk of
becoming infected with MDRTB strains include contacts of MDRTB cases and health care workers
caringfor MDRTB cases. Persons at increased risk of developing MDRTB include Category II
retreatment cases (default, relapse, failure) HIV coinfected and diabetics.. These cases should be
targetedforAFBcultureandDST.
127
TargetgroupsforDSTincludethefollowing:
Newcasesoftreatmentfailures
TreatmentrelapseaftercompletingCategoryIorIITBtreatment
Sputumpositivetreatmentdefaulters
ContactsofMDRTBcaseswithactiveTB
Diabetics
HIVpatients
Table20:ClassificationofsuspectedorprovenMDRorXDRTBcase
CLASSIFICATION
NewMDR(suspectedorproven
cases)
DESCRIPTION
Cases who have never received antiTB treatment or who
havereceivedantiTBtreatmentforlessthanonemonth
(formerWHOcategoryIV)
Previouslytreatedwithfirstline
drugsonly
Cases who have been treated for one month or more with
firstlineantiTBdrugsonly
Previouslytreatedwithsecond
Cases who have been treated for one month or more with
linedrugs
oneormoresecondlineantiTBdrugs,withorwithoutfirst
lineantiTBdrugs
Transferin
Cases who have been transferred from another register for

treatmentofdrugresistantTBtocontinuetreatment
Other
Cases who do not fit the above definitions including cases

whoweretreatedoutsideDOTSprogrammes
Diagnosis
DrugresistantTBisalaboratorybaseddiagnosis.CasesathighriskofdrugresistantTBshouldhaveAFB
culture and DST done. In Guyana, MDRTB is diagnosed using molecular methods (the Hain test) and
nitratereductaseassay(NRA).TheHaintestisamultiplexpolymerasechainreactionlineprobeassay
that detects M. tuberculosis complex and genetic mutations associated with isoniazid and rifampicin
Ministry of Health - Guyana, 2011 | Drug Resistant TB
128
resistance. . The test gives a rapid result (within 72 hours of submission of the specimen). NRA is
conductedwithsolidculturesandisbasedontheabilityofM.tuberculosistoreducenitratetonitrite,
detected by adding the Griess reagent to the medium. This test can be conducted either on M.
tuberculosisisolatesordirectlyfromclinicalspecimenwithaturnaroundtimeofabout14to21days.
TreatmentofMDRTB
AllsuspectedMDRandXDRTBcasesneedtobediscussedandevaluatedbyseniorTBphysiciansatthe
Georgetown Chest Clinic (centre of excellence) prior to beginning any treatment regimen. TheseTB
cases must be directlyobserved daily. Many of these TB cases may need special hospitalization to
closelymonitortheircareandaccessthenecessarylaboratorytestsandantiTBdrugs.Thisalsoprotects
thegeneralpublicandcontactsfrompossibleexposure11.
Generalprinciples
Cases classified as retreatment (failures, defaulters, or treatment relapse) should be considered
infected with drugresistant TB.. DST should be ordered before treatment is initiated. The empiric
treatmentregimencanbeutilizedforotherMDRTBsuspectsuntilDSTresultsareavailable.Theempiric
MDRTB treatment regimen must consist of at least four new drugs including an injectable agent
(Kanamycin, /Quinolone/ Ofloxacin/Levofloxacin) and other second line drugs (Ethionamide /
Protionamide and Cycloserine). Pyrazinamide may be added to this regimen. The empiric treatment
regimen may change depending on new information and availability of medications in country. The
empirictreatmentregimencanbeamendedonceDSTresultsareavailable.
ThechoiceofthetreatmentregimenmustbeguidedbythetreatmenthistoryandDSTresultsandmust
bedoneinconsultationwithanexperiencedTBphysician.Beforetreatmentisinitiatedwithsecondline
antiTBdrugs,theNTPmustbenotifiedofthecase.
For cases who are failing the intensive phase of retreatment (former WHO category II), , a standard
regimen containing three new secondline drugs (kanamycin, levofloxacin/ofloxacin and ethionamide)
andtwofirstlinedrugs(ethambutolandpyrazinamide)isrecommendeduntilDSTresultsareobtained.
The DST will guide to the specific drug sensitivity of the patient. The duration of this new intensive
129
phaseofsuspectMDRisdeterminedbythesputumcultureconversion.Sputumconversionisdefinedas
two sets of consecutively negative sputum smears and cultures taken 30 days apart. Sputum smears
should be done monthly throughout the full course of treatment. Cultures should be done initially,
followedby2monthintervals(i.e.,months2,4and6)duringtheintensivephaseandquarterlyinthe
continuationphaseofretreatmentforsuspectorprovenMDR.
RememberthesesuspectedMDRorXDRaretobemanagedbytheexperiencedphysiciansattheGCC.
TheavailabilityoftheabovemedicationswilldependonwhichareinthecountryattheNTP.
130
Table21:Treatmentregimenbasedonpatternofdrugresistance
MOSTRECENT
ANTITB
RESISTANCE
MDRREGIMEN
COMMENT
REGIMEN
HRZE
HR
6(ZE+KM/S+LEVO
EitherbothZandEcanbeused.Alternatively
/OFL+ETO)
toreducepillburdenEcanbeomitted.Sis
or18(ZE+OFL+
anoptioninthisregimenasprevious
ETO)
exposuretoregimenscontainingSisunlikely;
therefore,susceptibilityislikely.However,
KANismoreeffectivethanS,andistherefore
thepreferreddrug.
HRZES
HR
6(KM+
Casesinthiscategorywouldhavebeen
LEVO/OFL+ETO+CS exposedtoEandPontwooccasions.
+PAS)/
Therefore,susceptibilitytothesedrugsmay
18(LEVO/OFL+ETO+ havebeencompromisedandtheymayhave
CS+PAS)
reducedefficacy.Someexpertsstill
recommendedthatPbecontinuedbecause
ofitspotency,andintheabsenceof
evidenceofreducedefficacyitcouldstillbe
utilized.IfPisusedthenPASmaybeomitted.
Swouldhavebeencompromisedinthe
failingregimenandshouldnotbe
considered.
HRZES
Unknown
6(KM+
Similartoabove.
LEVO/OFL+ETO+CS
+PAS)/
18(LEVO/OFL+ETO+
131
CS+PAS)
Key: H = isoniazid; R = rifampicin; E = ethambutol; Z = pyrazinamide; S = streptomycin; OFL=ofloxacin; KAN=

