Tuberculosis Contact

Investigation and
Preventive Treatment
Training on the Field Implementation Guide

TB Innovations and Health Systems Strengthening (TBIHSS) Project

Outline of the Presentation

Why is TB Preventive Treatment (TPT) important? Role of TPT in TB elimination?

Is there evidence to support the use of TPT?

General Strategies and Screening for TPT eligibility​

TPT Initiation and Monitoring​

Care TB App Introduction and TB Contact Investigation (CI) Forms​

Frequently Asked Questions

Health Promotion and Communication

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Pre-Test

Pre-test: https://bit.ly/3FudKwY

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Why is TPT important?
Role of TPT in TB elimination?
Is there evidence to support the use of TPT?
Burden of TB Infection

Global Philippines

…About 25% of the world’s …About 40% of Filipinos are

population is infected with M.
tuberculosis
(1 out of 4 individuals)
Global tuberculosis report 2022. Geneva: World Health
Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO.
infected with M. tuberculosis
(2 out of 5 individuals)
Houben, R. M., & Dodd, P. J. (2016). The Global Burden of Latent
Tuberculosis Infection: A Re-estimation Using Mathematical
Modelling. PLoS medicine, 13(10), e1002152.
https://doi.org/10.1371/journal.pmed.1002152

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Global Vision of Ending TB by 2035

Rate of decline of TB incidence

needs to accelerate to an
average of 17% per year
between 2025 and 2035!!!

Extensive TB case finding +

provision of effective treatment to
all patients with TB disease +
massive provision of TPT to
others with TB infection

The end TB strategy. World Health Organization. 6

Modelling studies show that TPT will reduce TB incidence
and help end the TB epidemic
We need to do more than just treat
active TB, including tackling the vast
reservoir of latent TB infection
Mathematical modelling data from
Asia-Pacific suggests that TBI is a
key driver of TB transmission
TPT is a crucial tool to empty the TBI
reservoir, to help achieve TB
elimination goals
Current lack of an effective TB vaccine,
TPT is the primary modality available
to prevent progression to active TB
disease
Modelling studies in South-East Asia
show that increasing TPT coverage
could reduce annual TB incidence
and mortality rates
Trauer et al. Construction of a mathematical model for TB transmission in
highly endemic regions of the Asia-Pacific. J Theor Biol. 2014
Mandal et al. The potential impact of preventive therapy against tuberculosis in
the WHO South-East Asian Region: a modelling approach BMC 2020
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 TPT reduces active TB Cases

This modelling study shows that:

Household contact tracing and

yearly ACF campaigns reduce
TB incidence

Adding TPT to household

contact tracing can reduce
TB incidence even more
(17-27%)
Kasie et al. Timing of TB Transmission and the Impact of Household contact tracing. AJRCCM 2014

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Currently Recommended TPT Regimens:
Evidence of Efficacy and Safety

Recommended
• Isoniazid daily for 6 or 9 months (IPT)
• Isoniazid plus rifapentine weekly for 3 months (3HP)
• Isoniazid plus rifampicin daily for 3 months (3HR)

Alternatives
• Rifampicin daily for 4 months (4R)
• Isoniazid plus rifapentine daily for 1 month (1HP)

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Evidence that TPT Works in PLHIV: Isoniazid (INH)

Reduction in death
TPT reduces TB and risk of death
even without ART
37% in Temprano Study

Cochrane review of 12 RCTs showed that:

• TPT reduced TB risk by 33% for all and
by 64% if TST positive
• 6H efficacy was similar to 12H
• Currently available TPT regimens have
efficacy from 60-90% with protection
to 19 years

Akolo et al, Cochrane Database of Systematic Reviews, 2020 10

Household Contacts of People with Active TB Disease

High prevalence of TB disease – 3.6% among all

close contacts

HH contacts <5 years old have significantly higher

risk of acquiring TB infection and progressing rapidly
to TB disease

Children <2 years old are at greater risk for severe

and disseminated forms of TB with very high risk of
morbidity and mortality

WHO consolidated guidelines and operational handbook on tuberculosis.

Module 1: prevention - tuberculosis preventive treatment (2020)
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Household Contacts of People with Active TB Disease

WHO consolidated guidelines on TPT: Pooled estimates of risk for active TB among household
contacts stratified by age and baseline TBI status as compared with the general population

MAIN RESULT

All household contacts,

regardless of age or TB
infection status are at
higher risk for
progression to active
TB than the general
population

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Efficacy of TPT in TB contacts: Isoniazid (INH)

11 trials (73,375 patients)

6- or 12-months INH resulted in
60% reduction in risk of TB disease

No difference between 6 and 12

months of INH

TPT reduced deaths from TB

INH was associated with

hepatotoxicity in 0.36% (6H)
and 0.52% (12H)

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Evidence that TPT Works and is Safe:
3 months weekly Isoniazid-Rifapentine (3HP)

3HP is non-inferior to INH for adults,

adolescents and children over 2 years

Safer than INH with lower risk for

hepatotoxicity

Better adherence

Better treatment completion

Sterling N Engl J Med. 2011, Sterling AIDS. 2016,

Villarino JAMA Pediatr. 2015

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Evidence that TPT Works and is Safe:
3 months weekly Isoniazid-Rifapentine (3HP)

Short course Rifamycin-based

Regimens have similar
efficacy to 6 months of IPT in
PLHIV

3HP is both safe and effective

for those over 2 years of age
Martinson NEJM 2011

Years of Follow-up

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More evidence that TPT Works and is Safe:
Systematic review on Safety of 3HP

23 RCTs and 55 observational studies

Rate of any Adverse Event: 3HP (11.5%), 3-4R (20.0%),

6H (36.1%), 9H (17.6%)
Withdrawals due to Adverse Events: 3HP (1.7%), 9H (6.4%), 6H (3.8%)

Flu-like reactions: 3HP (2.2%), INH (0.05%)

Hepatotoxicity: 3HP (1%), 3-4R (0.01%), 6H (6.3%), 9H (3.1%)

Pease, Pharmacoepidemiol Drug Safety 2018

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Evidence that TPT Works and is Safe:
3 months daily INH and Rifampicin (3HR)

Systematic review showed efficacy

and safety profile of 3–4 months
daily HR was similar to 6H
Zenner. Ann Intern Med. 2017, Stagg HR, Ann Intern Med. 2014

A review compared effectiveness

of 3HR daily with 6H or 9H in
children:
Lower risk for adverse events
Higher adherence rate
Galli IJMS. 2016, Spyridis Clin Infect Dis. 2007, van Zyl. Int J Tuberc Lung
Dis. 2006

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Evidence that TPT Works and is Safe:
4 months daily Rifampicin (4R)

Non-inferior to 9H

Higher treatment completion rate

78.7% vs 62.8%
Better safety: All AEs- 2.8% vs 5.8%
Menzies, NEJM 2018

Systematic review 2017:

similar efficacy for 3–4R vs 6H

Daily rifampicin had less

hepatotoxicity than INH
Good option for contacts of INH
Zenner, Ann Intern Med. 2017; Stagg HR, Ann Intern Med. 2014
monoresistance TB patients
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Evidence that TPT Works and is Safe:
1 month daily INH and Rifapentine (1HP)

