Family and Community Med III

TUBERCULOSIS
Rosa Marie N. Flores, M.D., MPH, FPAFP, DFM
2nd Shifting /August 29, 2008
Trans group: JaViCi Code

A Family Approach to the Treatment of him/her amounts to at least 8 hours a

Tuberculosis day for 6 months
NATURAL COURSE OF TUBERCULOSIS
Session Objectives All starts with exposure
1. To describe the TB health situation the
Philippines.
2. To describe the various forms of TB, its Infected droplet
diagnosis & management.
3. To describe the National TB Control Program
ALVEOLAR INOCULATION
of DOH.
Multiplication of bacilli
Cellular and humoral
The successful completion of treatment of Tuberculosis immune
is associated with good social support from the family. response

_____________________________________________
PHILIPPINE DATA ON TUBERCULOSIS Primary Infection
• Approximately 15M Filipinos are infected with TB
• 75 Filipinos die of TB each day Primary Infection
• About 200,000 to 600,000 are spreading the • Subclinical usually with non specific symptoms
disease annually • Subside in 2 – 3 weeks
• The state of the TB problem has not changed • Transient mycobacteremia seeding distant sites
significantly the past 14 years like the pulmonary apex, renal cortex, epiphyses
of long bones or meninges
Inadequate case finding
Poor case holding Common Sites of Extra-Pulmonary Tuberculosis
» Non adherence of patients • Pleura
» Non adherence of doctors and health providers • Central nervous system
Inadequate prevention programs • Lymphatic system
Poor physician adherence • Gastrointestinal system
» 70% of doctors initially follow but divert
• Genitourinary systems
treatment resulting in more than 100 variations
• Bones and joints
» Do doctors know what the NTP and DOTS is?
• Disseminated (miliary TB)
_____________________________________________
Just a little review…
Terminally:
BASIC FACTS ABOUT TUBERCULOSIS
• Wasting (consumption)
• Caused by Mycobacterium tuberculosis • Hemorrhage
• Transmitted via the airborne route mostly from • Respiratory failure
infected persons when coughing
• The primary lesion in the lung & lymph nodes What is the probability that exposure leads to
infection and disease?
often heal spontaneously leaving a focus of • Concentration of droplet nuclei in the
dormant bacilli that can be reactivated at any environment
moment in an individual’s lifetime • Duration of exposure
• An infected person has a 5 - 10 % chance of
developing full blown TB in his/her lifetime Number of bacilli generated by the TB patient is
• A sputum (+) person infects 10-15 other influenced by:
persons annually • Disease in the lungs, airways, larynx
• A 50 % chance of becoming infected • Presence of cough or other forceful expiratory
from TB patient if time spent around measures

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
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• Presence of the bacilli in the sputum
• Extent of cavitation on chest radiograph
• Patient who does not cover mouth/ nose when
sneezing or coughing
ATS and CDC
A person who is infected with PTB coughs or
sneezes, releasing tiny particles of BACILLI . (This TB in Children
person may not even feel sick at the time.) Gold Standard of Diagnosis
 COUGHING
 Triad:
 TALKING
1. Exposure to an infectious case
 SNEEZING
2. (+) Tuberculin Test
3. Abnormal radiograph or PE
COMPARISON OF FEATURES OF THE AVAILABLE (STARKE, PIDJ, Nov 2000)
DIAGNOSTIC TESTS FOR TB
Adult versus Childhood TB
Test Sensitivit Specificity Field Cost Comments
y Use Cinical Pediatric TB Adult TB
Sputum 50-60% >95% High Free For Features
AFB to diagnosis
smear low & easier
response TB Primary Post-primary or
evaluation Pathogenetic tuberculosis Secondary or
Sputum 60 -90% > 99% Low High Takes stage reactivation TB
M. TB weeks;
Culture needed for
sensitivity
test Main Clinical features + Bacteriology
Chest x- 80% 70% Low Low For diagnostic history of (AFB smear and,
ray to to screening confirmation exposure to a if warranted,
mod mod. only; smear (+) case culture) Serial
needs to chest x-ray
be
confirmed
Serologic High* Mod* Low Mod. Not well
Tests to standardiz Bacillary load Low, hence, low High load (esp.
high ed; only infectiousness cavitary), highly
as an infectiousness
adjunct
PPD test High* Mod to Low Low Does not Treatment 2-3 drugs 4-5 drugs
High* to necessaril
mod y indicate
active TB
DOT Yes – by parent Yes – by health
PPD Testing Mandatory worker