kanamycin;ETH=ethionamide;CS=cycloserine.LEVO=levofloxacin
MostdrugresistantTBcaseswithpositivesputashouldsconverttonegativeaftercompletingsixmonths
of treatment with secondline antiTB treatment. Cases who remain persistently sputumpositive
beyondsixmonthsofobservedtreatmentwithsecondlineantiTBdrugsmustbeevaluatedformore
extensivedrugresistance.
In the continuation phase, a regimen of at least three drugs of certain or almost certain efficacy, of
which at least two must be oral secondline antiTB drugs started in the intensive phase, must be
utilized.Thedurationofthecontinuationphaseoftreatmentmustbeatleast18monthsaftersputum
conversion.
Table22:SecondlineantiTBdrugdosage
DRUG
Kanamycin
ACTION
Bactericidal
DOSAGEANDADVERSEEFFECTS
Theoptimaldoseis15mg/kgbodyweight,usually750mgto1g
givendailyor56daysperweek,bydeepintramuscularinjection.
Rotationofinjectionsitesavoidslocaldiscomfort.
Adverseeffects:Frequent:painatinjectionsite,renalfailure(usually
reversible).Occasional:vestibularandauditorydamage,
nephrotoxicity,peripheralneuropathy,rash.
Ofloxacin
Bactericidal
Tablets(200,300or400mg).Usualdose:400mgtwicedaily
Generallywelltolerated.
Adverseeffects:Occasional:gastrointestinalintolerance;CNS
headache,malaise,insomnia,restlessness,anddizziness.Rare:
allergicreactions;diarrhoea;photosensitivity;increasedLFTs;
132
tendonrupture;peripheralneuropathy.
Levofloxacin
PAS
Bacteriostatic
Tablets,sugarcoated,containingsodiumsalt:sodiump
aminosalicylate,0.5gofPAS.150mg/kgor1012gdailyin2divided
doses.Children:200300mg/kgdailyin24divideddoses.
Adverseeffects:Frequent:gastrointestinalintolerance(anorexiaand
diarrhoea);hypothyroidism(increasedriskwithconcomitantuseof
ethionamide).Occasional:hepatitis(0.30.5%);allergicreactions;
thyroidenlargement;malabsorptionsyndrome;increased
prothrombintime;fever.
Cycloserine
Bacteriostatic
Capsules(250mg).1015mg/kgdaily(max.1000mg),usually500
750mgperdaygivenintwodivideddoses
Adverseeffects:Frequent:neurologicalandpsychiatricdisturbances,
includingheadaches,irritability,sleepdisturbances,aggression,and
tremors,guminflammation,paleskin,depression,confusion,
dizziness,restlessness,anxiety,nightmares,severeheadache,
drowsiness.Occasional:visualchanges;skinrash;numbness,tingling
orburninginhandsandfeet;jaundice;eyepain.Rare:seizures,
suicidalthoughts.
Ethionamide/
protionamide
Bacteriostatic
Tabletscontaining125mgor250mgofactivedrug.Themaximum
optimumdailydoseis1520mg/kg/day(max.1g/day),usually
500750mg.
Adverseeffects:Frequent:severegastrointestinalintolerance
(nausea,vomiting,diarrhoea,abdominalpain,excessivesalivation,
133
metallictaste,stomatitis,anorexiaandweightloss).Occasional:
allergicreactions;psychoticdisturbances(includingdepression),
drowsiness,dizziness,restlessness,headache,andpostural
hypotension.Neurotoxicity(administrationofpyridoxinehasbeen
recommendedtopreventorrelieveneurotoxiceffects);transient
increasesinserumbilirubin;reversiblehepatitis(2%)withjaundice
(13%);gynaecomastia;menstrualirregularity,arthralgias,
leukopenia,hypothyroidismespeciallywhencombinedwithPAS.
Rare:reportsofperipheralneuritis,opticneuritis,diplopia,blurred
vision,andapellagralikesyndrome,reactionsincludingrash,
photosensitivity,thrombocytopeniaandpurpura.
MonitoringMDRTBcases
CaseswithMDRTBmustbesupervisedthroughouttreatment.Inareaswheredirectobservationisnot
available,theNTPmustbenotifiedsothatspecialarrangementscanbemadeforsupervisedtreatment.
The intensive phase of treatment for MDRTB cases is best conducted in an inpatient facility with
adequateairborneinfectioncontrolmeasures.MDRTBcasesthatarerenderednoninfectiousafterthe
intensive phase can be followed up at home. MDRTB cases on secondline treatment regimens must
receivetheirantiTBdrugsatleastfivedaysperweekthroughouttheentirecourseoftreatment.Cases
shouldbeseenmonthlybyaTBexperiencedphysician.Assideeffectsaremorecommonwithsecond
linethanfirstlineantiTBdrugs,DOTSworkersandtheclinicalteammustassesscasesforsideeffectsat
homeandclinicvisits2,11.
134
Table23:MonitoringMDRTBcasesontreatment
TYPEOFMONITORING
RECOMMENDEDFREQUENCY
Evaluationbyclinician
Atbaseline,thenmonthly
MonitoringbyDOT
AteveryDOTencounter
worker
Sputumsmearsand
Sputumsmearsmonthlythroughouttreatment
cultures
Culturesatmonths3,6,9,12,18and24
Weight
Atbaseline,thenmonthly
Chestradiograph
Atbaseline,thenevery6months
Serumcreatinine
Atbaseline,thenmonthlywhilereceivinganinjectabledrug
Serumpotassium
Monthlywhilereceivinganinjectabledrug
Thyroidstimulating
Every6monthsifreceivingethionamide/protionamideand/orPAS;and
hormone(TSH)
monitormonthlyforsigns/symptomsofhypothyroidism
(TSHissufficientforscreeningforhypothyroidism;itisnotnecessaryto
ensurehormonethyroidlevels)
Liverserumenzymes
Periodicmonitoring(every13months)forcasesreceivingpyrazinamidefor
extendedperiodsorforcasesatriskfororwithsymptomsofhepatotoxiticy
HIVscreening
Atbaseline,thenrepeatifclinicallyindicated
Pregnancytests
Atbaselineforwomenofchildbearingage,thenrepeatifindicated
Treatmentoutcomes
Suspected and proven MDR/XDRTB cases must be recorded in the TB register and reported using
standardformsprovidedbytheNTP.TreatmentoutcomesofMDR/XDRTBcasesareevaluatedsimilarly
astheoutcomesofotherTBcases.
Table24:TreatmentoutcomesdefinitionsforMDR/XDRTBcases
OUTCOME
DESCRIPTION
Cured
AcasewhohascompletedtreatmentaccordingtotheNTPsprotocolandhasat
least five consecutive negative cultures from samples collected at least 30 days
apartinthefinal12monthsoftreatment.1
135
Treatment
A case who has completed treatment according to the NTPs protocol but does
completed
not meet the definition for cure because of lack of bacteriological results (i.e.,
fewerthanfivecultureswereperformedinthefinal12monthsoftreatment).
Failed
Treatment will be considered to have failed if two or more of the five cultures
recordedinthefinal12monthsoftherapyarepositive,orifanyoneofthefinal
threeculturesispositive.2
Defaulted
Acasewhosetreatmentwasinterruptedfortwoormoreconsecutivemonthsfor
anyreason.
Died
AcasewhodiesforanyreasonduringthecourseofMDRTBtreatment.
Transferredout
A case who has been transferred to another reporting and recording unit and
whosetreatmentoutcomeisunknown.
If only one positive culture1 is reported during that time, and there is no concomitant clinical evidence of
deterioration,acasemaystillbeconsideredcured,providedthatthispositivecultureisfollowedbyaminimumof
threeconsecutivenegativeculturestakenatleast30daysapart.
2
Treatmentwillalsobeconsideredtohavefailedifaclinicaldecisionhasbeenmadetoterminatetreatmentearly
becauseofpoorresponseoradverseevents.Theselatterfailurescanbeindicatedseparatelyforthepurposesof
subanalysis2,11
Table25:Drugdosagebybodyweightofthecase2,3,11
DRUG
WEIGHT
<33kg
3350kg
5170kg
>70kg1
Streptomycin(S)(1gvial)
1520mg/kgdaily
500750mg
1000mg
1000mg
kanamycin(km)(1gvial)
1520mg/kgdaily
500750mg
1000mg
1000mg
136
Amikacin(Am)(1gvial)
1520mg/kgdaily
500750mg
1000mg
1000mg
Capreomycin(Cm)(1gvial)
1520mg/kgdaily
500750mg
1000mg
1000mg
Ofloxacin(Ofx)(200,300,400mg)
1520mg/kgdaily
800mg
800mg
8001000mg
Levofloxacin(Lfx)(250,500mg)
7.510mg/kgdaily
750mg
750mg
7501000mg
Moxifloxacin(Mfx)(400mg)
7.510mg/kgdaily
400mg
400mg
400mg
Ethionamide(Eto)(250mg)
1520mg/kgdaily
500mg
750mg
7501000mg
Protionamide(Pto)(250mg)
1520mg/kgdaily
500mg
750mg
7501000mg
Cycloserine(Cs)(250mg)
1520mg/kgdaily
500mg
750mg
7501000mg
Terizidone(Trd)(300mg)
1520mg/kgdaily
600mg
600mg
900mg
150mg/kgdaily
8g
8g
812g
Paminosalicylicacid(PAS)
(4gsachets)
Alsomaximumdose
137
14
INFECTIONCONTROL
ForTBinfectioncontrol,thefirstpriorityforallhealthcarefacilitiescaringforTBcasesorpeoplewith
TBsymptoms,istoimplementthesetofTBinfectioncontrolmeasureslistedbelow:
I.
Administrativecontrols
PromptlyidentifypeoplewithTBsymptoms(triage),separateinfectiouscases,controlthe
spreadofpathogens(coughetiquetteandrespiratoryhygiene)andminimizetimespentin
healthcarefacilities.
Provide a package of prevention and care interventions for health care workers, including
HIVprevention,antiretroviraltherapy(ART)andIsoniazidpreventativetherapy(IPT)forHIV
positivehealthcareworkers.
II.
Environmentalcontrols
Useventilationsystems.
Use ultraviolet germicidal irradiation (UVGI) fixtures, at least when adequate ventilation
cannotbeachieved.
III.
PersonalProtectiveEquipment
Useparticulaterespirators(N95respiratorsforhealthcareworkersandsurgicalmasksfor
TBcases).
IV.
Facilitylevelmeasures(managerialactivities)
Identify and strengthen local coordinating bodies for TB infection control, and develop a
facility infection control plan (including human resources, and policies and procedures to
ensureproperimplementationofthecontrols)forimplementation.
138
Rethink the use of available spaces and consider renovation of existing facilities or
constructionofnewonestooptimizeimplementationofTBinfectioncontrolmeasures.
Conduct onsite surveillance of TB disease and infection among health care workers and
assessthefacilityforinfectioncontrolchallenges
Addressadvocacy,communicationandsocialmobilization(ACSM)forhealthcareworkers,
TBcasesandvisitors.
MonitorandevaluatethesetofTBinfectioncontrolmeasures.
Participateinrelevantresearchefforts.
Ideally there should be an infection control committee at each health care facility. However, there
couldbeafocalpersonforinfectioncontrol,i.e.,nursewhosurveysthehealthcarefacility/chestclinic
monthlytoensurethatitisincompliancewiththerecommendedoftheinfectioncontrolguidelinesfor
thehealthcarefacility.Thefocalpersonshouldthensubmitareportoffindingsandrecommendations
(correctiveactionplan)totheNTP.
AnInfectioncontrolChecklistshouldinclude:
AllTSTconversionsandoutcomes.
Allneedlesticksorsharpitempuncturesandoutcomes.
SubmissionoftheabovetotheNTPforevaluationanddevelopmentofaplanfortrainingand
improvedsafety.
TBinfectioncontrolbuildsontheimplementationofgeneralinfectioncontroleffortsandthoseaimed
atcontrollingairborneinfection.ThismayalsohelptodestigmatiseTBinfection,becausethefocusof
the public health interventions is to provide universal access for persons with symptoms of
communicablediseases.
To avoid nosocomial transmission of TB, time spent in health care facilities should be minimized, and
communitybasedapproachestothemanagementofTBcasesshouldbeprioritized.
Ministry of Health - Guyana, 2011 | Infection Control
139
InHIVprevalentsettings,thefocusinhealthcarefacilitiesshouldbeon(andinthecontextofpreviously
notedmeasures):
Separating TB cases living with HIV and other forms of immunosuppression from those with
suspectedorconfirmedactiveTB
ProvisionofapackageofpreventionandcareforHIVpositivehealthcareworkers
PossiblejobrelocationtolowerriskareasinthecaseofHIVpositivehealthcareworkers
ReferenceshouldbemadetotheNationalInfectionControlPolicyandPlan(tobecompletedin2011by
theMOH)formoredetailsonthenationalinfectioncontrolguidelines.
DetailedInfectionControlmeasures
Environmentalcontrols
Guyana is located in the tropics hence health care facilities should be designed to maximize use of
naturalventilation.
Ventilationsystemsshouldbedesignedandmaintainedtominimizemicrobialtransmissionand
contamination.Thissystemshouldallowforcontinuousairflowinandoutofthehealthcare
facility.
Adequatebedspacingisimportanttopreventinfection.Thecloserthebedstheincreasedrisk
ofthespreadofinfectionsairbornetothenextpatient.Therearenosetcriteriabutatleast2.7
metersbetweenbedsisrecommended.Themeasurementisdonefromthecenterofonebed
tothenext.Thereneedstobeenoughroomtoadequatelycleanbetweenbeds5,9.
Isolation rooms should have negative air pressure; an airhandling system (induction and
extraction)providing612airchangesperhour.Itisrecommendedthattheairisventedoutof
the room with the air being discharged through a filtration mechanism, separately from the
centralventilationsystem.Systemsmustbecheckedbyengineeringservicestoensuretheyare
infactnegativepressure.
140
Administrativecontrols
Standardprecautionsrequirethathealthcareworkersassumethatbloodandbodysubstancesofall
persons are potential sources of infection, regardless of diagnosis or presumed infectious status.
Additional precautions are needed for diseases transmitted by air, droplets and contact. These are
termed additional (transmissionbased) precautions. The terms standard precautions and
additional(transmissionbased)precautionshavereplacedprevioustermssuchasuniversalbloodand
body fluid precautions, universal precautions and barrier nursing. In other words all persons are
presumedtobeinfectiousnomatterwhattheirpresentdiagnosis.
Standardprecautionsmustbeusedbyallhealthcarestaffandvisitors,theseinclude:
Standardprecautionaryguidelinestopreventpuncturewounds:
Takecaretopreventinjurieswhenusingneedles,scalpelsandothersharpinstruments
orequipment.
Place used disposable syringes and needles, scalpel blades and other sharp items in a
punctureresistant container with a lid that closes and is located close to the area in
whichtheitemisused.
Takeextracarewhencleaningsharpreusableinstrumentsorequipment.
Neverrecaporbendneedles.
Sharpsmustbeappropriatelydisinfectedand/ordestroyedasperthenationalstandards
orguidelines.
SeeAppendix16fortheGuyananationalguidelinesonPostExposureProphylaxis(PEP)HandHygiene:
Appropriate hand hygiene can minimize the transmission of microorganisms acquired on the hands
duringduties.Handhygienenecessitiesinclude:cleanrunningwater,antimicrobialsoap,papertowels,
alcoholbasedantisepticagent(usedintheabsenceofwaterandsoap).Washordecontaminatehands:
Afterhandlinganyblood,bodyfluids,secretions,excretionsandcontaminateditems;
Betweencontactwithdifferentpatients;
Betweentasksandproceduresonthesamepatienttopreventcrosscontamination
betweendifferentbodysites;
141
Immediatelyafterremovinggloves;and
Use antibacterial soap, or antimicrobial agent such as an alcoholic hand sanitizer or

waterlessantisepticagent.
Airborne precautions are designed to reduce the transmission of diseases by air. Airborne
transmission occurs when droplet nuclei (evaporated droplets) <5 micron in size are
disseminated in the air. These droplet nuclei can remain suspended in the air for some time.
Droplet nuclei are the residuals of droplets and when suspended in the air, dry and produce
particles ranging in size from 15 micron. These particles can remain suspended in the air for
long periods of time, especially when bound on dust particles. The following air borne
precautionsneedtobetakenatTBsites:
Implementstandardprecautions.
PlaceinfectiousTBcaseinasingleroomthathasamonitorednegativeairflowpressure,
andisoftenreferredtoasanegativepressureroom.Theairshouldbedischargedto
theoutdoorsorspeciallyfilteredbeforeitiscirculatedtootherareasofthehealthcare
facility.
Keep doors closed. Anyone who enters the room must wear a special, high filtration,
particulaterespirator(i.e.,N95respirators).
Limit the movement and transport of a TB case from the room for essential purposes
only. If transport is necessary, minimize dispersal of droplet nuclei by masking the TB
casewithasurgicalmask.
Itisimportant togainthesupportof engineeringservicesto ensurethatthenegative

airflowpressureismaintained.Thismustbemonitoredonaweeklybasisorwhenevera
newTBcaseenterstheroom.
NB:Forinfectioncontrolmeasuresinthelaboratoryandatsputummicroscopysites,referenceshouldbe
madetotheLaboratoryManualandSputumMicroscopySiteManual.
142
PersonalProtectiveEquipment
Personal protective equipment reduces but does not completely eliminate the risk of acquiring an
infection. It is important that personal protective equipment be used effectively, correctly, and at all
times where contact with blood and body fluids may occur. Continuous availability of personal
protective equipment and adequate training for its proper use are essential. Personal protective
equipmentshouldbechosenaccordingtotheriskofexposure.
Health care workers should assess whether they are at risk of exposure to blood, body fluids,
excretionsorsecretions,andchoosepersonalprotectiveequipmentaccordingtothisrisk.
Avoid any contact between contaminated (used) personal protective equipment and surfaces,
clothingorpeopleoutsidetheclinicalcarearea.
Discardusedpersonalprotectiveequipmentinappropriatedisposalbags,anddisposeofasper
thepolicyofthefacility.
Donotsharepersonalprotectiveequipment.
Healthcareworkersmustalsobeawarethattheuseofpersonalprotectiveequipmentdoesnotreplace
theneedtofollowbasicinfectioncontrolmeasuressuchashandhygiene.
Personalprotectiveequipmentincludes:
Gloves:
Wear gloves when touching blood, body fluids, secretions, excretions or mucous
membranes.
ChangeglovesbetweencontactswithdifferentTBcases.
Change gloves between tasks/procedures on the same TB case to prevent cross