Brief TB A5279: Multicenter randomized open

label Phase 3 trial in PLHIV over 13

Daily HP for 4 weeks vs 9H

Similar efficacy as 9H

No increase in adverse events

No resistance issues

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Comparing Rate of Adverse Events Between Regimens

Hepatotoxicity rate of newer regimens is 0.4% with 3HP

much lower than older 0.3% with 4R
regimens 2.7% with 6H

No death or mortality reported in No hepatotoxicity from either 3HP

clinical trials for 3HP and 4R regimens or 6H in children or adolescents

Flu-like symptoms may occur in first 2 to 4 weeks of TPT, but

usually mild and resolve spontaneously

Sterling et al, NEJM, 2011; Menze D et al, 2018; Villarino, JAMA 2015

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TPT does not create drug resistance

Randomized controlled trials and systematic reviews show no significant

association between TPT and drug resistance

Regimens Risk ratio (95% CI)

INH 6-12 month (13 studies) 1.45 (0.85 – 2.47)

INH 36 month (One study) 5.96 (0.24 – 146)

Rifamycin-containing regimens
3.45 (0.72 – 16.56 P= 0.12)
(6 studies)

WHO 2015 guidelines on the management of latent tuberculosis Infection; Balcells ME, Emerging Infectious Disease, 2006; S Den Boon, IJTLD 2016

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Summary

TPT works on an individual level to Evidence shows that we

prevent progression from TBI to should scale-up TPT to all
active TB disease who need it

Modelling studies show that TPT will Use of Rifapentine for TPT in
also further reduce TB incidence young children and pregnant
compared to strategies that focus on women requires further study
only treatment of active TB disease

TPT does not cause drug

There are now several choices for
resistance
TPT with strong data showing that
they work and are safe

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Questions?
General Strategies and
Screening for TPT Eligibility
Major Challenges in Implementing Strategies for
TB Prevention

Weak and nonsystematic performance of CI

Low Coverage of TPT

Variable implementation of infection prevention and control
measures
Hence, there is a
TPT is not a priority need to strengthen CI
and TPT services to
Insufficient logistics
improve CI and TPT
Inadequate access to chest x-ray to support ruling out of coverage!!!
active TB disease
Long duration of the current TPT regimen

Receptiveness of patients to treatment before symptom onset

Source: 2019 Philippines TB Joint Program Review Report 25

CI and TPT Field Implementation Guide

Main objectives:
Enhance CI and TPT coverage
Ensure the quality of CI and TPT services

Provides guidance in identifying persons

eligible for TPT, promoting the uptake of and
ensuring adherence to TPT

Intended for program managers and staff,

implementers, and community health workers
Provides strategies and tools that may
help address barriers in the field
implementation of TPT

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What is TB infection?

State of persistent immune response

to stimulation by MTB antigens with no
evidence of clinical manifestations
of active TB disease

No signs or symptoms of TB but at

risk for active TB disease

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 What is the difference between TB Infection and TB disease?

TB infection TB disease
TB bacilli mainly dormant and locally contained TB bacilli multiplying and may be spreading
Person is not sick (no TB symptoms) Person is sick (TB symptoms)
Cannot transmit TB to others Can transmit TB to others
TB treatment cures disease, prevents death and stops
TPT prevents progression to TB disease
transmission

https://microbiologycommunity.nature.com/posts/19192-the-spectrum-of-tuberculosis-and-why-it-matters
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Natural History of TB Infection

70-90% exposed but

TB EXPOSURE not infected
Child or adult spends time
with someone who has TB INFECTION
infectious TB disease Child or adult breathes in
TB bacteria into his or her
Person’s lungs
lungs, then carries live
are healthy
(often dormant) bacteria
inside the body but
remains well with no
signs or symptoms of TB
5-10% will develop
active TB during
10-30% will get TB
their lifetime (higher
infection
for PLHIV)
TB DISEASE Exposure to infection
depends on various factors:
Child or adultbecomes unwell with signs and symptoms intensity, duration, and
of TB because the bacteria are multiplying frequency of exposure,
environment, and host
immune responses
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 What are the risk factors for progressing from
TB infection to TB disease?

Being a child contact less HIV infection Diabetes mellitus Excessive alcohol and
than 5 years of age substance use,
including tobacco use

Low body weight Silicosis or Migration from regions with Cancer and
or malnutrition other occupational high rates of tuberculosis immune-modulation
lung diseases treatment

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Strategies to Address
Constraints in Health Facilities
Barriers in TPT
implementation Limited screening
day for TB
Accessing healthcare
Diagnostic delay
Access delay Limited access to transport No nearby CXR facility
Financial constraint Lack of PPD supply

Identifying if active TB
Recognizing risk of or latent TB infection
Lack of communication
developing TB allowance for contact tracing
“I’m healthy. I don’t
feel the need for TPT” Facility staff not familiar with
protocol on TPT
Stigma against TB

Treatment delay

Patient delay Insufficient TPT drugs

Incomplete contact details
Fragmented reporting
mechanism

Household contacts of Treatment for active TB or

BCTB index cases TB preventive therapy
Identifying Persons Potentially
Eligible for TPT​
How do we identify persons potentially eligible for TPT?

Contact Investigation

“a systematic process of identifying “allows for early diagnosis of TB

exposed persons as early as possible and an opportunity to treat TB
and facilitating diagnostic infection, thereby preventing
investigations and treatment” future tuberculosis disease”

Identifying other people with risk factors for TB

• PLHIV • Those with immune-suppressive

• With diabetes medical conditions
• Persons who smokes • Malnourished
• With silicosis
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Definition of Terms in Contact Investigation
Index Case
is a person with bacteriologically
confirmed pulmonary TB (BCTB)
around whom a contact
investigation is centered
Household (HH) Contact
a person who has shared the
same enclosed living space as
the index case
Close Contact
a person who is not in the
household but who has shared an
enclosed space, such as a place
of social gathering, workplace or
facility for extended periods during
the day with the index case during
3 months before the start of the
current course of treatment
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Steps in Contact Investigation

Once a case is registered for treatment, interview the

Interview index case and explain the importance of contact
investigation

List & Ask for the name of all HH and close contacts,
regardless of age, and list all of them in the DS-TB
Record Treatment Card and Presumptive Masterlist

Request index case to interview HH and close contact, and offer

options on how contacts will be interviewed: Contacts should be
Request Teleconsultation; Ask to visit the facility; Participate in an ACF evaluated within 7
event; House visit days from
treatment initiation
of the index case
Interview each of the contacts (or their caregivers) for
Interview signs and symptoms of TB
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Steps in Contact Investigation

Offer CXR if available (e.g., voucher, ACF, ICF) to all contacts

Offer who are 5 years old and above. If not, perform symptom
screening including those under 5 years of age

Test contacts for active TB (rapid TB diagnostic test) or TB

Test infection (TST or IGRA) depending on results of symptom
and/or CXR screening

Provide results to contacts (or their caregivers) and discuss

Provide appropriate management based on results

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Steps in Contact Investigation

Counsel contacts (or their caregivers) prior to initiating TB

Counsel treatment or TPT

Perform baseline clinical evaluation and laboratory tests (if

Manage necessary), provide appropriate management (start TB treatment
or TPT) and support treatment completion