5 mm = recent close contact; patients with fibrotic or

healed lesions on radiograph; HIV infected persons
BASIC PRINCIPLES OF TREATMENT OF TB
10mm = patients with special medical conditions • Give the safest, most effective therapy in
(8 mm) like DM, hodgkin’s disease prescribed duration
 steroid use • Choose multiple drugs to which the organisms
 high prevalence region or are (likely) susceptible
 travel to there residents of congested • Never add single drug to failing regimen
homes/living conditions • Ensure complete adherence to therapy
– DOTS for all!
15mm = all others • with proper treatment 95% will be cured
• after 2-3 weeks of correct treatment, patient no
[classmates di ko alam bakit may 8mm jan. magulo din longer highly contagious
ppt ni dra.]
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Isoniazid 5 (4-6) mg/kg, and not exceed

400mg daily
TB TREATMENT: WHY MULTIPLE DRUGS?
Rifampicin 10 (8-12) mg/kg, and not to exceed
Characteristics TB Subpopulations & Drug Activity 600mg daily

Site in the Lungs Inside Inside Intracellular -

cavities closed Macrophage Pyrazinamide 25 (20-30) mg/kg, and not to exceed
lesions 2g daily
Type of Milieu Aerated, Low PO2; Acidic pH;
high PO2 acidic- pH phagosomes
6.5
Ethambutol 15 (15-20) mg/kg, and not to exceed
1.2g daily
Growth rate Rapid slow slow

Size of pop. 107-9 104-6 104-6

Drugs active HRS HRZ HRZE Streptomycin 15 (12-18) mg/kg, and not to exceed
1g daily

 Natural Resistance: A predictable random mutation

in untreated M. TB
• Isoniazid: 1 in 104
TB Treatment in Children and Infants
• Rifampicin: 1 in 107
• Strep SO4: 1 in 104 Children: In most cases, treat with same regimens used
• Pyrazinamide 1 in 10 3 for adults
Infants: Treat as soon as diagnosis suspected
• Ethambutol: 1 in 105
Pregnancy, Lactation and TB Treatment
Likelihood of a bacillus spontaneously developing  During Pregnancy
resistance to 2 unrelated agents is the product of - HRE x 9 mos. (12 months if cavitary)
individual drug resistance probabilities  Past acute hepatitis
- HRE up to 6 mos. after sputum Hepatitis Virus (+)
 Acquired Resistance: A predictable forced mutation usual short course
 Chemotherapy
in patients on anti-TB drugs
 Alcoholism
• Monotherapy - leads to resistance to the drug
 Chronic liver disease
• Amplifier effect in MDR-TB - resistance to some
- RIF + INH + 1 or 2 non hepatotoxic drugs Strep or
drugs in the combination regimen leads to the
EMB
development of resistance to the remaining  Hepatic Failure
drugs. - Strep + EMB + if necessary, lower doses of INH or
RIF
 May individualize according to:  Acute Hepatitis
• bacterial burden - Defer treatment until hepatitis
• local resistance rates resolves; if not possible give 3SE / 6H
• drug availability conversion
• affordability PZA and SM are contraindicated
 During Lactation
No anti-TB drug contraindicated
NTP: DRUG DOSAGE ADJUSTMENT
Caution if both mother and baby are using INH
* add Vit B6 at 25 mg/kg/day if INH is used
Drug Dose per kg body weight and  Liver Disease and TB treatment
maximum dose  Extra pulmonary TB Treatment
Recommendation:
2HRZE / 4-7HR
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* For TB Meningitis, Miliary TB and bone/joint TB: Corticosteroids in TB treatment
2HRZE / 10 HR Indications:
 Renal Failure and TB treatment  Miliary TB with ARDS and DIC
Safest regimen: 2HRZ/4HR  TB meningitis when complicated
If needed, the following may be used or added in  TB pericarditis
Normal doses but less frequent intervals: All Level 4 evidence
Strep, EMB, Kanamycin, Capreomycin,
Cycloserine,Thioacetazone DELAY IN CONSULTATION
Give Vit. B6 with the INH • Misinterpretation of symptoms
• Protean manifestations of TB
Grade C recommendation
 HIV (+) Patient and TB treatment • Health care delivery system weaknesses
the control of tuberculosis lies in adequate case
Susceptibiltiy test available: holding
2HRZE / 4-7HR (or up to 6 mos. after sputum
conversion) STIGMA
“pandidirihian ako”
Susceptibiltiy test NOT available: “hindi na ako puede magtrabaho”
9HRZE ( 12 mos. if cavitary) “wala sa lahi namin yan!”
* Strict DOT for all cases
OTHERS
Chemoprophylaxis in Tuberculosis Historical : “consumption”
Regimens: Body image: The emaciated hungry look
INH alone - 6 - 9 month
INH + EMB - When primary drug resistance to INH is ADHERENCE IS THE KEY TO CONTROL OF
high TUBERCULOSIS