contaminationbetweendifferentbodysites.
RemoveglovesimmediatelyafteruseandbeforeattendingtoanotherTBcase.
Washhandsimmediatelyafterremovinggloves.
Disposableglovesshouldnotbereused;disposalshouldbeaccordingtothehealthcare
facilityprotocol.
143
Surgicalmask:Usedtoprotectmucousmembranesofthemouthandnosewhenundertaking
procedures that are likely to generate splashes of blood, body fluids, secretions or excretions.
Surgicalmaskshavebeendesignedtoresistfluidstovaryingdegreesdependingonthedesignof
the material in the mask. Surgical masks should not be reused and should be disposed of
accordingtothehealthcarefacilityprotocol.SurgicalmasksshouldbewornbytheTBcaseto
avoid spreading droplets >5 mm in the environment (these are not 100% protective but
decreasetheriskofdropletdispersion).
N95 respirators: Should be worn by all health care workers who are caring for infectious TB
cases. Each health care worker in this setting should be fittested to determine which N95
respiratorbestfitstheirfacethusofferingthemmaximumprotection.Oncefittestedaperson
willonlyneedtorepeatfittestingiftheyopttouseadifferenttypeofN95respiratorsorifthey
gained/lostweight,grewfacialhair,orsufferedfacialinjury.N95respiratorsareveryeffective
inpreventingtransmission.EachN95respiratorcanbewornfor35daysdependingonnumber
ofhoursofuseeachday,howmuchthehealthworkerperspiresandstorageandhandling.N95
maskshouldbestoredbyhangingfreely.
Apron/gown:Protectthehealthcareworkerandtheirworkingclothesfrombloodborneand
tissuepathogenswhichmaycontaminatepatientsorotherhealthcareworkers.Theuseof
longgownswithlongsleevesshouldalwaysbeusedwithappropriatemasksandglovesto
protectthehealthcareworker.Disposablegownsshouldberemovedcarefullyanddiscarded
intotheappropriatebins.
Donningpersonalprotectiveequipment
WhenusingPPE,theapron/gownshouldbedonnedfirst,thenthemask/respiratorandthenthegloves.
Removalofpersonalprotectiveequipment
WhenremovingPPEthegown/apronshouldberemovedfirst,thentheglovesandthemask/respirator
lastly.
144
CareofHealthCareWorkers
A health assessment should be conducted for health care workers upon recruitment and annually
thereafter. If a health care worker is found to be infected with TB or has TB disease this should be
promptly reported to the NTP. The health assessment should include immunization history, previous
exposurestocommunicablediseases(e.g.TB)andimmunestatus.Everyhealthcareworkershouldhave
an annual TST unless they have a history of a positive TST, treated for TB infection or TB disease and
thusshouldbefollowedyearlywithachestxrayannually.
Immunizationsrecommendedforhealthcarepersonnelinclude:HepatitisAandB,influenza,measles,
mumps,rubella,tetanus,anddiphtheria.Immunizationagainstvaricellaandrabiesmaybeconsidered
inspecificcases.
145
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
15
SURVEILLAN
U
NCE,MON
NITORINGANDEVA
ALUATION
13
Diseasesurveillance:Theongoinggsystematicccollectionand
danalysisofd
dataandtheprovisionof
informatio
onwhichlead
dstoactionb
beingtakento
opreventand
dcontroladissease,usuallyyoneofan
infectioussnature.
RecordiingandReeporting
Accurate records of all
a individual TB cases, maintenance
m
of registers, and regularr reporting are all
required data collection and reporting components of an efficient survveillance systtem. The NTP has
danumbero
ofdatacollecctiontoolsthatarereview
wedandupdaatedperiodiccallyasdatan
needs
developed
changeovvertime.Thesedatacollecctiontoolsare:
uyana, 2011 | 15
5
14
46
TBMedicalRecord(Appendix10):Initiallycompletedat thefirstclinicvisit.TheTBcaseismonitored
throughout treatment and a health assessment is conducted at each clinic visit and recorded on the
followupsheets.
ActiveTBCaseReport(Appendix11):Filledinduplicate;theoriginalcopyisfilledwhenaTBcasestarts
treatment(Sections1to5)andissubmittedtotheNTP.Thetreatmentcompletionsection(Section6)
ontheduplicatecopyiscompletedwhenaTBcasecompletestreatmentandissubmittedtotheNTP.
Treatment should ideally be completed six months after commencement; however, a treatment
outcome should be reported within one year after a TB case started treatment. The Active TB Case
ReportsareaccumulatedovertheperiodofthemonthandsubmittedtotheNTPatthesametimethe
MonthlyReportissubmitted.
Registers: The data recorded in the TB Medical Record should be used to update the respective
registers,onadailybasis.Therearethreecategoriesofregisters,Regionalregistersareusedatregional
TB clinics/BMUs and is designed specifically for the regional setting, GCC registers are designed to be
usedattheGeorgetownChestClinicandPrisonregistersusedatthecorrection/detentionfacilities..
RegionalregistersareusedattheTBclinics.
Screening Register: Used to record all persons (walkin, referred, contact of TB cases)
whowerescreenedforTB.
Day Book: Used to assign appointments to TB cases, monitor missed appointments,
monitorcasesofTBdiagnosisandtreatmentateachclinicvisit.
BasicManagementUnit(BMU)Register:UsedtomonitorthetreatmentofallcasesofTB
diseaseorHIVTBcoinfection.
IPT Register: Used to monitor treatment of all cases of TB infection or TB HIV co
infection.
HIV Register: Used to monitor all HIVinfected persons who are being treated for TB
infectionorTBdisease.
Laboratory Register: Used to track smear microscopy investigation and results for each
TBsuspectandTBcase.

Evaluation
2011 | Surveillance, Monitoring and
147
TransferRegister:UsedtorecordallTBcasestransferredintooroutoftheBMU.
GeorgetownChestClinicregistersconsistsofthefollowing:
ScreeningRegister:Usedtorecordandmonitorallpersons(walkin,referred,contactof
TBcases)screenedforTB.
Respiratory Symptomatic Register: Used to record and monitor persons with signs and
symptomsofTB.
InvestigationRegister:Usedtomonitorallrequesteddiagnostictestsandtestresultsfor
eachTBsuspectandTBcase.
DayBook:UsedtomonitorTBdiagnosisandtreatmentateachvisit.
Appointment Register: Used to assign clinic appointments to TB cases and monitor
missedappointments.
BMU Register: Used to monitor treatment of all cases of TB disease or TB HIV co
infection.
IPT Register: Used to monitor treatment of all cases of TB infection or TB HIV co
infection.
HIV Register: Used to monitor all HIVinfected persons who are being treated for TB
infectionorTBdisease.
Laboratory Register: Used to track smear microscopy investigation and results for each
TBsuspectandTBcase.TransferRegister:UsedtorecordallTBcasestransferredintoor
outoftheBMU.
PrisonregistersareusedatthefiveprisonsandtheNewOpportunityCorp(inRegion2),these
consistof:
PrisonDayBook:usedtorecord,onadailybasis,allcasesscreenedandtreatedforTB.
BMU Register: used to monitor treatment of all cases of TB disease or TB HIV co
infection.

Evaluation
148
BMUMonthlyClinicReport(Appendix12.):Comprisedofdatagatheredfromtheaboveregisters.Itwas
developed by the NTP to facilitate monthly reporting of data from TB clinics/ BMUs to the NTP. The
BMU Monthly Clinic Report is submitted to the NTP by the 8th day of the month following the month
beingreported.ThePrisonMonthlyTBClinicReport(Appendix13)isutilisedbytheprisonsandNew
OpportunityCorptofacilitatemonthlyreportingofdatatotheNTP.
SurveillanceDataFlow
Allreportssubmittedshouldfollowthesurveillancestructurewhichisorganisedatthreelevels:
LevelI(TBclinic/BMU):thisiswherethecaseisdiagnosedandmanagedandistheprimarypointof
datacollectionandreporting.
Level II (regional DOTS Supervisor and RHO): monitors, supervises and provides guidance and
feedbacktotheTBclinics/BMUswithinitsjurisdiction,andverifiesreportsfromtheTBclinic/BMU
totheNTP.
LevelIII(nationallevel):collects,verifies,collatesandanalysesalldatafromtheTBclinics/BMUS.
The collation of the data is done by entering the BMU Monthly Clinic Reports in the NTP annual
spreadsheet and also the TB electronic database. This data is then analysed and the resulting
informationisusedtopreparereportsfordatadisseminationandfeedbacktostakeholders.
TB Clinic/BMU
Key
Regional
Feedback
Dataflow
National
Evaluation
149
Feedbackshouldalsobeprovidedattheregionalandperipherallevels.Feedbackcanbedoneformally
(reports,reviewmeetings,newsletters)orinformally(oralfeedback).
Monitoring is the routine tracking of programs using input, process, and outcome data that are
collectedonaregular,ongoingbasis.Processevaluationisusedtomeasurethequalityandintegrityof
programimplementationandtoassesscoverage.TheoverallpurposeofM&Eistomeasureprogramme
effectiveness, identify problem areas, gather lessons learned, and improve overall performance. M&E
activities are used to assess progress towards specific objectives and address weaknesses in program
design. A number of different methods or approaches to tracking changes and measuring program
performance are employed: monitoring, evaluation (i.e., process, outcome, and impact), and
surveillance13.
MonitoringandEvaluation
The data reported to the NTP is used to understand the local epidemiology of TB, monitor project
implementation, evaluate programme performance, inform program plans, and allocate resources.
Indicators are variables used to measure progress towards a goal, objective or target. Listed and
explainedinthetablesbelowaretheindicatorsusedbytheNTP.
Table26:ImpactandoutcomeindicatorsusedbytheNTP
INDICATOR
TBcasedetectionrate
DESCRIPTION
ThisindicatormeasuresanNTPSsabilitytodiagnoseandcollect
dataonTBcases.Ahighcasedetectionratewillmeanthat
transmissionbyundiagnosedinfectiousTBcasesiscurtailed,thus
resultinginlessTBdiseaseandlessTBrelatedmortalityinthe
population.

Evaluation
150
INDICATOR
DESCRIPTION
ThereisanemphasisonsmearpositiveTBcases(definitions2and
3)becausethesearethebacteriologicalconfirmedcaseswhich
representinfectiouscasesofTBthatareofthehighestpriorityin
termsofTBcontrol.
ThereisanemphasisondetectionunderDOTS(definition3)
becausedetectioninthecontextofaninternationally
recommendedTBcontrolstrategyisimportant.
Calculation:
a) Numerator:NumberofnewTBcasesdetected.
b) Denominator:EstimatednumberofnewTBcasescountrywide.
c) Numerator:NumberofnewsmearpositiveTBcasesdetected.
d) Denominator:EstimatednumberofnewsmearpositiveTBcases
countrywide.
e) Numerator:NumberofnewsmearpositiveTBcasesdetected
underDOTS.
f) Denominator:EstimatednumberofnewsmearpositiveTBcases
countrywide.
Treatmentsuccessrate
ThisindicatormeasuresanNTPscapacitytoretainTBcases
ofnewsmearpositive
throughacompletecourseofchemotherapywithafavourable
TBcases
clinicalresult.
Calculation:
a) Numerator:NumberofnewsmearpositivePTBcasesregistered
inaspecifiedperiodwhowerecuredandcompletedtreatment.
b) Denominator:TotalnumberofnewsmearpositivePTBcases
registeredinthesameperiod.
DOTScoverage
Thisindicatormeasurestheextentacountryspopulationis

Evaluation
151
INDICATOR
DESCRIPTION
coveredbyDOTS.Thegoalistocover100%ofthepopulation.
Calculation:
a) Numerator:PopulationlivingintheareaofBMUsimplementing
theDOTSstrategy.
b) Denominator:Totalpopulation.
Smearpositivityamong
TBsuspects
Thisindicatormeasurescasedetectioneffortsofhealthcare
workers.Increasedcasedetectioneffortshouldleadtoincreased
casedetection.
Thetargetforthisindicatorshouldbearound10%:Avaluehigher
than10%mayindicatethathealthcareworkersarenotwellaware
ofTBsymptomsandonlyconductsputumforAFBmicroscopyfor
casesatadvancedstagesofTBdisease=.
WhenchestXraysareusedasafiltertoselectcaseswhoshould
haveasputumsmearexamination,positivityratesareexpectedto
behigherthan10%.
Calculation:
a) Numerator:NumberofTBsuspectsfoundtobesmearpositive
duringaspecifiedperiod.
b) Denominator:TotalnumberofTBsuspectsscreenedbysputum
microscopyduringthesameperiod.
SurveillanceofMDRTB
Thisindicatormeasurestheavailabilityofinformationondrug
susceptibilityinnewandpreviouslytreatedTBcases,mainlywith
regardstomultidrugresistance(i.e.,resistancetoatleastisoniazid
andrifampicin).
Calculation:Yes/No.
HIVseroprevalence
SurveillanceofHIVprevalenceamongTBcaseswillgiveinformation