Update Update patient records, and facility forms and registers

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 ALIVE Contact Investigation
Kausapin ang index case at ipaliwanag ang kahalagahan ng
contact investigation

• Kumustahin tungkol sa buhay-buhay

• Tanungin ang pangalan ng lahat ng kasama sa bahay o hanapbuhay
Ask kung may sintomas ng TB
Maaaring: 1) Kausapin gamit ang telepono 2)Puntahan sa bahay 3)
Papuntahin sa health center

List Ilista lahat ng pangalan sa Contact Investigation Form

Magbigay ng tamang impormasyon tungkol sa TB Preventive Treatment

• 1 sa 4 na tao ay may TB bacteria
Inform • 1 sa 10 tao na may TB infection ay maaaring tuluyang magkasakit ng TB
Ibigay din ang kahalagahan ng TB Preventive Treatment sa mga kasama sa
bahay o hanapbuhay

Verify Muling tanungin ang kausap kung naiintindihan ang ibinahagi. Kung maaari,
maglaan ng panahon para sa tanungan at kwentuhan

Palakasin ang loob at hikayatin na:

Encourage • Mag-TPT Tanggal Bacteria Power

• Magpa-check up sa health center or TB clinic
Strategies and Tools in Identifying Persons
Eligible for TPT
Enhance uptake of TB screening and investigation of TB/TB infection among household and/or close
contacts of index or source active TB cases:

Strategies Tools/Materials
Resolve myths surrounding TB/TB Frequently asked questions in resolving
infection and TPT among HCWs and clients myths to address the concerns of HCWs

Send an invitation brochure or card for IEC materials to address clients’ concerns
their health check (invitation card or leaflet)

Conduct telephonic education, Forms for contact tracing and screening

counseling, and symptomatic screening, and by non-medical people (BHW, TB
and arrange for an appointment to do patient support group, CSO members)
TB/TB infection workup at the convenient
time of clients

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 FREQUENTLY ASKED QUESTIONS to
address myths about TB infection and TPT
If TB infection is not contagious, and there are
no clinical manifestations (i.e., no clinical signs
and symptoms), then why is treatment needed
for TB infection?
Will TPT create drug-resistance to TB?
IEC Material for Index Case and Contacts
(An invitation card or leaflet)
We are concerned about the health of your family. Hence we would like
to invite all your family members to come for health check-ups, which will
include examination and chest X-rays. Based on the result of the
check-up, either treatment for TB disease or preventive treatment for TB
infection will be provided. The whole service package is free of charge.
Should you need any further information, please call us at XXXXXXX.
Then graphic illustration on MTB entry to body – incubation period –
disease (simple graphic illustration).

Is TB preventive treatment safe?

Is it mandatory to perform a tuberculin skin test

(TST) or interferon-gamma release assay
(IGRA) before starting TPT for all people
potentially eligible for TPT?

Is it mandatory to provide TPT under strict

directly observed treatment (DOT)?
CI and Screening Form Para sa Community Health Workers/Volunteers
Pangalan o Initial ng Index Case: ______________________________ Index TB No: ________________
Paalala: Gumamit ng extra sheet kung mayroong >5 miyembro ng pamilya

Kasaria
Resulta ng interview
Bilang

Edad
Pangalan Sintomas ng TB na 2 linggo o higit pa
Petsa:___________________ Karagdagang Action

n
(First-Middle-Last) (markahan ang akma)
(MM/DD/YYYY)
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
1 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi na
 Tatawagang muli
__________________________ interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
2 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi na
 Tatawagang muli
__________________________ interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
3 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang
 Tatawagang muli
__________________________ client/Hindi na interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
4 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang
 Tatawagang muli
__________________________ client/Hindi na interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
5 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang
 Tatawagang muli
__________________________ client/Hindi na interview

a= para sa <5 years old na walang TB signs and symptoms; b=any one with at least one sign or symptom; para sa >5 years old regardless of signs and
symptoms
 CI and Screening Form for Community Health Workers/Volunteers
Name or Initial of Index Case: ______________________________ Index TB No: ________________
Note: Use an extra sheet if there are >5 family members

Result of Interview
Name TB Signs and Symptoms lasting for ≥2
No. Age Sex Date:___________________ Further Action
(First-Middle-Last) weeks (tick applicable)
(MM/DD/YYYY)
 None  Cough
 Refer for TPTa  Made appointment
Fever  Weight Loss
1  Refer for further TB workup b Date: _______________
Night Sweat  Others (specify)
 Not seen client/Not interviewed  To call again
______________________________
 None  Cough
 Refer for TPTa  Made appointment
Fever  Weight Loss
2  Refer for further TB workupb Date: _______________
Night Sweat  Others (specify)
 Not seen client/Not interviewed  To call again
______________________________
 None  Cough
 Refer for TPTa  Made appointment
Fever  Weight Loss
3  Refer for further TB workup b Date: _______________
Night Sweat  Others (specify)
 Not seen client/Not interviewed  To call again
______________________________
 None  Cough
 Refer for TPTa  Made appointment
Fever  Weight Loss
4  Refer for further TB workupb Date: _______________
Night Sweat  Others (specify)
 Not seen client/Not interviewed  To call again
______________________________
 None  Cough
 Refer for TPTa  Made appointment
Fever  Weight Loss
5  Refer for further TB workupb Date: _______________
Night Sweat  Others (specify)
 Not seen client/Not interviewed  To call again
______________________________
a=for <5 years old + no TB signs and symptoms; b=any one with at least one sign or symptom; for >5 years old regardless of signs and symptoms
Strategies and Tools in Identifying Persons Eligible
for TPT
STRATEGIES
Systematically identify, screen,
and investigate people from
targeted risk groups as they come
for care in health facilities for TB
and TB infection by using a
checklist
*Ask the index case to identify all
household contacts and/or at least
five (5) significant close contacts
outside the household
TOOLS/MATERIALS
A checklist to identify persons at risk:
Risk Group Yes No
a) Household contacts
b) Close contacts
c) People living with HIV
d) Patients receiving dialysis
e) Patients preparing for an
organ or hematological
transplantation
f) Patients initiating anti-
TNF treatment
g) Patients with silicosis
If “Yes” to any, investigate for TB/TB
infection based on the latest NTP Manual of
Procedures and offer TPT if eligible.
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Strategies and Tools in Identifying Persons Eligible
for TPT

Community and Congregate Setting

TB CI and TPT provision should be Targeted vulnerable groups

integrated into ACF include the following:
• Urban and rural poor
CI may be limited only to the household • Those living in
and close contacts of index TB cases congregate settings
identified in the ACF activities • Workplaces (including
schools)
Whenever an active TB is diagnosed in
any of the ACF, immediately ask for
household and close contacts - screen
them for TB and TB infection

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Preparation in Conducting ACF and TPT Activities
in Congregate Settings and Workplaces

Obtain prior approval from relevant authorities and community leaders

Discuss and prepare strategies to address the stigma and confidentiality

and privacy of index cases

Ensure the availability of required resources

Engage in proper planning for its implementation with all concerned

stakeholders

Conduct proper training to staff undertaking the combined ACF and TPT
strategies

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 Who are the eligible for TPT?