Grade A recommendation DOTS Improved Adherence

Revised National TB Control Program
Surgery for Extrapulmonary TB Components of DOTS
1. Ventricular decompression for hydrocephalus 1. Political will and support
2. Drainage of TB adenitis 2. Microscopy center
3. Renal TB drainage 3. Sufficient medicines
4. Pelvic TB clean-up surgery 4. Accurate and complete documentation
5. TB epididymitis and orchitis
5. DOTs partner
6. TB pericarditis
7. Osteoarticular TB
8. Pott’s disease Direct Observation of Treatment (DOT)
Who can be the treatment partner ???
All Level 4 Evidence • Staff of the health center such as midwife or
nurse
Indications for Resectional Surgery in • Member of the community such as BHW or local
Tuberculosis government official or former TB patient
• Member of the patient’s family
Group Indication Criteria
Background Information: Philippines
A Failure to Despite 4-6 mos. good • 84 million population (2004)
convert regimen
• Department of Health sets policies, standards,
B Previous or more after a standard Tx
relapse or 1 or more during MDR guidelines
treatment 2 - TB Unit
C Multi-Drug Resistance to 4 or more - Centers for Health Development
Resist drugs • Health program implementation is the mandate
D High risk for Destroyed lung or lobe of LGUs( Devolution )
relapse - Rural Health Units (RHUs); Health Centers
- Barangay Health Stations (BHSs)

TB Situation
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 One of the 22 high-burdened countries
(WHO TB Watchlist)
 3rd (151/100,000) in the Western Pacific - Case
Notification of all cases
 6th leading cause of deaths (1998)
 6th leading cause of morbidity
 Prevalence of Smear (+) cases – 3.1 /1,000
(240,000 cases)
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• Passive case finding shall be implemented in all
health centers, health stations.
• Sputum microscopy work shall be performed
only by adequately trained health personnel.
• Quality control of smear examination must be
observed. Validation system must be
established.

What had been done?

1910 - PTS organized
1930 - TB Commission established
1954 - TB Law passed
1978 - Nationwide implementation of NTP Caseholding Objectives:
1987 - SCC in Blister-packs introduced  To render as many Smear (+) cases as non-
1992 - Local Government Code implemented infectious & cured as early as possible.
1994 - PhilCAT organized  To treat seriously-ill Smear (-) cases & other
1996 - D.O.T.S. strategy pilot-tested
potentially infectious cases.
2002 - D.O.T.S. nationwide (98% coverage)
2003 - GDF & GFATM grant approvals - PPM
Classification of TB Cases based on location of
NTP Objectives lesions:
 Pulmonary Smear (+)
 Increase Case Detection Rate from 61% (2003)  Smear (-)
to 70%  Extra-pulmonary
 Increase Cure Rate from 77% (2002) to 85%
TB cases:
 Based on history of anti-TB treatment
Directly Observed Treatment Short-course
 Important in determining tx regimen
(D.O.T.S.)
 Political commitment
 Quality microscopy service TYPES OF TB CASES:
 Regular availability of drugs  New - no tx or <1m tx
 Standardized records & reports  Relapse – previous TB treatment & Sm(+) again
 Supervised treatment  Transfer - in - change tx facility
 Return After Default - interrupted tx / Sm (+)
Program Components  Treatment Failure - still (+) on 5th month
 CASE FINDING  Others - became (+) on 2nd m;
- interrupted tx / Sm(-)
Objectives:
To identify TB symptomatics Treatment Regimens
To identify & diagnose TB cases early
TB TB Patients To DRUGS AND DURATION
Passive Casefinding – TB symptomatics present Treatment Be
themselves at the health facility. Regimen Given
Treatment
Active Casefinding - purposive effort to find TB cases
among the symptomatics who don’t seek consultation. Initial Continuation
Phase Phase
Major Policies on Case finding:
• Direct sputum smear microscopy shall be the
primary NTP diagnostic tool.
• All TB symptomatics must undergo sputum
examination, with or without X-ray results.
Only contraindication is massive hemoptysis.
• Three sputum specimens must be submitted
1st spot, early morning, 2nd spot
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I New smear- 2 HRZE/ 4 HR/

Treatment Partner:
positive PTB;
new smear-  Watches the patient take his drugs daily
negative PTB  Reports & traces the patient if he defaults
with extensive  Provides health education regularly
parenchymal  Motivates the patient on sputum ff-ups
involvement;
extra- Who will undergo supervised treatment ?
pulmonary TB  Priority are the Smear (+) TB cases

Who could serve as Treatment Partner ?