Evaluation
152
INDICATOR
amongTBcases
DESCRIPTION
abouttheepidemicsofbothTBandHIV.Inparticular,itgivesan
indicationofthedegreeofoverlapintheepidemicsinanygiven
setting,andwhencomparedwiththeHIVprevalenceinthegeneral
population,itwillgiveanindicationoftheimpactofHIVontheTB
epidemicinanygivensetting.
Calculation:
a) Numerator:TotalnumberofnewlyregisteredTBcases
(registeredoveragivenperiodoftime)whoareHIVpositive
Denominator:TotalnumberofnewlyregisteredTBcases
(registeredoverthesamegiventimeperiod)whoweretested
forHIVandincludedinthesurveillancesystem.
b) Numerator:TotalnumberofnewlyregisteredsmearpositiveTB
cases(registeredoveragivenperiodoftime)whoareHIV
positive.
c) Denominator:Totalnumberofnewlyregisteredsmearpositive
TBcases(registeredoverthesamegiventimeperiod)whowere
testedforHIVandincludedinthesurveillancesystem.
PercentofHIVpositive
Thisindicatorisintendedtoprovideinformationontheproportion
casesenrolledinHIV
ofHIVpositivepersonsincareandontreatmentwhohavestarted
care(PreART)oron
onTBtreatment.
treatment(ART)who
startedTBtreatment
Anincreaseinthisindicatorovertimewouldsuggestimprovements
inTBscreeningandaccesstoTBdiagnosisandtreatmentservices
amongHIVinfectedpersons.
Calculation:
a) Numerator:NumberofHIVpositivepersonsinHIVcarewho
startedTBtreatment.

Evaluation
153
INDICATOR
DESCRIPTION
b) Denominator:NumberofHIVpositiveadultsandchildren
receivingaminimumofoneclinicalservice.
Numberandpercentage
ThisindicatorwillhelptheNTPtoprojectnationalrequirementsfor
ofTBcaseswhohadan
HIVtestsandrelatedcommodities,aswellasnational
HIVtestresultrecorded
requirementsforhealthcareworkertraining.
intheTBregister
Trackingthisnumberfromyeartoyearwillprovideinformationon
amongthetotal
whetherproviderinitiatedHIVtestingandcounsellingisbeing
numberofregisteredTB
targetedandprovidedappropriatelytoTBcases,sothatHIV
cases
positiveTBcasescanaccessappropriateHIVservices.
Calculation:
a) Numerator:NumberofTBcasesregisteredduringagiventime
periodwhohadanHIVtestresultrecordedintheTBregister.
b) Denominator:TotalnumberofTBcasesregisteredduringthe
sametimeperiod.
Percentofestimated
Thisindicatorprovidesameasureoftheextenttowhich
HIVpositiveincidentTB
collaborationbetweenthenationalTBandHIVprogrammesare
casesthatreceived
ensuringthatpeoplewithHIVandTBdiseasesareabletoaccess
treatmentforTBand
appropriatetreatmentforbothdiseases.However,thisindicator
HIV
willalsobeaffectedbylowuptakeofHIVtesting,andpooraccess
toHIVcareandART,andtoTBdiagnosisandtreatment.
Calculation:
a) Numerator:NumberofadultswithadvancedHIVinfectionwho
receivedantiretroviralcombinationtherapyinaccordancewith
thenationallyapprovedtreatmentprotocol(orWHO/UNAIDS
standards)andwhowerestartedonTBtreatment(in
accordancewithnationalTBprogrammeguidelines),withinthe

Evaluation
154
INDICATOR
DESCRIPTION
reportingyear
b) Denominator:EstimatednumberofincidentTBcasesinpeople
livingwithHIV.
Casenotificationrate/
TBincidencerate
Theindicatorprovidesinformationontheburdenofdisease,
numberofcasestobetreated,andresourcesrequired.
Trendsovertimeincasenotificationusuallyindicatechangesin
programcoverageandcapacitytodetectTBcases.Athighlevelsof
casedetection,theindicatorreflectschangesintheprevalenceof
TBinthecommunity.
Calculation:
a) Numerator:NumberofnewTBcasesreportedinthepastyear(x
100,000).
b) Denominator:TotalmidyearpopulationofGuyana.
RetreatmentTBcases
ThisindicatorrepresentsthepercentageofTBcaseswhorequire
moreextensivetreatmentandshouldbesuspectedofhaving
acquireddrugresistance.
Ineffectivetreatmentorincorrectadministrationofmedication
mayresultinalargeproportionofretreatmentcases,whichpoints
todeficienciesinthemedicationusedand/ornonadherenceto
DOTSonthepartofTBcasesandhealthcareworkers.
Calculation:
a) Numerator:NumberofretreatmentTBcasesregisteredduringa
specifiedtimeperiod.
b) Denominator:TotalnumberofTBcasesregisteredinthesame
period.
Newextrapulmonary
ThisindicatorprovidesthenumberofTBcaseswithsiteofdisease

Evaluation
155
INDICATOR
TB(EPTB)cases
DESCRIPTION
definedasextrapulmonaryinthepastyear.
EPTBisdefinedasadiseaseoforgansotherthanthelungs(e.g.,
pleura,lymphnodes[includingintrathoraciclymphnodes],
abdomen,genitourinarytract,skin,jointsandbones,meninges).
Calculation:
a) Numerator:NumberofnewEPTBcasesregisteredduringa
specifiedtimeperiod.
b) Denominator:TotalnumberofnewTBcasesregisteredinthe
sameperiod.
Deathrate
ThisindicatormeasuresthepercentageofTBcasesregisteredina
specifiedperiodthatdiedduringtreatment,irrespectiveofcause.
EvaluationoftreatmentoutcomesofTBcasesisusedtodetermine
qualityandeffectivenessofservicesdeliveredbyanNTP.TBcases
thatdiedforanyreasonduringtheircourseoftreatmentare
designatedasdied.Causeofdeathisnotfurtherspecified(e.g.,
deathduetoTBversusother)inbasicreportingoftreatment
outcomes.
Calculation:
inaspecifiedperiodthatdiedduringtreatment,irrespectiveof
cause.

Evaluation
156
INDICATOR
DESCRIPTION
ThisindicatorprovidestheestimatednumberofdeathsduetoTB
Mortalityrate
inaspecifiedtimeperiod.Itisthereforeadirectindicatorofthe
burdenofTBinthepopulation.
Calculation:
a) EstimatednumberofdeathsduetoTB(allcases)peryear,per
100000population:NoofTBDeathsx100,000
750,000
Treatmentfailurerate
Evaluationoftreatmentoutcomesofnewpulmonarysmear
positiveTBcasesisusedtodeterminethequalityandeffectiveness
ofservicesdeliveredbyanNTP.
Thisindicatormeasuresoneofthepossibleoutcomeindicatorsfor
TBcases.TBcasesthataresputumsmearpositiveatfivemonthsor
laterduringthecourseoftreatmentaredesignatedastreatment
failure.
Calculation:
inaspecifiedperiodthataresmearpositivefivemonthsorlater
afterinitiatingtreatment.
Treatmentdefaultrate
Evaluationoftreatmentoutcomesofcasesisusedtodetermine
ofnewsmearpositive
NTPqualityandeffectiveness.TBcaseswhosetreatmentwas
cases
interruptedfortwoormoreconsecutivemonths(i.e.,TBcasesthat
didnotupliftantiTBdrugsfortwoormoremonthsatanytime
afterregistration)aredesignatedasdefault.Anydefaultshould
promptfurtherinvestigationtodeterminewhethertheinterruption

Evaluation
157
INDICATOR
DESCRIPTION
couldhavebeenpreventedand/orwhetherprogramme
interventionsarewarranted.
Calculation:
inaspecifiedperiodwhointerruptedtreatmentformorethan
twoconsecutivemonths
Existenceof
ThisindicatormeasuresaTBcontrolprogrammescapacityto
comprehensive
accuratelydiagnoseandmonitorTBcasesatalllevelsofthepublic
laboratorynetwork
healthdeliverysystem,andperformotherhigherlevellaboratory
functions,suchasmycobacteriumdrugresistancesurveillance.
TBmicroscopy
coverage
TherearetwomeasuresofTBmicroscopyassessingtheadequacy
ofpopulationcoveragebyTBmicroscopyunit(TMUs).The
populationcoveredbyaTMUshouldneitherbetoolarge,sincethis
couldresultinpoordiagnosticqualityowingtoworkoverloadof
laboratorystaff;nortoolow,sincethiscouldresultinpoor
diagnosticqualityowingtoalackofroutineuseofthenecessary
skills.
Calculation:
a) Numerator:NumberofTMUsthatcoverapopulationofasize
withinarecommendedrange.
b) Denominator:TotalnumberofTMUs.
c) Numerator:Totalpopulation.
d) Denominator:TotalnumberofTMUs
TBmicroscopy
Thisindicatormeasurestheexistenceofonecriticalcomponentof

Evaluation
158
INDICATOR
DESCRIPTION
unitssubmittingslides
aQAsystem,whichisdefinedasasystemdesignedtocontinuously
forrechecking
improvethereliability,efficiency,anduseofTBlaboratoryservices.
NTPsshouldhaveaQAsystemthatcoversallTBlaboratoriesinthe
country.
AlowproportionofTMUswithQAresultsindicatestheneedfor
furtherdevelopmentofthelaboratoryQAsystem.
Calculation:
a) Numerator:NumberofTMUsforwhichsliderecheckingresults
areavailableduringaspecifiedperiod.
b) Denominator:TotalnumberofunitsperformingTBsmear
microscopyduringthesameperiod.
Table27:OutputindicatorsusedbytheNTP
OUTPUTINDICATOR
DESCRIPTIONOFINDICATOR
Respiratorysymptomatics
ProportionofrespiratorysymptomaticsscreenedforTBatTB
screened
serviceoutlets
PeopleeducatedonTB(ACSM)
NumberofpeoplereachedthroughTBeducationalsessions
EnablersSupport
PercentageofnewTBcasesreceivingenablersincentive
TBHIVVCT
NumberandpercentageofTBcasesreceivingvoluntaryHIV
counsellingandtesting(includingtheprovisionofHIVtestresult)
TBHIVIPT
NumberofnewlyenrolledHIVpositivepersons(preARTorART)
startingIPTwithinthereportingperiod.
TBHIVARV
NumberandpercentageofHIVpositiveTBcaseswhostartor
continuepreviouslyinitiatedART,duringorattheendofTB
treatment
Casedetectioninprisons
NumberofnewTBcasesdetectedamongstprisoners

Evaluation
159
OUTPUTINDICATOR
Treatmentsuccessinprisons
DESCRIPTIONOFINDICATOR
Treatmentsuccessrate,newsmearpositiveTBcasesamong
prisoners
MDRTBontreatment
NumberandpercentageoflaboratoryconfirmedMDRTBcaseson
secondlineantiTBtreatment
MDRTBtreatmentsuccess
NumberandpercentageoflaboratoryconfirmedMDRTBcases
successfullytreated(curedpluscompletedtreatment)amongthose
onsecondlineantiTBtreatment
MDRTBadherence
NumberandpercentageoflabconfirmedMDRTBcasesstill
receivingtreatmentafter12months
MDRDST
Percentageofretreatmentstrainsidentifiedwithdrugsusceptibility
testing
Healthcareworkerstrained
NumberofhealthcareworkerstrainedinDOTSandTBHIV
management
Collaborationwithmalaria
NumberofmalariamicroscopistsinRegions1,7,8&9performing
qualityassuredsputummicroscopy
Decentralisation
NumberofnewhealthfacilitiesimplementingDOTS
Regionalreporting
Numberandpercentageofquarterlyreportsreceivedfromtheten
regionsontime,completeandaccurate
RecordingandEvaluatingTBTreatmentResponse
CohortAnalysisofTreatmentOutcomes
AcohortanalysisisasystematicreviewofthemanagementofTBcasesandtheircontactswith
TBdisease.ATBcohortisagroupofTBcasescountedoveraspecificperiodoftime,usually3
months.