TST NOT REQUIRED TST REQUIRED NOT ELIGIBLE

(Eligible for TPT) (Eligible ONLY if positive) For TPT
<5 years old, BCTB index <5 years old, CDTB index ---
HH contacts
>5 years old, BCTB index, >5 years old, BCTB index, no TB
>5 years old, CDTB index
with TB risk* risk

Close contacts --- All ages, BCTB index All ages, CDTB index
Age <1 year old
PLHIV Ages >1 year old --- (if not contact of a person
with TB)
• Patients receiving dialysis,
• Patients preparing for an organ or
hematological transplantation
Other Risk Groups --- ---
• Patients initiating anti-TNF
treatment
• Patients with silicosis
*TB risk - PLHIV, diabetes, smokers, those with immune-suppressive medical conditions, malnourished, with multiple people with TB in same household
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Procedures to Rule Out
Active TB Disease and
Investigation for TB Infection
Screening to Rule Out Active TB Disease

4-symptom screening (ADULT): with any of the following

symptoms lasting for 2 weeks or more:

Unexplained Fever
Cough Night sweats
weight loss

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Screening to Rule Out Active TB Disease

4-symptom screening (PLHIV): with any of the following

symptoms regardless of duration:

Cough Weight loss Night sweats Fever

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Screening to Rule Out Active TB Disease

Symptom screening (CHILDREN): with any of the following

symptoms lasting for 2 weeks or more:

Unexplained weight
Coughing/wheezing Unexplained fever
loss or failure to thrive

If the child is a contact of a TB case, also ask for the presence of

fatigue, reduced playfulness, decreased activity or anorexia

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Screening to Rule Out Active TB Disease

If no signs and symptoms of TB, perform CXR

Findings suggestive of TB on CXR should be

evaluated to rule out active TB disease

Exception: among <5 years old contacts

Unavailability of CXR should not be a barrier to TPT.

Physician may offer TPT later but the regimen to be
given should not contain rifamycin

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Testing for TB Infection

WHO recommends either a TST or IGRA

No strong evidence that one test should

be preferred over the other in terms of
predicting progression from TB infection
to TB disease

Neither of the tests is considered as gold

Tuberculin Skin Test
standard in detecting TB infection
(TST)

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Performing TST

Either 5-TU or 2-TU PPD can be used for TST

Inject 0.1 mL of PPD intradermally into the inner

surface of the forearm with a tuberculin syringe, the
needle bevel facing upward

If the injection is done correctly, it will produce a

pale elevation of the skin (a wheal) from 6 to
10 mm in diameter

Skin reaction should be read between 48 and 72

hours and measured in millimeters of the
induration (palpable, raised, hardened area or
swelling) but not erythema (redness)
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Interpreting TST Results

Diameter of the indurated area should be

measured across the forearm (perpendicular to
the long axis)
Positive TST:
➢ An induration of at least 10 mm
regardless of BCG vaccination
➢ 5 mm in immunocompromised children
(e.g., severely malnourished)

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Interpreting IGRA Results

In-vitro blood tests that detect interferon

gamma in blood using ELISA
Requires fresh blood to be processed within 8-
30 hours after collection

RESULTS:
• POSITIVE: suggests that TB infection is likely
• NEGATIVE: suggests that TB infection is
unlikely
• Indeterminate: suggests need for further
investigation/repeat testing

63
 Eligibility of Risk Groups for TPT using TST
TST NOT REQUIRED TST REQUIRED NOT ELIGIBLE
(Eligible for TPT) (Eligible ONLY if positive) For TPT

<5 years old, BCTB index <5 years old, CDTB index ---
HH contacts
>5 years old, BCTB index, >5 years old, BCTB index, no TB
>5 years old, CDTB index
with TB risk* risk

Close contacts --- All ages, BCTB index All ages, CDTB index

Age <1 year old

PLHIV Ages >1 year old --- (if not contact of a person
with TB)
• Patients receiving dialysis,
• Patients preparing for an organ
or hematological transplantation
Other Risk Groups --- ---
• Patients initiating anti-TNF
treatment
• Patients with silicosis
*TB risk - PLHIV, diabetes, smokers, those with immune-suppressive medical conditions, malnourished, with multiple people with TB in same 64
household
NOTE: In selecting the appropriate algorithm,
check the age and HIV status of the contact being
evaluated

Investigation for Active TB

Disease and TPT in Children
<5 years old with HIV
Negative or Unknown HIV
Status (contacts of both BC-
and CD-TB cases)

*If household contact of BC-TB, no need to perform TST/IGRA

If household contact of CD-TB or close contact of BC-TB, perform TST/IGRA
• If positive, start TPT
• If negative or not available, do not give TPT
 Investigation for Active TB
Disease and TPT in Children
≥5 years old and Adults with
HIV Negative or Unknown
HIV Status (only contacts of
BC-TB cases)

*Risk Factors:
1. PLHIV
2. Persons with diabetes
3. Smokers
4. Those with immunosuppressive medical conditions
5. Malnourished (underweight or BMI of <18.5)
6. With multiple people with TB in same household people
(2 or more regardless of whether BC-TB or CD-TB)
Investigation for TB Disease
and TPT in Children 1 to 4
years old with HIV Infection
 At the time of diagnosis of HIV

Investigation for TB Disease

and TPT in Children ≥5
years old with HIV
Infection and Adults with
HIV Infection
Questions?
TPT Initiation and Monitoring
Counselling

Counsel person eligible for TPT

Disseminate educational leaflets with
messages
Key messages
• What is TB infection
• Why take treatment for TB infection
• Medicines to be taken
• Potential side effects
• Taking TPT: every dose matters
• Limiting alcohol use
• How to store the pills
• Other considerations

71
 Potential Adverse Events (AEs)
Suspected Culprit
Known AEs Rare AEs
Anti-TB Drugs
• Asymptomatic elevation of serum liver
• Convulsions
enzyme
• Pellagra
• Hepatitis
Isoniazid • Arthralgia
• Peripheral neuropathy
• Anemia
• Skin rash
• Lupoid reactions
• Sleepiness and lethargy

• Gastrointestinal reactions (abdominal pain, • Osteomalacia

nausea, vomiting) • Pseudomembranous colitis
• Hepatitis • Pseudoadrenal crisis
Rifampicin
• Generalized cutaneous reactions • Acute renal failure
• Thrombocytopenic purpura • Shock
• Discoloration of body fluids • Hemolytic anemia

• Gastrointestinal reactions (abdominal pain, • Hypotension/syncope

nausea, vomiting) • Decrease in white blood cell
• Hypersensitivity reactions (flu-like and red blood cell count
Rifapentine
symptoms)
• Hepatitis • Decreased appetite
• Discoloration of body fluids • Hyperbilirubinemia
72
 Baseline Clinical Examination
Risk Factor for AE Action if Risk Factor is Present
Flu-like signs and symptoms:
❑ Fever, headache, runny nose, and joint Defer TPT until symptoms resolve
pain
Increased risk of hepatotoxicity:
❑ History of liver disease
❑ Regular use of alcohol Do a liver function test (AST and ALT)
❑ Chronic liver disease Do not give TPT if AST and ALT are >3 times ULN
❑ Pregnancy / Within 3 months postpartum
❑ Age >60 years