II Previously 2 HRZES/ 5 HRE  Health Staff, Barangay Health Worker,
treated smear- 1 HRZE Community Volunteer, Family Member
positive PTB;
relapse;
Where will D.O.T. take place ?
treatment
 Health facility
failure;
treatment after  Treatment Partner’s House
interruption  Patient’s House

III New smear- 2 HRZE/ 4 HR/ How long is treatment supervised ?

negative PTB  Daily drug intake is supervised during the
(other than in
entire course of treatment.
Category I

RECORDS and REPORTS

Schedule of Sputum Follow-up Examinations
CAT I : 2nd, (3rd), 4th, 6th
CAT II : 3rd, (4th), 5th, 8th
CAT III : 2nd
Major Policies on Case Holding
• No patient shall be initiated into treatment
unless a case holding mechanism for the
treatment compliance has been agreed upon by
the patient & health workers.
• The national &/or local governments shall ensure
the provision of drugs to all sputum (+) TB
cases.
• No patient shall be initiated into treatment
unless a case holding mechanism for the
treatment compliance has been agreed upon by
the patient & health workers.
• The national &/or local governments shall ensure
the provision of drugs to all sputum (+) TB
cases.
 NTP Laboratory Request Form
 Laboratory Register
 NTP Treatment Card
 NTP Identification Card
 TB Case Register
 NTP Referral Form
Reports
 Quarterly Report on Laboratory
 Quarterly Report on Casefinding
 Quarterly Report on Treatment Outcomes
Major Policies on Recording / Reporting
 Shall rely on all government health facilities,
including government hospitals.
 Shall include all cases of TB, classified according
to internationally accepted case definitions.
 Shall include private physicians & private clinics,
after agreement with parties concerned has
been made.
 Shall allow the calculation of the main indicators
for evaluation. (Cure Rate, Case Detection Rate)
Program Indicators

Supervised Treatment CASEFINDING

• A mechanism of ensuring treatment compliance  Proportion of Sputum (+) (60%)
• TB patient is motivated to take his drugs = Total No. Sputum (+) cases discovered
• Cured Total No. of Pulmonary TB cases
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 Proportion of 3 sputum examination (90%) 2. Described the various forms of TB , it’s diagnosis
= No. TB symptomatics with 3 specimens & management.
Total no. TB symptomatics examined 3. Described the National TB Control Program of
 Positivity (15-20%) DOH.
= No. Sputum (+)s discovered_______
Total no. TB Symptomatics examined
 Case Detection Rate (CDR=70%) Student Activity:
= No. of New Sputum (+) cases discovered
Group 1 – Role play – Disclosure to a patient that he/
TP x 145/100,000 (Incidence)
she has TB
COHORT ANALYSIS
Group 2- Role play – Convincing the patient to undergo
• A group of patients having the same attributes
6 months TB treatment
at a certain period of time to determine
treatment outcome. Group 3- Role play – Health education to group of
• Treatment Outcomes: mothers on how to prevent TB in the home
Cure Rate = 85 %
End of Tran
Completion Rate
• Tx Failure Rate Defaulter Rate Ei classmates snsya na, hndi yung mismong powerpoint yung
• Death Rate pnagkopyahan namin nito. Pnahiram lang kami ng sec A. Inayos
• Trans-Out Rate na lang namin sa abot ng aming makakaya para mas
maintindihan. Salamat! =)
Cure Rate
= Total no. New Sputum (+)cases who got CURED
Total no. New Sputum (+) cases evaluated

General Attributes: Tuberculosis

New, Pulmonary Sputum (+) case

Differentiating Attribute - CURED (Tx Outcome)

Cure - New Sputum (+) case, completed tx,

Sputum (-) at the end of treatment

TREATMENT OUTCOMES

Cured Completed
 Completed tx BUT no sputum
ff-up result at end of treatment

Treatment Failure
 Smear (+) at 5 mos. of tx

Defaulter
 Interrupted tx for 2 months or
more and not retrieved back

Transfer Out
 Change in tx facility

Died (Hehe toxic pa din ang filler! Haha. Hi na lang sa inyong lahat!)
 Transpires during course of tx.

SUMMARY
1. Described the TB health situation the Philippines.
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