Evaluation
160
Cohortanalysisoftreatmentshouldbedoneattheendofeveryquarter.AcohortofTBcasesconsists
ofallthosesputumsmearpositivePTBcasesregisteredduringaquarter(i.e.,1Januaryto31March;1
Aprilto30June;1Julyto30Septemberand1Octoberto31December).Newandpreviouslytreated
casesformseparatecohorts.Evaluationsoftheendoftreatment(6months)outcometakesplaceabout
threemonthsafterallTBcasesinthecohorthavecompletedtheircourseoftreatment.
Thefundamentalconceptofacohortreviewisaccountability.StaffisaccountabletoSupervisorsand
totheprogramforhowwelltheyarecaringfor/managingcasesandtheprogramisaccountabletothe
publicforcontrollingtuberculosis.ThomasFriedenMD,MPH,NewYorkCityCommissionerofHealth.
TBcasesarereviewedapproximatelysix(6)monthsaftertheyarereported;atthistime,manyoftheTB
cases would have completed treatment or are nearing the end of treatment. Cohort analyses are
conducted by a team consisting primarily of a case manager (doctor/Medex), supervisor (Regions:
RegionalDOTSSupervisors,GCCDOTSSupervisor)andmedicalreviewer(Regions:RegionalTBMedical
Officer, GCC Director). The following information should be presented on each case by the case
manager:
TBcasesdemographicinformation
TBcasesstatus:clinical,laboratory,radiology
Drugregimen,adherence,completion
Resultsofcontactinvestigation
Data(inabsolutenumbers)areextractedfromtheregisteraccordingtothefollowingindicators:
NewsputumsmearpositiveandsmearnegativeTBcases
NewsmearpositiveTBcasesaccordingtoagegroupandsex
Relapses,failures,defaulters,returnafterdefaultanddeaths
ExtrapulmonaryTBcases
CulturepositiveandnegativeTBcases
Casesontreatmentandretreatment
CasesonART

Evaluation
161
Outcomeinrelationtocure,treatmentcompletion,failure,default,transferordeath
ThepossibletreatmentoutcomesandtheirstandardiseddefinitionsfornewTBcasesare:
Cured: A TB case is considered cured if at end of treatment sputum exam is negative AND if
there has been at least one other negative sputum exam during treatment. An end of
treatmentsputumspecimenissenttothelab0ratoryonemonthpriortoendingtherapy.
Treatmentcompleted:ATBcasethathascompletedtreatmentbutresultsofsputumexamare
notavailableonatleasttwooccasions,priortothecompletionoftreatment.
Treatment failure: A TB case that remains sputumpositive at five months or later after
commencingtreatment.
Died:ATBcasethatdiesforanyreasonduringthecourseoftreatment.
Treatment interrupted: A TB case whose treatment was interrupted for two or more months
(default).
Transferred out: A TB case that has been transferred to another reporting unit and for whom
thetreatmentoutcomeisnotknown.
Treatmentoutcomeevaluationshouldalsoincluderesultsofsputumexamsat2months,5monthsand
at the end of treatment. Results of culture and antimicrobial susceptibility testing, atypical
mycobacteria identification, as well as the documentation of HIVTB coinfection will also aid in
monitoringthemagnitudeoftheproblem.
Teammembersshouldusetheinformationgatheredatcohortreviewsto:
Followuponcasesandcontactinvestigations;
Addresshealthcareworkertrainingissues;and
Addressoperationalissues.
Ministry of Health - Guyana, 2011 | APPENDICES
162
APPENDICES
Appendix:I..AppointmentCard
Appendix:2..........DomiciliaryorAmbulatoryCaseTreatmentSheet
Appendix:3..........TreatmentCard
Appendix:4..........LaboratoryRequestforMycobacteriumTuberculosisInvestigation
Appendix:5..........InvestigationRequisitionForm
Appendix:6..........ChestXRayExaminationRequestCard
Appendix:7..........CombinedRequisitionandIssueVoucher
Appendix:8..........DiseaseNotificationForm
Appendix:9..........TBHIVEducational/SensitisationSessionForm
Appendix:10.......TBMedicalRecord(TBPatientChart)
Appendix:11........ActiveTBCaseReport
Appendix:12.......BMUMonthlyClinicReport
Appendix13........PrisonMonthlyTBReport
Appendix:14........MissedAppointmentFollowupForm
Appendix:15.......Standardoperatingprocedures
1. TBdiseaseinHIVNegative&sputumnegativepersons
2. TB infection (Isoniazid prophylaxis) in HIV negative or persons of
unknownstatus
3. TBdiseaseinHIVnegative&sputumpositivepersons
4. TBinfection(Isoniazidprophylaxis)inHIVpositivepersons
5. TBDiseaseInHIVNegative&SputumPositivePersons
6. TBdiseaseinHIVpositive&sputumpositivepersons
Appendix16............PostExposureProphylaxisNAPS
163
Appendix1
AppointmentCard
164
Appendix2
DomiciliaryorAmbulatoryCaseTreatmentSheet
165
Appendix2
DomiciliaryorAmbulatoryCaseTreatmentSheetBack
166
Appendix3
TreatmentCard
167
Appendix4
Laboratoryrequestformformycobacteriumtuberculosisinvestigation
168
APPENDIX5
InvestigationRequisitionForm
169
170
171
172
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
uyana, 2011 | APPENDICES
A
17
73
Appendix:6
ChestXRayExaminationRequestCard
NationalTuberculosisProgramme
XRaySlip
Nameofpatient...Age.
Sex.ClinicN0.
Referredfrom.
Tel#........................................Date.....................................
ParttobeXRayed.
Signature..
174
Appendix:7
CombinedRequisitionandIssueVoucher
175
GUYANATU
UBERCULOSISMA
ANUAL2011EDITION
NATIONALG
GUIDELINESFOR
RTHEPREVENTIO
Ap
ppendix:8
DiseaseN
NotificationForm
uyana, 2011 | APPENDICES
A
17
76
Appendix:9
TBHIVEducational/SensitisationSessionForm
MINISTRYOFHEALTH
EducationandSensitisationSession
SigninForm
Location:________________________Date:_______________________

Haveyoueverbeen
involvedinaTB/HIV
sensitizationsession
before?
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Signature
Address
YES
Organisation
NO
177
Appendix:10
TBMedicalRecord(TBPatientChart)
MinistryofHealth
NationalTuberculosisControlProgramme
TBPatientClinicChart
Clinicname_______________________
District_____________
FirstName__________________________
___/______/_______
PUID#__________________________
dd/mm
/yyyy
LastName__________________________Middle____________
Knownas_____________________________________________
Dateofbirth____/_____/______Age_____
dd/mm/yyyy
GenderMaleFemale
EthnicityIndoGuyaneseAfroGuyanese
AmerindianMixedPortuguese
ChineseOther____________________
Address_____________________________________________
____________________________________________________
Telephonenumber_________________(Home)
_________________(Work)
_________________(Mobile)
NextofKin:
FirstName_____________________
Lastname_____________________Initials_____
Relationship______________________________
Region________
Clinicregistrationnumber:_________
Dateregistered
Admitting
diagnosis________________
__
________________________
___________
Case
manager________________
__________
________________________
______________
DOT
worker__________________
__________
________________________
______________
Typeofpatient:
Newsmear+ve
178
ContactNumber__________________(Home)
__________________(Work)
__________________(Mobile)
Sputum+veTB
(Relapse,Failure,default,
chronicTB)
SputumNegativeTB
Smear+veTBafter
supervisedretreatment
ExtrapulmonaryTB
DRTB
Datetreatment
initiated_____/____/______
dd/mm/yyyy
Treatmentmodality
DOTSSelf
administered
Datetreatment
outcome_____/____/_____
_
dd/mm/yyyy
Treatmentoutcome
Cured
Completetreatment
Failedtreatment
Default
Transferredout
Died
Comments________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
179
Cough/Sputum>2weeks
Ifyesduration_______________________
Character:__________________________
Y N
Wheezing/SOB
___________ Ifyesduration_______________________
_________
Y N
__________
____
Fever,unexplained
Y N
Fatigue
Y N
Ifyesduration_______________________
__________ Ifyesduration_______________________
__________
____
Weightloss/anorexia
Y N
Lymphadenopathy
Y N
Ifyesduration______________________
__________ Ifyesduration_______________________
__________
Site________________________________
__________
__________
Othersymptoms___________________________________________________________________________________
Hemoptysis
Ifyesduration_______________________
Y N
__________
Y N
__________
____
PASTMEDICALHISTORY
TBYN
Dateofdiagnosis____/_____/_____
TypeofTB:PulmonaryExtrapulmonary
Treatmentoutcome:DefaultedTreatmentfailure
CuredorcompletedtreatmentStillontreatment
HIVpositive?YN
Dateofdiagnosis:____/_____/_____
BaselineCD4count:_____________________________
LatestCD4count:_______________________________
ARTstatus:ARTPreART
DateARVstarted:____/_____/_____
NightSweats
Ifyesduration_______________________
SOCIALHISTORY
Comments:
YN __________________
_______
YN __________________
__________________
YN __________________
__________________
YN
__________________
YN __________________
__________________
____________
____________
ContactofTBpatient?
Homeless?
Alcoholic?
Substanceabuse?
Cigarettesmoking?
ARVregimen:EFVTruvadaOther
INFORMATIONOFC ONTACTS
DiabetesYN
Dateofdiagnosis____/___/_____
Typeofdiabetes:Type1TypeII
Treatment:OralmedicationInsulin
HypertensionYN
Name
Age
1._______________
____
________________
2._______________
________________
____
Type
Inv.forTB
_______________________
YN
_______________________
_______________________
YN
_______________________
180
Treatment________________
3._______________
____
_______________________
YN
_______________________
____
_______________________
YN
_______________________
____
_______________________
YN
_______________________
____
_______________________
YN
_______________________
7._________________ ____
__________________
_______________________
YN
_______________________
________________
BronchialasthmaYN
Treatment___________________
4._______________
________________
5.______________
AllergiesYN
Pleasestate____________________________________
LiverdiseaseYN
LMP(dd/mm/yyyy)_____/______/________
________________
6.______________
________________
181
PHYSICALEXAMINATION
Bodyweight________Pulse________BP____________Temperature________Respiratoryrate________
Generalappearance NADAbnormalN/A
Describe:___________________________________________________
___________________________________________________________
Skinand
lymphnodes
NADAbnormalN/A
___________________________________________________________
___________________________________________________________
HEENT
NADAbnormalN/A
___________________________________________________________
___________________________________________________________
Respiratorysystems NADAbnormalN/A
___________________________________________________________
___________________________________________________________
Cardiovascular
system
NADAbnormalN/A
___________________________________________________________
___________________________________________________________
Abdomen
NADAbnormalN/A
___________________________________________________________
___________________________________________________________
Nervoussystem
Extremities
NADAbnormalN/A
NADAbnormalN/A
___________________________________________________________
___________________________________________________________
INVESTIGATIONS
REFERRAL
Date:(dd/mm/yyyy)Result
1stsputum
____/___/____ ___________________
nd
2 sputum
____/___/____ ___________________
___________________________________________________________
3rdsputum
Problemlist
____/___/____ ___________________
Sputumculture ____/___/____ ___________________
_______________________________________________
1.___________________________________________________
2.___________________________________________________
HIV
TST
CD4count
____/___/____ PosNeg
Notdone/refused
___________________
____/___/____ ___________________
RFT
LFT
____/___/____ BUN_________________ Medicine