Increased risk of peripheral neuropathy:

Give pyridoxine (vitamin B6) prophylaxis.
❑ Malnourished
Adults and children >1 year old: 10 to 25 mg/day in
❑ Diabetes adults including pregnant and lactating women, and
❑ HIV people with other risk factors (depending on which
formulary is available)
❑ Chronic alcoholism
For infants: 5 to 10 mg/day (including infants of
❑ Renal insufficiency lactating women who are taking isoniazid containing
❑ Pregnancy and lactation TPT regimen should receive vitamin B6 even if the
infant is not on TPT)
❑ Infant 73
Baseline Laboratory Examination

1. For those with risk of hepatotoxicity, do baseline Liver Function

Tests (AST, ALT). IF >3X elevated, defer TPT; If LFT cannot be
done, recommended to defer TPT.
➢ History of liver disease
➢ Regular use of alcohol
➢ Chronic liver disease
EXCEPTION:
➢ HIV infection PLHIV can be given TPT even if LFTs not available
➢ Age > 60 years
➢ Pregnancy or within 3 months of delivery

74
Baseline Laboratory Examination

IF using daily INH (6H, 3HR)

2. For adolescents and adults (>15 yo), baseline LFT is desirable. IF

>5X elevated, defer TPT

➢TPT may still be given even if LFT cannot be done.

➢Monitor clinically for possible hepatotoxicity – abdominal pain,
vomiting, jaundice.

75
Precautions for Women of
Reproductive Age (14-54 years old)

• Perform a pregnancy test if in doubt

(e.g., missed period)
• Ask if any contraceptive is being taken
• Advise if receiving oral contraceptives
containing estrogen to:
o Take an OCP containing a higher
dose of estrogen (50 μ)
o Use another form of contraception
following consultation with a
clinician
• Rifapentine should not be used for
pregnant women

76
 Precautions for PLHIV

Due to the cytochrome P450 isoenzyme inducing effect of rifamycin-containing

regimen, the blood concentration of some antiretrovirals can be
substantially decreased to a clinically significant level
Ask if PLHIV are on antiretroviral therapy (ART) or not and which antiretroviral
drugs are being taken and adjust ART if required
Can Co-Administer with
Antiretrovirals
3HR 3HP 4R 6H
Efavirenz Yes Yes Yes Yes
Protease inhibitors (lopinavir, No No No Yes
ritonavir) and Nevirapine
Raltegravir, Dolutegravir Yes, but Yes, no dose Yes, but Yes
increase dose adjustment increase dose
(adults)

77
 TPT Regimens

Regimen Drugs Dosing and Duration

Isoniazid, Weekly for 12 weeks

3HP
Rifapentine (3 months)

Isoniazid,
3HR Daily for 3 months
Rifampicin

4R Rifampicin Daily for 4 months

6H Isoniazid Daily for 6 months

• Choose the appropriate regimen and dosage

79
 TPT Regimens

Categories Regimens Preferable Regimens

3HR is preferred; use
pediatric dispersible fixed-
3HR, 4R, and 6H
<2 years old dose combination formulation
(all are daily dosing regimens)
If pediatric FDC is not
available: use 6H
3HR, 4R, and 6H For children <25kg: 3HR is
(all are daily dosing regimens) preferred; use pediatric
>2 years old dispersible FDC formulation
3HP
(once weekly for 12 weeks, If pediatric FDC is not
12 dosages) available: use 6H or 3HP
Pregnant 6H, 3HR, and 4R
women (all are daily dosing regimens)

80
Initiation of TPT

• Use the TP treatment card for treatment initiation

• Educate about TB infection and TPT and counsel
on adherence plan:
➢ Agreed TPT delivery plan
➢ Preferred time and day to ensure doses are
remembered
➢ Set one time and remind each family member
(alarm clock, phone, watch or physical
calendar)

81
Follow-up During Treatment Course

Conduct regular follow-up:

➢ Educate about AEs
➢ Agree on the follow-up plan, either in person at a health
facility or by phone
➢ Those with a high risk of hepatotoxicity need
monthly liver function tests (LFTs)
➢ If unable to attend the clinic, the BHW can call and ask
about AE signs and symptoms by telephonic checking
monthly

Ensure continuous drug supply:

➢ Dispense a whole course of supply for shorter treatment
regimens, especially for 3HP, 3HR, and 4R, and at least
2 to 3 months for a longer regimen (i.e., 6H)

82
Potential AEs and Management Strategies (1)

Adverse Event Suggested Management

• Advise staying hydrated

Flu-like signs • Paracetamol 500 mg every 4 hours as needed
and symptoms • If severe and not tolerated, consider switching to
the alternate regimen (6H)

• Metoclopramide 10 mg TID as needed

• Advise staying hydrated
Nausea and
• Avoid spicy and greasy food
vomiting
• Oral rehydration solutions if there is mild
dehydration

83
Potential AEs and Management Strategies (2)

Adverse Event Suggested Management

• If AST and/or ALT >3 but <5 times ULN without signs and
symptoms of hepatitis, continue TPT and repeat AST and
ALT weekly
Hepatotoxicity • If AST and/or ALT >3 times ULN with signs and symptoms
of hepatitis or if AST and/or ALT >5 times ULN with or
without signs and symptoms of hepatitis, stop TPT and do
not reintroduce
• Use BPNS to screen and assess the severity of
peripheral neuropathy
• If mild: give 100 to 150 mg of pyridoxine in adults and
Peripheral
50 mg in children
neuropathy • If not better or worsens with an increased pyridoxine
dose, stop H-containing regimen and consider switching
to 4R
84
Potential AEs and Management Strategies (3)

Adverse Event Suggested Management

• Calamine lotion or topical steroid preparation BID on the
affected area; chlorpheniramine 8 mg BID or TID orally may
be given
• If with itchiness, generalized rashes, swelling of lip or nose
Skin tips with or without fever, withhold TPT
hypersensitivity • Desensitization starting with a low dose once hypersensitivity
reaction reaction is resolved. If with Steven-Johnson syndrome,
consult with regional TB-MAC or specialist, and follow their
advice.
• If it is due to isoniazid, switch to 4R
• If it is due to rifampicin or rifapentine switch to 6H

85
Potential AEs and Management Strategies (4)

Adverse Event Suggested Management

Orange-red • Reassure that it is just the staining from a drug in
discoloration of body the regimen and is harmless
fluid (tear, saliva,
urine, milk, urine) • Advise to continue TPT

• Investigate for active TB disease or other diseases

Any occurrence of TB • If no active TB disease, continue TPT
signs and symptoms • If active TB disease, stop TPT and provide drug-
susceptible TB or drug-resistant TB treatment

If no occurrence of AEs, congratulate the client and encourage them to continue TPT
Ask about any difficulties adhering to TPT

86
Reminders

In general, do not reintroduce TPT if there is a major ADR requiring

need to discontinue TPT

Reporting of serious adverse events (SAEs) and adverse events of special

interest (AESIs) is highly encouraged
• Use the Food and Drug Administration [FDA]’s Suspected Adverse
Reaction form
• Report can be sent via email at pharmacovigilance@fda.gov.ph,
adsm@doh.gov.ph, and ntp.pharmacovigilance@gmail.com

87
Monitoring and
Management Form of
Adverse Events During
TPT by HCWs in Health
Facilities
 Can be delivered through treatment
supporters (e.g., BHW), family members, or
clients themselves

Delivery of
Other assisted technology may help ensure
TPT and adherence, such as video observation and
Support to SMS or texting after taking DOT

Adherence
Education and counseling are crucial to
capacitate and empower clients to take
responsibility for their health
 Management of Missed Dose or Treatment Interruption

Instruction to clients in case of missed does on 3HP:

Take the missed dose as soon as remember and continue as in the usual fixed schedule. For
example, Client XX is taking TPT every Saturday for 3HP weekly regimen. But XX forgot the dose
on Week 3 Saturday and remembered on Monday. XX should take the missed dose now
(Monday) for Week 3 and the usual Saturday dose continues from Week 4 onwards.

But if it is <72 hours before the next scheduled dose, just skip the missed dose.
For daily regimens:
Take the missed dose when remembered and continue longer to make up for
the required doses within the maximum extended duration of the regimen that
the client is taking.

Extension of treatment duration to make up for missed

doses:
The extension period is not more than an additional 1 month
for 3HP and 3HR, 5 weeks for 4R, and 2 months for 6H.
90
Defining Treatment Outcomes

An individual who has completed the prescribed treatment duration and

Completed remains well or asymptomatic during the entire period

Lost to follow-up An individual who interrupted TPT for 2 consecutive months or more

Died An individual who dies for any reason during treatment

Failed An individual who developed active TB disease anytime while on TPT

An individual who has been transferred to another health facility with proper
referral slip for the continuation of TPT and whose treatment outcome is not
Not evaluated known; include here discontinued by a physician because the patient cannot
tolerate (e.g., severe ADR) or those who refused to continue.

91
For every person with TB that presents/consults in your
health facility... or you have encountered in your community
or workplace… or for every person dying with TB….

Let us start asking ourselves…

Could this have been

prevented with TB
preventive treatment?
Questions?
Care TB App Introduction and
Care TB App
TB Contact Introductionand
Investigation and
TB ContactTreatment
Preventive Investigation and
Forms
Preventive Treatment Forms
Care TB App

This app is your companion in the various aspects of clinical tuberculosis

(TB) care. Brought to you by the Philippines National Tuberculosis (TB)
Control Program of the Department of Health, you’ll find answers and
support with Care TB.

KEY FEATURES

If you are a TB patient, you can:

• Retrieve your electronic health record from the Integrated TB Information
System (IT IS)
• Receive daily reminders and inspiration throughout your TB journey
• Chat with your doctor (if also using Care TB), other patients, and
concerned communities
• Report side effects, treatment adherence and issues with clinical services
• Get relevant information on TB screening, testing, treatment, and
prevention

95
Care TB App

If you are a TB care provider, you can:

• Track your patients' progress including laboratory test results, adherence

monitoring, and patient-reported side effects
• Scan and digitize hand-written screening forms
• Connect with other care providers using unique client QR codes
• Securely communicate with patients and receive alerts when patients are
at risk

If you are a close contact of a TB patient, you can:

• Track your lung health through the screening and testing process
• Get reminded for regular check-ups during the two-year follow-up period
• Encourage family members and friends with TB in their treatment journey
• Access relevant information on TB screening, testing, treatment, and
prevention

96
Care TB App

97
Care TB App

Care TB Registration
https://youtu.be/fsYkvECfyxw

Care TB Getting Started

https://youtu.be/FGSB4mri-Ug

98
CareTB Data Fields

108
CareTB Dashboard

109
CareTB Network

110
Patient Pathway

111
 Pros and Cons of CareTB app
Pros Cons: Requires the following

Real-time encoding Smartphone/device

Stable internet connection/cellular data

User-friendly fields
Care TB app downloaded in device
Paperless forms
Registration of user; account
activated prior to first use
With practice, less time needed for data
management Tech-savvy user

Secured database with export function for data Availability is dependent on KMITS server
analysis
Support TB cascade of Care Orientation for users needed

112
CI and Screening Form Para sa Community Health Workers/Volunteers
Pangalan o Initial ng Index Case: ______________________________ Index TB No: ________________
Paalala: Gumamit ng extra sheet kung mayroong >5 miyembro ng pamilya

Kasaria
Resulta ng interview
Bilang

Edad
Pangalan Sintomas ng TB na 2 linggo o higit pa
Petsa:___________________ Karagdagang Action

n
(First-Middle-Last) (markahan ang akma)
(MM/DD/YYYY)
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
1 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi na
 Tatawagang muli
__________________________ interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer para sa further TB workupb
2 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi na
 Tatawagang muli
__________________________ interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer for further TB workupb
3 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi na
 Tatawagang muli
__________________________ interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer for further TB workupb
4 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi
 Tatawagang muli
__________________________ na interview
 Wala  Nagpapawis sa gabi  Refer para sa TPTa
 Made appointment
 Ubo  Pumapayat  Refer for further TB workupb
5 Petsa: _______________
 Lagnat  Iba pa (isulat sa blanko)  Hindi nakita ang client/Hindi
 Tatawagang muli
__________________________ na interview

a= para sa <5 years old na walang TB signs and symptoms; b=any one with at least one sign or symptom; para sa >5 years old regardless of signs and
symptoms
 CI and Screening Form for Community Health Workers/Volunteers
Name or Initial of Index Case: ______________________________ Index TB No: ________________
Note: Use an extra sheet if there are >5 family members
Name Result of Interview
TB Signs and Symptoms lasting for ≥2
No. (First-Middle- Age Sex Date:___________________ Further Action
weeks (tick applicable)
Last) (MM/DD/YYYY)
 None  Cough  Refer for TPTa
 Made appointment
Fever  Weight Loss  Refer for further TB workupb
1 Date: _______________
Night Sweat  Others (specify)  Not seen client/Not
 To call again
______________________________ interviewed
 None  Cough  Refer for TPTa
 Made appointment
Fever  Weight Loss  Refer for further TB workupb
2 Date: _______________
Night Sweat  Others (specify)  Not seen client/Not
 To call again
______________________________ interviewed
 None  Cough  Refer for TPTa
 Made appointment
Fever  Weight Loss  Refer for further TB workupb
3 Date: _______________
Night Sweat  Others (specify)  Not seen client/Not
 To call again
______________________________ interviewed
 None  Cough  Refer for TPTa
 Made appointment
Fever  Weight Loss  Refer for further TB workupb
4 Date: _______________
Night Sweat  Others (specify)  Not seen client/Not
 To call again
______________________________ interviewed
 None  Cough  Refer for TPTa
 Made appointment
Fever  Weight Loss  Refer for further TB workupb
5 Date: _______________
Night Sweat  Others (specify)  Not seen client/Not
 To call again
______________________________ interviewed
a=for <5 years old + no TB signs and symptoms; b=any one with at least one sign or symptom; for >5 years old regardless of signs and
TB Preventive Treatment Register
TB Preventive Treatment Register
Questions?
Frequently Asked Questions
(FAQs)
If TB infection is not contagious, and there are no clinical
manifestations (i.e., no clinical signs and symptoms), then why
is treatment needed for TB infection?
Some bacteria (TB germs) remain alive silently, but not
active and no replication (i.e., sleeping germs)