Creatinine_____________
____/___/____ ALT__________________
AST__________________
Bilirubin(T)____________
Direct________________
Indirect_______________
CBCwithdiff
____/___/___ WBC_____________
RBC______________
HB_______________
3.____________________________________________________
Medication
Dosageand
frequency
Startdate
Stopdate
182
Poly________________
Lymph______________
Mono_______________
Eosin_______________
Baso________________
RBS/FBS
____/___/__ ___________________
ChestXray
_________________
_________________
_________________
___________
___________
___________
___________
_____________________
_____________________
_____________________
_____________________
Physiciansname:__________________________Signature________________________________
FOLLOW UPSHEETDate:_____/____/______
dd/mm/yyyy
PatientName:_________________________________________Clinic#:_________________PUID:________________________
SYMPTOMS
MEDICATIONADHERENCE
YN
Cough
Comments_______________________
________________________________
Hemoptysis
YN
________________________________
Fever
YN
________________________________
________________________________
Wheezing/SOB
YN
________________________________
Othersymptoms__________________________________________________
#ofdosesdue_______
#ofdosestaken______
Rateadherence:
___________________________________
___________________________________
PHYSICALEXAMINATION
Bodyweight________Pulse________BP____________Temperature________Respiratoryrate________
Appearance
NADAbnormalN/A
Describe:_______________________________________________________
_____________________________________________________________
Skin
NADAbnormalN/A
______________________________________________________________
HEENT
NADAbnormalN/A
______________________________________________________________
Respiratory
NADAbnormalN/A
______________________________________________________________
Cardiovascular
NADAbnormalN/A
______________________________________________________________
183
Abdomen
NADAbnormalN/A
______________________________________________________________
Nervoussystem
NADAbnormalN/A
______________________________________________________________
PHYSICIANSORDERS
INVESTIGATIONS
Date
Result
Sputum
__________
___________________
Sputum
Sputumculture
__________
__________
___________________
___________________
HIV
__________
PosNeg
NotdoneRefused
CD4Count
RFT
LFT
__________
__________
__________
___________________
BUN_______________
Creatinine__________
ALT________________
AST________________
Bilirubin(T)__________
Direct______________
Indirect_____________
RESULTS
ChestXray(dd/mm/yy)_____/____/_______
Results:__________________________________________________
_________________________________________________________
_________________________________________________________
Diagnosis/Plan:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Medicine
Medication
Dosage
Startdate
dd/mm/yyyy
and
frequency
Stopdate
dd/mm/yyyy
CBCwithdiff
__________
WBC_______________
RBC________________
HB_________________
Poly________________
Lymph______________ NextAppointmentdate(dd/mm/yyyy):_______/________/_________
Mono_______________
Eosin_______________
Baso________________
RBS
__________
____________________
184
TBSUMMARYFOLLOWUPSHEET
Summary
parameter
Initiation
Date
Followup
Date
Date
Date
Date
Date
Date
Date
Date
Result/Rx Result/Rx
Result/Rx
Result/Rx
Result/Rx
Result/Rx
Result/Rx
Result/Rx
Result/Rx
Bodywt
Pulse
BP
Resp.rate
Temperature
Sputum
microscopy
Sputumculture
DST
CXR
RBS
BUN/
Creatinine
LFT
CD4
185
Viralload
TBregimen
ARTregimen
CTX
Y
N
YN YN YN YN YN YN YN YN
Sideeffects
#ofHRZE(S)
doses
#HRdose
Actionstaken
(referral/
admission)
Dr.initials
NB.Shadedcellsarescheduledinvestigations
186
GUYA
ANATUBERCULO
OSISMANUAL2011EDITION
NATIIONALGUIDELIN
NESFORTHEPREEVENTION,TREA
ATMENT,CAREA
ANDCONTROLO
OFTUBERCULOSIIS
App
pendix:11
ActiveTB
BCaseRepo
ort
MinisstryofHealth
h,
Guyana
A
Active
TB Case Repor
rt
Clinic:__________________________
NationalTubercu
ulosis
Proggramme
1. Demograph
hics
Sex:
Nam
me:
Dateofbirth:
Firstt___________________
_________
____/______
_
__/_______
Ethnicity:
Female
Male
AGIGAIMiixOther
Lastt
________________________
_____
Usu
ualresidenceRegion#[]
Cityy/Town/Villagge_________
______________________
_____
PUID#:
Lot#andStreet
__________________________
__________
Date
eofregistrattion:
(dd/mm/yyyy)
2. Diagnosiss
2
Site
eofinfection:Pulmo
onary
Extrap
pulmonary(sttate)_______________________________________
_____/_______/________
Che
estXray:NormalA
AbnormalNotdone
UnknownIfabno
ormalCavvitaryNo
oncavitary
Cate
egoryofpatie
ent:NewRelapseTreatmeentafterfailurreTreatmentafterdeefaultTrransferin
O
Others
Ministry of Hea
alth - Guyana, 2011
2
| APPENDIC
CES
187
Iftransferin,fromwhichclinicwaspatient
transferred___________________________________________________________
Sputummicroscopy:
3. BacillarystatusMicroscopyandCulture
Culture:
13.DSTordered:
YesNo
Monthsoftreatment
Bef 23 56
ore
Tx
Other
EndofTx BeforeTx Other
Resistance:
P P Pos Pos Pos

os os
Neg Neg Neg
N N
eg eg ND ND ND
N N
D D
U
nk
Unk
EndofTx
Unk
Unk
Pos
Pos Pos
Neg
Neg Neg
ND
ND ND
Unk
Unk Unk
INHRMPPZAEMB
Strep
Others_________________________
U
nk
Casecriteria:
SputumpositiveCulturepositiveClinicaldiagnosis
Other_______________________________
4. Treatmentanddetailsofcontacts
Datetreatmentstarted:____/_______/_______Treatmentcategory:CATICATIICATIII
CATIV
TreatmentmodalityDOTSSelfadministeredCounsellingdoneTuberculosisHIV/AIDS
TreatmentregimenINHRMPEMBPZAStrepKanamycinCapreomycin
Ofloxacin
PASEthionamideRifabutin
Other________________________________
188
Detailsofcontacts:#ofcontacts________#investigatedforTB_______#onIPT________#onTBRx
________
5. Riskfactorsandcasefindings
FirstepisodeofTB?YesNo
Ifno:Yearofpreviousdiagnosis_______Clinicofprevious
diagnosis________________________
HIVstatusPositiveNegativeTestrefusedCPTprescribedYesNo
UnknownIfHIVpositive,dateofHIVdiagnosis____/______/_______Ifyes,CPTstart
date_____/______/_______
EligibleforARTYesNoUnknownARTstatusPreARTOnART
IfyesdateARTinitiation____/______/_______ART
regimen______________________________________________
Exposuretoaninfectiouscaseinpast2
years:
YesNoUnknown
Casefinding
Knownorsuspectedsubstanceabuse:
YesNoUnknown
SymptomscompatiblewithTB
Diabetesmellitus:
YesNoUnknown
Referral
Longterm(>3months)corticosteroid
use:
YesNoUnknown
Contactinvestigation
Homelessness:
YesNoUnknown
Occupationalscreening
PreviousabnormalchestXray:
YesNoUnknown
HealthWorker
Livesinacorrectionalsettingattimeof
diagnosis:
YesNoUnknown
Otherscreening
Postmortem
Treatment
Cured
6. Treatmentoutcome
Defaulted
FailedTransferredout
189
completed
Date___/____/_____ Date____/____/______ Date___/___/_____Date___/_____/_______
Date____/____ dd/mm/yyyy dd/mm/yyyy