The sleeping germs become reactive, replicate, and

cause TB disease at any point in the person’s lifetime,
though it is most common in the first 5 years after
exposure

Therefore, it is better to take TPT than wait for

progression to TB disease when the germs wake up and
replicate, resulting in damage to the lungs or the spread
of the disease outside the lungs or to other people
If TB infection is not contagious, and there are no clinical
manifestations (i.e., no clinical signs and symptoms), then why
is treatment needed for TB infection?
• 5–10% of those with TB infection will develop active TB
disease, usually within 5 years
• Highest risk for progression in children <5 years and
those with compromised immunity.
• PLHIV are 20 times more likely to develop active TB
• TPT works to reduce active TB
• Key component of the strategy to end the TB epidemic
• We need to do more than just treat active TB as there is a
vast reservoir of latent disease

Comstock GW, et al. The prognosis of a positive tuberculin reaction in childhood and adolescence. Am J Epidemiol. 1974 Feb;99(2):131–8
Vynnycky E. Lifetime Risks, Incubation Period, and Serial Interval of Tuberculosis. Am J Epidemiol. 2000 Aug 1;152(3):247–63.0
Getahun H, Matteelli A, Chaisson RE, Raviglione M. Latent Mycobacterium tuberculosis Infection. N Engl J Med. 2015 May 28;372(22):2127–35
Who should take TPT?

At-risk populations:
• This includes people
1. People with elevated risk of progression from deprived of liberty
infection to TB disease (prisoners) in contact with
• PLHIV BC-TB, as well as health
• Those with silicosis, anti-tumour necrosis care workers
factor, dialysis, and organ/haematologic • Systematic TBI testing and
transplant treatment should be
considered in these groups.
2. People with increased likelihood of exposure
to TB disease
• Household contacts of BCTB:
• Children <5 years
• Children 5 years and above, adolescents and
adults
Why limit TPT to contacts of bacteriologically confirmed
(BC) TB and not clinically diagnosed (CD) TB?

Focus TPT on those who will benefit most: those at greatest risk of
acquiring TBI and progressing to TB disease

Potential infectiousness: disease site, AFB smear/ culture/molecular

testing status, length of symptoms and CXR findings

Likelihood of transmission to contacts: clinical characteristics,

exposure extent/duration and environmental factors

Pulmonary BCTB is higher risk than EPTB and CDTB

Philippines guidance: household contacts of CDTB under 5 years

old can be given TPT if TST is positive
Is it mandatory to perform a tuberculin skin test (TST) or
interferon-gamma release assay (IGRA) before starting
TPT for all people potentially eligible for TPT?

No, it is not mandatory to perform TST or IGRA before starting TPT

for every person

A systematic review of 12 randomized control trials among PLHIV and 19

studies among household contacts, particularly children <5 years old,
showed that the benefit of TPT in the reduction of TB disease outweighed
the risk regardless of TST or IGRA results (i.e., negative, positive, or
unknown)

Hence, it is not mandatory to have a TST or IGRA before starting TPT for
these two specific groups after excluding active TB disease
Is it mandatory to perform a tuberculin skin test (TST) or
interferon-gamma release assay (IGRA) before starting
TPT for all people potentially eligible for TPT?

However, for children ≥5 years old and adult household

contacts who do not have other risk factors for TB such as
diabetes, smokers, those with immune-suppressive medical
conditions, malnourished, with multiple TB cases in the
same household, TST or IGRA is recommended
(WHO guidelines, NTP’s MOP 6th edition, March 2018)

Currently, IGRA testing is only available in the private sector

and is not covered by the NTP
Can we give TPT to someone with a suspicious CXR
when Xpert is negative?

If active TB is not clearly ruled out, we should not give TPT

No bacteriological test has 100% sensitivity

Do not prescribe TPT, if suspect active TB disease

Instead employ further investigations or refer to specialist colleagues

WHO Operational Handbook (2020) - If CXR is abnormal, detailed

investigation for TB disease and other diseases are required
Will TPT create drug-resistance to TB?

No - TPT does not create drug-resistant TB!

Randomized controlled and systematic review studies show no

significant risk of developing acquired drug resistance from
rifamycin or isoniazid containing TPT
(Seden B, IJTLD, 2016; Balcells EM, Emer ID, 2006; Flynn AG, Clin ID, 2019)

Ruling out active TB disease before starting TPT will

prevent the development of acquired drug resistance

Regular follow-up is required to ensure early detection

of any active TB that develops
Is TPT safe?

Yes, TPT is safe. Still, it is essential to identify pre-existing risk

factors for toxicity before TPT initiation, choose the safest regimen
for each patient, and monitor adverse events (AEs) closely

Most concerning AE related to TPT is hepatotoxicity -

rate with newer regimens is much lower!

No death or mortality reported in clinical trials for 3HP

and 4R regimens
(Sterling TR, et al, NEJM, 2011; Menze D et al, 2018)

TPT is safe for children and adolescents with no

hepatotoxicity from either 3HP or 6H
(Villarino, JAMA 2015)
Is TPT safe?

Liver function tests are not required before or during

treatment, except for those with an underlying risk of
hepatotoxicity such as chronic active hepatitis, regular
alcohol intake, pregnancy, or postpartum status

Other possible AEs are flu-like signs and symptoms which

usually occurs within 2 to 4 weeks of TPT initiation, is mild,
and resolves spontaneously in 1 to 2 days

It is important to educate and counsel clients about

possible AEs, to monitor for them regularly, and to
manage all adverse events properly
Is it mandatory to provide TPT under strict directly
observed treatment (DOT)?

No, it is not mandatory to provide TPT under strict DOT!

However, it is advisable to promote TPT adherence by using

treatment supporters or digital adherence interventions
reinforced with proper education and counseling

Shorter regimens such as 3HP and 4R yield improved TPT

completion rates of >85% whether treatment is provided
under DOT or self-administered treatment
(Nijie JB et al, Am J PR 2018)
Should TPT be repeated for additional exposures?

Effect of repeating TPT is unclear and there are no recommendation in WHO 2020 guidelines

Studies are ongoing

TPT can halt progression to TB very effectively for many years, but re-infection
with TB bacilli after completing treatment may reverse this protection

In high TB transmission settings, daily IPT for 36 months or longer is

recommended, conditionally

WHO Operational Handbook: A repeat course of TPT should however be considered

among HIV-positive or HIV-negative persons who previously completed a course of
TPT but have been exposed thereafter to a household/close contact with TB

Currently available TBI tests (TST/IGRA) do not convert to negative after TPT, so are
not useful for eligibility of repeat course; therefore, careful assessment of exposure
intensity and benefit- harm balance should guide the decision
Evaluation of the Effect of 3HP vs Periodic 3HP vs 6H in
HIV-Positive Individuals (WHIP3TB)

• Multicountry RCT compared giving 3HP

annually for 2 years versus once
• TB incidence in 3HP-twice group
• Compared treatment completion rates and and 3HP-once group was similar
effectiveness
(HR 0.96 [CI, 0.61 to 1.50])
• 3 groups: 3HP annually for 2 years, 3HP
once or 6H once • In settings with high TB
• Treatment completion in the first year transmission, a second round of
was 90.4% versus 50.5% for the TPT did not provide additional
combined 3HP groups (n = 3610) versus
benefit to persons receiving ART
6H group (n = 404) (RR, 1.78 [95% CI,
1.61 to 1.95])

Churchyard G Ann Intern Med 2021 Oct;174(10):1367-1376.