/______
dd/mm/yyyyClinic__________________
dd/mm
/yyyy
Deathbeforeorduringtreatment:YesNoUnknownIfyes,dateofdeath
____/_______/_______
TBwasthecauseofdeathTBcontributedbutwasnotthecauseofdeathTBdidnotcontributetodeath
Unk
Datereportprepared:_____/_____/_______Nameofpersonpreparingreport:
dd/mm/yyyy
______________________________________
Notes
Datereportreceived:____/_____/______
Dates:Pleaseusedateformatasdate/month/year
Ethnicity:AGAfroGuyanese,IGIndoGuyanese,AIAmerindian
Riskfactors:PosPositive;NegNegative;NDNotdone;UnkUnknown
Treatmentcategory:CATINewsmearpositive,smearnegativewithextensivelunginvolvement
orextrapulmonary;CATIIPreviouslytreatedsmearpositivecases;CATIIISmearnegativecases;CATIV
provenorsuspectedMDRcases
190
Appendix:12
BMUMonthlyClinicReport
MinistryofHealth
NationalTuberculosisProgramme
PleaseNote:
Thisreportshouldbefilledmonthly,induplicate;
MONTHLYCLINICREPORTNameofBasicManagementUnit:____________________________
Year:_________Reportforthemonthof:_____________________
1.GeneralPatientLoad
1.a
Totalpatientstreatedforallcauses
1.e
Totalcasesreceivinginjection
1.b
TotalTBcasestreated
1.f
TotalcasesonIPT
1.c
#ofnewTBcasestreated
1.g
#ofnewcasesonIPT
1.d
#ofcasestransferredoutoftheclinic
1.h
#ofcasestransferredintotheclinic
2.NewTBCaseFindings
2.a
NewTBcasesregistered
2.h
NewcaseswithanHIVtestresult
2.b
NewTBcasesforwhomsputumwereordered
2.i
NewcasesthatareHIVpositive
2.c
NewTBcasesthataresputumpositive
2.j
NewcaseswithHIVstatusunknown
2.d
NewTBcasesthataresputumnegative
2.k
NewcasesofLymphadenitis
2.e
NewTBcasesthataresputumunknown
2.l
NewcasesofMiliaryTB
2.f
Newsputum+vecasesthatweretestedforHIV
2.m
NewcasesofTBMeningitis
2.g
NewsputumpositivecasesthatareHIVpositive
2.n
NewcasesofotherExtraPulmonaryTB
191
3.NewpulmonarysmearpositiveTBcasesbyagegroup,gender,DOTSandNonDOTS
04
514
1524
2534
3544
4554
5564
65+
Total
Dots
Non
Dots
Dots
Non
Dots
Female
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Non
Dots
Dots
Non
Dots
Male
4.Newpulmonarysmearnegative/smearunknownTBcasesbyagegroup,gender,DOTSandNonDOTS
04
514
1524
2534
3544
4554
5564
65+
Total
Dots
Non
Dots
Dots
Non
Dots
Female
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Non
Dots
Dots
Non
Dots
Male
5.ExtrapulmonaryTBcasesbyagegroup,gender,DOTSandNonDOTS
04
514
1524
2534
3544
4554
5564
65+
Total
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Male
Female
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Non
Dots
6.Laboratory
6.a
TotalnewcasesthatstartedTBRx3mthsago
6.j
#sputumdoneduringthereportingmonth(followup)
192
Dots
Non
Dots
6.b
#ofsputumpositivecasesthatstartedRx3mthsago
6.k
Totalnumberofsputumnegative(allcases)
6.c
#ofcasesthatsputumconverted
6.l
#ofsputumnegative(newcases)
6.d
#ofBCGvaccinesadministered
6.m
#ofsputumnegative(followupcases)
6.e
TotalTSTdoneduringreportingmonth
6.n
Totalnumberofsputumpositive(allcases)
6.f
#ofcaseswithreactionfrom1014mm
6.o
#numberofsputumpositive(newcases)
6.g
#ofcaseswithreaction15mmandabove
6.p
#numberofsputumpositive(followupcases)
6.h
Totalsputumdoneduringthereportingmth(allcases)
6.q
Totalnumberofsputumnotdone
6.i
#sputumdoneduringthereportingmonth(new)
6.r
#ofMalariaMicroscopistsdoingsputummicroscopy
7.MultiDrugResistantTB
7.a
#ofnewsuspectedMDRcases
7.b
#ofnewsputumsentforDrugSensitivityTesting
7.c
#ofconfirmedMDRcasesonsecondlineTBRx
7.d
#ofconfirmedMDRcasesstillonRxafter12mths
8.RadiologicalInvestigation
8.a
#ofnewcasesthathadchestxray
8.b
#offollowupcasesthathadchestxray
9.TB/HIVCoinfection
9.a
TotalnumberofcaseswithaHIVtestresult
9.i
#ofnewcoinfectedcasesplacedonART
9.b
TotalnumberofcaseswithaHIVpositiveresult
9.j
TotalnumberofHIVpositivecases
9.c
Totalnumberofcoinfectedcasesbeingmanaged
bythisclinic
9.k
#ofnewHIVpositivecases
9.l
TotalnumberofHIVpositivecasesplacedonIPT
9.m
#ofnewHIVpositivecasesplacedonIPT
9.d
#ofnewcoinfectedcasesbeingmanagedbythis
clinic
9.e
TotalnumberofcoinfectedcasesonCTX
9.n
TotalnumberofHIVpositivecasesonIPTplacedonART
9.f
#ofnewcoinfectedcasesonCTX
9.o
#ofnewHIVpositivecasesonIPTeligibleforART
9.g
TotalnumberofcoinfectedcasesplacedonART
9.p
#ofnewHIVpositivecasesonIPTplacedonART
9.h
#ofnewcoinfectedcaseseligibleforART
193
194
10.Retreatment
Totalnumber
of
HIV
+ve
Sputum
ordered
ve
reregistered
cases
10.a
Defaulted
10.b
Relapsed
10.c
Failedtreatment
Didnot
provide
sputum
Positive
sputum
Negative
sputum
Not
being
DOTS
Had
DST
done
Unknown
sputum
On
DOTS
11.ContactandCommunitySurveillance
11.a
#ofpersonsregisteredinthesymptomaticregister
11.h
#ofcontactsofsputumnegativeTBcasesscreened
11.b
#ofsymptomaticsscreenedbyTSTforTB
11.i
11.c
#ofcontactsofknowncasesplacedonIPT
#ofsymptomaticsscreenedbysputumforTB
11.j
#ofcontactsofknowncasesplacedonTBtreatment
11.d
#ofsymptomaticsthataresputumpositive
11.k
Totalnumberofcasescounselled
11.e
#ofcontactsofnewcasesscreenedbyTSTforTB
11.l
#ofnewcasescounselled
11.f
#ofcontactsofnewcasesscreenedbysputumfor
TB
11.m
#ofhealthworkersscreened
11.n
#ofhealthworkerswhoaresputumpositive
11.o
#ofvisitstoprisons
11.g
#ofcontactsofsputumpositiveTBcasesscreened
12.Advocacy,CommunicationandSocialMobilization
12.a
#ofeducationalsessionsheldatthisclinic
12.b
#ofeducationalsessionsheldatschools
13.HighRiskGroup
13.a
Totalnumberofcasesreceivingenablerincentive
13.b
#ofnewcasesreceivingenablerincentive
14.TreatmentOutcomeofTBcases
Cured
Howmanycasesregisteredone
yearagowere
Completed
Non
Dots
Non
HIV+
Dots
Dots
HIV+
Dots
Died
Dot
s
Failed
Non
Non
HIV+
Dots
Default
Dots
Non
HIV+
Dots
Dots
Dots
Newpulmonarysmear+ve
14.b
Newpulmonarysmearve&
unknown
Newextrapulmonary
Non
HIV+
14.a
14.c
Transferred
195
Dots
HIV+
Dots
Relapsepulmonarysmear
+ve
Treatmentfailurepulmonary
smear+ve
14.f
pulmonarysmear+ve
14.g
ConfirmedMDR
14.h
Otherretreatment(sputum
ve,unknown,otherDR)
14.d
14.e
15.TreatmentOutcomeofIPTpatients
DevelopedTB
disease
Howmanypatientsregistered
Default
New
oneyearago
HIV+
HIV
Completed
treatment
HIV+
HIV
Died
HIV+
Defaulted
HIV
HIV+
HIV
15.a
TSTfrom5mmto9mm
15.b
TSTfrom10mmto14mm
15.c
TST15mmandabove
15.d
TSTfrom5mmto9mm
15.e
TSTfrom10mmto14mm
15.f
TST15mmandabove
16.NewCasesTransferred
Transferred
HIV+
HIV
17.OutcomeforTransferredcasesregisteredoneyearago
Treatment
Failed
Defaulted
Transferred
dd/mm/yyyy
BMUwhich
patients
transferredfrom/to
Died
Dateof
Diagnosis
NamesofPatients
NamesofPatients
Completed
treatment
In
Out
196
18.SupervisoryvisitsconductedbyNationalTuberculosisProgramme(NTP)
18.aHowmanyvisitsweremadetothisclinic:
18.cNamesofpersonswhovisited:
18.bActivitiesconducted:
19a.Preparedby:__________________________19.bDesignation:___________________19.cDatereportwasprepared:
_________________
dd/mm/
yyyy
20a.Verifiedby:___________________________20.bDesignation:____________________20.cDatereportwasverified:
__________________
ThisboxistobefilledbyNTPStaffonly:
Nameofpersonverifyingthisreport:_________________________Comments:
197
Appendix13
PrisonMonthlyTBReport
MINISTRYOFHEALTH
PRISONMONTHLYTBREPORT
NameofPrison:_________________________________Reportforthemonthof:____________Year:______
Nameofpersonfillingthisform:___________________________Designation:__________________________
GeneralPatientLoad
Totalcasestreatedforallcauses
Totalcasesreceivinginjection
TotalnewTBcasestreated
TotalnewcasesofferedIPT
TotalTBcasestreated
TotalcasesonIPT
Numberofinmatestransferredoutoftheclinic
Numberofinmatestransferredintotheclinic
NewCaseFindings
Newcasesregistered
NewcaseswithaVCTtestresult
Newcaseswithsputumordered
NewcasesthatareHIVPositive
Newcasesthatweresputumpositive
NewcaseswithHIVstatusunknown
Newcasesthatweresputumnegative
NewcasesofTBLymphadenitis
Newcasesthatweresputumunknown
NewcasesofmiliaryTB
NewcasessputumpositivethatweretestedforHIV
NewcasesofTBmeningitis
NewsputumpositivecasesthatareHIVpositive
NewcasesofotherExtraPulmonaryTB
NewPulmonarysmearpositivebyagegroup,gender,DOTSandNonDOTS
014
Dots
Non
1524
Dots
Non
2534
Dots
Non
3544
Dots
Non
4554
Dots
Non
5564
Dots
Non
65+
Dots
198
Non
Total
Dots
Non
Dots
Male
Dots
Dots
Dots
Dots
Dots
Dots
Dots
Female
NewPulmonarysmearnegative/smearunknownTBcasesbyagegroup,gender,DOTandNonDOTS
014
1524
2534
Dots
Non
Dots
Female
Male
Non
Dots
Dots
3544
Non
Dots
4554
5564
65+
Total
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
ExtrapulmonaryTBcasesbyagegroup,gender,DOTSandNonDOTS
014
1524
2534
Dots
Non
Dots
Female
Male
Non
Dots
Dots
3544
Non
Dots
4554
5564
65+
Total
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Non
Dots
Dots
Laboratory
TotalnewcasesthatstartedTBtreatment3monthsago
Totalsputumdoneduringmonth(allcases)
Numberofabovecaseswithapositivesputum
Numberofsputumdoneduringmonth(new)
Ofthosehowmanydidsmearat23months
Numberofsputumdoneduringmonth(followup)
Numberofcasesthatsputumconvertedat23months
Numberofsputumnegative(new)
TotalTSTdone
Numberofsputumnegative(followup)
Numberofcaseswithreaction10to14mm
Numberofsputumpositive(new)
Numberofcaseswithreaction>15mm
Numberofsputumpositive(followup)
MultiDrugResistantTB
NumberofnewsuspectedMDRcases
NumberofconfirmedMDRinmatesonsecondlineRx
199
NumberofnewsputumsentforDrugSensitivityTesting
NumberofconfirmedMDRcasesstillonRxafter12mths
RadiologicalInvestigation
Numberofnewcasesthathadchestxray
Numberoffollowupcasesthathadchestxray
TBHIVCoinfection
NumberofcasesthathadanHIVtestdone
NumberofnewcoinfectedcaseseligibleforART
NumberofcasesthattestedpositiveforHIV
NumberofnewcoinfectedcasesplacedonART
Totalnumberofcoinfectedcasesmanagedbythisclinic
TotalnumberofHIVpositivecases
Numberofnewcoinfectedcasesmanagedbythisclinic
NumberofnewHIVpositivecases
TotalnumberofcoinfectedcasesonCTX
TotalnumberofHIVpositivecasesonIPT
NumberofnewcoinfectedcasesonCTX
NumberofnewHIVpositivecasesonIPT
TotalnumberofcoinfectedcasesplacedonART
Retreatment
HIV
TotalNumberof
Default
Reregisteredcases
+ve
ve
Sputum
ordered
Positive
sputum
Negativ
e
sputum
Unknown
sputum
OnDOTS
Not
being
DOTS
Had
DST
done
Relapsed
TreatmentFailure
SurveillanceandCommunityOutreach
NumberofcasesregisteredintheSymptomaticRegister
NumberofcontactsofknowncasesplacedonIPT
NumberofsymptomaticsscreenedbyTSTforTB
NumberofcontactsofknowncasesplacedonTBRx
NumberofsymptomaticsscreenedbysputumforTB
Totalnumberofcasescounseledinclinic
Numberofsymptomaticsthataresputumpositive
Numberofnewcasescounseledinclinic
NumberofsymptomaticsplacedonIPT
Numberofeducationalsessionsheld
200
NumberofsymptomaticsplacedonTBtreatment
NumberofstaffthatwerescreenedforTB
Numberofcontactsofknowncasesscreened
Numberofstaffthataresputumpositive
TreatmentOutcomeofTBinmates
Cured
Howmanycasesregistered
oneyearagowere..
Completed
Died
Failed
Default
Transferred
H
I
V
Dots
+
Non
Non
Non
Non
Non
Non
DOTS
HIV+ DOTS
HIV+ DOTS
HIV+ DOTS
HIV+ DOTS
HIV+ Dots
DOTS
DOTS
DOTS
DOTS
DOTS
Newpulmonarysmear+
Newpulmonarysmearve
&UK
Newextrapulmonary
Relapsepulmonarysmear
+ve
Treatmentafterfailure
pulmonarysmear+ve
pulmonarysmear+ve
ConfirmedMDR
Otherretreatment(ssve,
UK,
otherDR)
TreatmentOutcomeofIPTinmates
DevelopedTBdisease Completedtreatment
Howmanycasesregisteredone
yearagowere..
HIV+
HIV
HIV+
HIV
Died
HIV+
Default
HIV
HIV+
HIV
201
Transferred
HIV+
H
I
V
New
TSTfrom10mmto14mm
TST15mmandover
TSTfrom5mmto9mm
TSTfrom10mmto14mm
TST15mmandover
NewTransferredinmates
Outcomefortransferredinmatesregistered
oneyearago.
Dateof
Diagnosis
Prisonwhich
inmates
transferred
from/to
NameofInmates
NameofInmates
Out
In
Transferred
Defaulted
Failed
Died
Cured&Completed
Default
TSTfrom5mmto9mm
dd/mm/yyyy
SupervisoryvisitsconductedbyNationalTBProgramme
Namesofpersonswhovisited:
Signaturesofstafffillingreport:
Date:
Activitiesconducted:
202
TobecompletedbyNTPpersonnelonly
VerifiedBy:
Date:dd/mm/yyyy
Appendix:14
MissedAppointmentFollowupForm
MINISTRYOFHEALTH
MISSEDAPPOINTMENTFOLLOWUPFORM
PatientName:________________________________________________________________________
FirstnameOthername
Lastname
PatientType:______________________________Gender:MaleFemaleAge:________(yrs)
Address:_________________________________________________ Contactnumbers:________________
Dateofmissedappointment:_____________________Dateofnewappointment:_____________________
dd/mm/yyyy dd/mm/yyyy
Reasonformissedappointment:_________________________________________________________________
NameofDOTWorker:_____________________________
Attemptstocontactpatientandinformhim/herofnewappointmentdate
1stvisit/telephonecall:__________________________________
Commentifcontactnotmade
2ndvisit/telephonecall:__________________________________
Date:________________
dd/mm/yyyy
Date:________________
dd/mm/yyyy
203
3rdvisit/telephonecall:__________________________________ Date:_________________
dd/mm/yyyy
Losttofollowup:______________________________________________________________________________
______________________________________
___________________________________
SignatureofDOTWorkerdd/mm/yyyy
SignatureofDOTSupervisordd/mm/yyyy
Datesubmitted
Datesubmitted
Key:patienttype
204
Appendix:15
Standardoperatingprocedures
Appendix15.1
GUYANANATIONALTUBERCULOSISPROGRAMME
TBDISEASEINHIVNEGATIVE&SPUTUMNEGATIVEPERSONS
(Patientsareseenbythenurseandappropriatelabsandchestxraysareorderedinadvanceorpatientscomewithsameandareferral)
1st (Initial)Doctors visit

Reviewresults:sputumX3;chestXray,VCTresult,TST
ChestXraysuggestiveofactiveTB;ClinicalsuspicionhighforactiveTB
Baselinetestsordered:CBC;LFT;FBS;RBS;RFTs,AFBculture
EnrollmentinDOTS(4drugs:Ethambutol,Rifampicin,Isoniazid;,Pyrazinamide,B6)
Doctorsvisit 2weeks
Evaluatetreatmentandlabresults.
Doctorsvisit 1month Orderchestxrayand
sputumx2priortothenextvisit
Doctorsvisit2months
SPUTUMNEGATIVE
Doctorsvisit2months
SPUTUMPOSITIVE
Continue4drugsforonemonth.Repeatsputumand
cultureforAFBandbeginIsoniazid,Rifampicin,B6afterthe
onemonthextensionregardlessofsputumresults.
Doctorsvisit 4months
Order5monthsputum
SPUTUMNEGATIVE
Doctorsvisit6months
Withchestxray;repeatsputum
TREATMENTCOMPLETED
SPUTUMPOSITIVE
TreatmentfailurePatientbegins
retreatmentregime.RequestCultureand
DST
Followupvisit6monthsaftercompletion
(Withsputumandchestxray)
205
Appendix 15. 2
TBINFECTION(ISONIAZIDPROPHYLAXIS)
INHIVNEGATIVEORPERSONSOFUNKNOWNSTATUS
TST:59mm;1014mm;>15mm
ChestXray: neg, sputum:negX2, RuleoutactiveTBdisease
1st(Initial)Doctorsvisit
Reviewresults:sputumX23;chestxray;VCTresult,TST
Baselinetestsordered:CBC;LFT;FBS;RFTs
Doctorsvisit
1month
Doctorsvisit
3months
(With chestXray;sputum
TREATMENTCOMPLETED
Followupvisit 6monthsaftercompletion
(Withchestxrayandsputumifnecessary)
206
Appendix15.3
TBDISEASEINHIVNEGATIVE&SPUTUMPOSITIVEPERSONS
(Patientsareusuallyseenbythenurseandlabs,xraysandsputumorderedorthepatientcomeswiththesameandareferral)
1st (Initial)Doctorsvisit

Baselinetestsordered:CBC;LFT;FBS;RBS;RFTs

EnrollmentinDOTS(4drugs:Ethambutol,Rifampicin,Isoniazid,Pyrazinamide,vitaminB6)
Doctorsvisit2weeks

Evaluatetreatmentandlabresults.Ordersputumjustpriortonextvisit

Doctorsvisit2months
Doctorsvisit2months

NEGATIVESPUTUM
POSITIVESPUTUM
SputumandChestXrayorderedbefore
Continue4drugsforonemonth.Repeatsputumandculturefor
Reduce to 2 drugs (Isoniazid, rifampicin, B6)
AFB&DSTandbeginIsoniazid,Rifampicin,B6aftertheonemonth

extensionregardlessofsputumresults.

Doctorsvisit4months
Evaluate
and order
sputum
at 5 months
SPUTUMPOSITIVE
SPUTUMNEGATIVE

retreatmentregime.Sendforsputum

cultureandDST.
TREATMENTCOMPLETED

(withsputumandchestxray)
Followupvisit1yearaftercompletion
STOP/DISCONTINUETREATMENT
(IFLFTs>5timesnormalrange)
DISCHARGE
207
Appendix15.4
TBINFECTION(ISONIAZIDPROPHYLAXIS)INHIVPOSITIVEPERSONS
TST:>5mm;ChestXray:neg,sputum:negX2,RuleoutactiveTBdisease
st
1 (Initial)Doctorsvisit
Reviewresults:sputumX23;chestxray;VCTresult,TST
Baselinetestsordered:CBC;LFT;FBS;RFTs;CD4asapplicable;EvaluationforHAART
atNAPC&Tsite
Doctorsvisit1month
Clinicalassessment:
SideeffectsofmedicationsandAssessmentofadherence
Doctorsvisit6months
TREATMENTCOMPLETED
RepeatannualCXRattheNAP
C&Tsite
208
APPENDIX15.5
TBDISEASEINHIVNEGATIVE&SPUTUMPOSITIVEPERSONS
(Patientsareusuallyseenbythenurseandlabs,xraysandsputumorderedorthepatientcomeswiththesame
andareferral)

Baselinetestsordered:CBC;LFT;FBS;RBS;RFTs
EnrollmentinDOTS(4drugs:Ethambutol,Rifampicin,Isoniazid,Pyrazinamide,vitaminB6)

Doctorsvisit
2weeks

Evaluatetreatmentandlabresults.Ordersputumjustpriortonextvisit

Doctorsvisit2months

Doctorsvisit2months
NEGATIVESPUTUM
POSITIVESPUTUM
SputumandChestXrayorderedbefore
Continue4drugsforonemonth.Repeatsputumandculture
Reduceto2drugs(Isoniazid,rifampicin,B6)
forAFB&DSTandbeginIsoniazid,Rifampicin,B6aftertheone
monthextensionregardlessofsputumresults.

Doctorsvisit4months

Evaluateandordersputumat5months

SPUTUMNEGATIVE
SPUTUMPOSITIVE

retreatmentregime.Sendforsputum

cultureandDST.
Doctorsvisit6months

Withchestxray

Followupvisit 2yearaftercompletion

(Withsputumandchestxray)

TREATMENT COMPLETED
DISCHARGE
AnnualChestXray
(With sputum and chest xray)
DISCHARGE
209
APPENDIX15.6
TBDISEASEINHIVPOSITIVE&SPUTUMPOSITIVEPERSONS
Reviewresults:sputumX3;chestxray,VCTresult,TST)
ChestxraysuggestiveofactiveTB;ClinicalsuspicionhighforactiveTB
Baselinetestsordered:CBC;LFT;FBS;RBS;RFTs;VDRL;HepBsAg;VIA;CD4*andadherencecounselingifapplicable;
evaluationofHAART;
EnrollmentinDOTS(4drugs:Ethambutol,Rifampicin,Isoniazid,Pyrazinamide,B6,Cotrimoxazole)
Patientdoingwell
Patientdoingpoorly
Doctorsvisit2weeks
Clinicalassessment:
Sideeffectsofmedications&
Assessmentofadherence
DOTS/HAART
Evaluatepatient
andlabs
CD4<200:MonitorIRIS212
weeks.Ordersputumfornext
visit
Improved
MODIFYREGIMEN
& FOLLOWUP
Doctorsvisit 1month
StartHAARTifeligible,CD4<200
Ordersputumfornextvisit
Doctorsvisit2months
SPUTUMPOSITIVE
Continue4drugsforonemonth.Thenrepeatsputum,culture&
DSTandbeginIsoniazid;Rifampicin;B6aftertheonemonth
extensionregardlessofsputumresults.
Doctorsvisit2months
SPUTUMNEGATIVEReduceto2drugs
(Isoniazid; Rifampicin; B6)
Unimproved
Repeatsputumat5months
SPUTUMNEGATIVE
SPUTUMPOSITIVE
TreatmentfailuredoAFBCultureandDST.Patient
beginsretreatmentregime
210
Appendix16
PostExposureProphylaxisNAPS
MinistryofHealth
NationalSurveillanceFormforOccupationalandNonOccupationalExposure
CONFIDENTIAL
IncidentReg.No:......................
NameofReportingFacility.......................................................
Name(last,first,m).........................................Address(H)..................................Address(W).............................
DateofBirth(dd/mm/yy)..........................Sex Male FemaleTelephoneNumber..........................
Emergencycontactperson
Name..........................................Address...........................TelephoneNumber.........................
Date/timeofexposure.......................................Locationexposureoccurred......................................................
Date/timeofconsultation...................................DatelastHIVtestandresult..............................................
OccupationalExposure
Activityattimeofexposure:.....................................................................................................................................
NatureofInjury(e.g.cut,splashorneedlestick,includingboreofneedle):............................................................
Detailoftheexposure,includingthetypeandamountoffluidormaterialandtheseverityoftheExposure:
...................................................................................................................................................................................
Sexual/NonOccupationalExposure MultiplepersonsYes No IfYEShowmany......................................
NatureofExposure.....................................................................................................................................................
....................................................................................................................................................................................
Detailoftheexposure,includingthetypeandamountoffluidormaterialandtheseverityofthe
Exposure:....................................................................................................................................................................
Historyofantiretroviraltreatment:...........................................................................................................................
Detailsofexposuresource:
SourcematerialcontaminatedYes No Unknown
SourceisHIVinfectedYes No Unknown
HIVtestdonetosourceYes No IfYESresults:Negative Positive
Detailsofexposedperson:
ExposedisHIVinfectedYes No Unknown
HIVtestdoneYes No IfYESresults:Negative Positive Date....................
SexualAssault:
EmergencycontraceptiveprovidedYes No IfNOwhy...........................................................................
STIprophylaxisprovidedYes No IfNOwhy...........................................................................
AntiretroviralTreatmentdispensed:Yes No IfYES,timedispensed,within2hrs after2hrs

DateandtypeofRegimenadministered: Truvada+EfavirenzORDate:................................
Dimune+Kaletra(ifpregnantorcannottolerateEFV)
Date:................................
Medicalhistoryandrelevantnotes:.............................................................................................................................
......................................................................................................................................................................................
................................................................................................................................................................................
Signature/stamp...................................................Date:.............................................
211
REFERENCES
1. WHOGlobalTuberculosisControl2009and2010
2. WHOTreatmentofTuberculosisGuidelines4thedition2009
3. CaribbeanGuidelinesforthePrevention,Treatment,CareandcontrolofTuberculosisandTB/HIV
2010
4. CDCGuidelinesfortheInvestigationofContactPersonswithTBinfection,MMWR,December16,
2009
5. Wilson,A.P.R.,ReducingHospitalInfectionbyDesign,JournalofHospitalInfection(2006)62,264
269
6. GuyanaNationalTuberculinSkinTest(TST)guidelines2010
7. GuyanaNationalGuidelinesforManagementofHIVinfectedandHIVexposedAdultsandChildren
8. GuyanaNationalTBProgramAnnualReport2009
9. WHOPolicyonTBInfectioncontrolinHealthCareFacilities,congregateandHouseholdSettings,
2009
10. WHORapidAdvice:TreatmentofTuberculosisinChildren,2010
11. WHOManagementMDRTB,2010
12. WHOGuidelinesforIntensiveTBCaseFindingandIsoniazidpreventivetherapyforpeopleliving
withHIVinresourceconstrainedsettings,2010
13. WHOCompendiumofIndicatorsforEvaluatingNationalTBProgrammes2004
14. Reichman,I,HershfieldE.Eds.Tuberculosis:AComprehensiveInternationalApproach.NewYork,
MarcelDekka,ContactTracinginTuberculosis:1993:283
15. WHOTreatmentofTuberculosis:GuidelinesforNationalProgrammes,3rdEd.2003.NEnglJMed
200I4;351:174151
16. WHO.Guidancefornationaltuberculosisprogrammesonthemanagementoftuberculosisin
children.2006.
17. WHOModelFormulary2008.www.who.int/selection_medicines/list/en/)
18. TuberculosisCoalitionforTechnicalAssistance.InternationalStandardsforTuberculosisCare(ISTC),
2ndedition.TuberculosisCoalitionforTechnicalAssistance,TheHague,2009.
Ministry of Health - Guyana, 2011 | REFERENCES
212

Tuberculosis Guidelines Guyana 2011

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Tuberculosis Guidelines Guyana 2011

Încărcat de

Drepturi de autor:

Formate disponibile

GUYANA TUBERCULOSIS MANUAL

THE MINISTRY OF HEALTH

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | 1

Ministry of Health - Guyana, 2011 | Introduction

lowestinccidenceratess,atfour(4) andone(1)inevery10000persons,rrespectively. Theseagesp

Ministry of Health - Guyana, 2011 | Introduction

Ministry of Health - Guyana, 2011 | 2

Ministry of Health - Guyana, 2011 | National Tuberculosis Programme

Ministry of Health - Guyana, 2011 | National Tuberculosis Programme

and ensures implementation of high quality comprehensive care and appropriate

Produce and generate information, education and communication materials for

Conduct educational programmes about TB aimed at destigmatizing TB, mobilize TB

Ministry of Health - Guyana, 2011 | National Tuberculosis Programme

Ministry of Health - Guyana, 2011 | National Tuberculosis Programme

Ministry of Health - Guyana, 2011 | National Tuberculosis Programme

Ministry of Health - Guyana, 2011 | 3

Ministry of Health - Guyana, 2011 | 3

Ministry of Health - Guyana,

2011 | Tuberculosis Transmission and

Ministry of Health - Guyana,

2011 | Tuberculosis Transmission and

Ministry of Health - Guyana,

2011 | Tuberculosis Transmission and

Ministry of Health - Guyana, 2011 |

Ministry of Health - Guyana, 2011 | 4

Ministry of Health - Guyana, 2011 | 5

Ministry of Health - Guyana, 2011 | 5

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | Diagnosis of Tuberculosis

Ministry of Health - Guyana, 2011 | 6

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | Laboratory Services

Ministry of Health - Guyana, 2011 | 7

Ministry of Health - Guyana, 2011 | Directly Observed Treatment ShortCourse (DOTS)

Ministry of Health - Guyana, 2011 | Directly Observed Treatment ShortCourse (DOTS)

Ministry of Health - Guyana, 2011 | Directly Observed Treatment ShortCourse (DOTS)

Ministry of Health - Guyana, 2011 | Directly Observed Treatment ShortCourse (DOTS)

Ministry of Health - Guyana, 2011 | Directly Observed Treatment ShortCourse (DOTS)

Ministry of Health - Guyana,

2011 | Management of missed