145
Communicating about TPT
TB
DISEASE
TB
INFECTION
Situation analysis

• COVID-19 pandemic restrictions

• Lack of awareness & knowledge about TPT
among clients & providers
• Risk of TB perceived as low
• Attitude towards taking antibiotics without
active disease
• Lack of supply
Situation analysis

• COVID-19 pandemic restrictions

• Lack of awareness & knowledge about TPT
among clients & providers
• Risk of TB perceived as low
• Attitude towards taking antibiotics without
active disease
• Lack of supply
Audience segmentation
Secondary
(Influencer)
Primary
(Campaign beneficiaries)

• Decision-makers
• Health service providers
• Media practitioners
Individuals affected by TB, including contacts • Allies
& household members • Religion leaders
What is our big idea?

• Highlight TPT’s
 The Strategy
1. Tanggal Bacteria Power 2. Dress-up of Select
Communication Package Health Facilities

3. 1-2-3 Strategy 4. Convergence to 5. Media Engagements

HIV/AIDS
 Audience persona

Maya, a factory worker, recently found out that one of

her close friends has been diagnosed with active
tuberculosis (TB).

They often spend time together on weekends, sharing

meals and attending social gatherings.

Since she doesn't have active TB and feels healthy,

she struggles to understand why she should take a
medication for a disease she doesn't have.
Tanggal Bacteria Power

A comprehensive set of materials

and strategies designed to
effectively communicate the
importance, benefits, and
procedures related to
tuberculosis (TB)
preventive treatment to various
target audiences.
TPT Job Aid
TPT Job Aid for CHWs
ist
TPT Posters
Envelope

Game Insert for Kids

Envelope

ADR Flyer
3HR FAQ
Cert of Completion
Simulation exercises and
handling objections
Gawing ALIVE ang Contact Investigation
 Kumustahin tungkol sa buhay-buhay

A Ask
Tanungin ang pangalan ng lahat ng kasama sa bahay o hanapbuhay kung may
sintomas ng TB
Kumustahin gamit ang telepono

L List

I Inform

V Verify

E Encourage
A-sk…

• Practice interview skills of asking

open- & close-ended questions.
• Magpakilala
• Kumpirmahin kung tama ang
tinatawagan
• Kumustahin tungkol sa buhay-
buhay.
 TB?
A Ask

Gamitin ang contact investigation form na makukuha sa health

L List facility

I Inform

V Verify

E Encourage
L-ist

• Gamitin ang contact investigation

form na makukuha sa health facility
• Ilista ang lahat ng kasama sa bahay
o hanapbuhay na matagal na
nakakasama ng pasyente
A Ask

L List

Magbigay ng tamang impormasyon tungkol sa TB at TPT

I Inform

V Verify

E Encourage
I-nform…
Magbigay ng tamang impormasyon tungkol sa TB
Preventive Treatment:
• Ang lahat ng kasama sa bahay o hanapbuhay ng
isang pasyente sa TB ay marapat lamang na mag-TPT
Tanggal Bacteria Power sa loob ng 3-6 buwan upang
maagapan ang paggising ng natutulog na TB bacteria
sa loob ng katawan ng isang tao.
• 1 sa 4 na tao ay may TB Infection: Maraming kaso ng
sakit na TB ang nagsimula sa TB Infection
• 1 sa 10 tao na may TB Infection ay maaaring tuluyang
magkasakit ng TB
A Ask

L List

I Inform

Muling tanungin ang kausap kung ano ang naintindihan sa iyong

V Verify ibinahagi.

E Encourage
V-erify…

• Engage participant with a short

review of key points

• Muling tanungin ang kausap

kung ano ang naintindihan sa
iyong ibinahagi
A Ask

L List

I Inform

V Verify

Palakasin ang loob ng kausap at hikayatin na:

E Encourage • Mag-TPT Tanggal Bacteria Power
• Magpa-check-up sa health center o TB clinic
 E-ncourage…
End client interface with positive
reinforcement
& words of encouragement.

• Palakasin ang loob ng kausap at hikayatin

na:
1. Mag-TPT Tanggal Bacteria Power
2. Magpa-check-up sa health center o
TB clinic
 Kumustahin tungkol sa buhay-buhay

A Ask
Tanungin ang pangalan ng lahat ng kasama sa bahay o hanapbuhay kung may
sintomas ng TB
Kumustahin gamit ang telepono
Gamitin ang contact investigation form na makukuha sa health facility

L List

Magbigay ng tamang impormasyon tungkol sa TB at TPT

I Inform

Muling tanungin ang kausap kung ano ang naintindihan sa iyong ibinahagi.

V Verify

Palakasin ang loob ng kausap at hikayatin na:

E Encourage • Mag-TPT Tanggal Bacteria Power

• Magpa-check-up sa health center o TB clinic
“Di ko interesado” “Wala ako sakit”

“Di ko yan priority ngayon”

“Wala ako budget magpagamot”

“Tawag ka ulit sa isang buwan”

“Kailangan ko magtrabaho”
Questions?
MOST COMMON OBJECTIONS
ANSWERED!
 “Wala ako sakit”
“Di ko interesado”
“Di ko yan priority ngayon”

“Wala ako budget magpagamot”

“Tawag ka ulit sa isang buwan”

“Kailangan ko magtrabaho”
Simulation: Contact Investigation
(5 minutes each round)

Round HRH Client Observer Type of objection

1 “Di ako interesado”
2 “Wala akong sakit”
3 “Wala akong budget para dyan”
4 “Di ko yan priority”
5 “Kailangan ko magtrabaho”
6 “Sabihin ko muna sa asawa ko”
7 “Balikan mo ako next month ”

HRH: Gawing (A-L-I-V-E) ang Contact Investigation

Client: Kumpletuhin ang istorya
Observer: Ilista and obserbasyon. Tasahin kung nagmit ang ALIVE sa Contact Investigation

189
Gabay sa Kliyente

1. Kumpletuhin ang istorya

2. Mag-focus sa klase ng “objection” na naka-assign

190
Gabay sa HRH

1. Magpakilala sa pasyente. Ipaliwanag ang dahilan ng pagbisita o

pagtawag
2. Kumustahin ang kliyente at magpakita ng koneksyon
3. Makinig sa mga sinasabi ng kliyente. Magbigay ng oras sa maiksing
kwentuhan
4. Magbigay ng magandang kaalaman tungkol sa TPT
5. Hikayatin na magtungo sa Health Center para mag-TPT

191
Gabay sa Observer

1. Makinig nang mabuti sa sinabi ng HRH

2. Tignan kung nakinig ang HRH sa kliyente at tasahin kung anong klase
ng impormasyon ang inilatag ng HRH
3. Tasahin kung nagamit ang konsepto ng ALIVE
4. Tasahin kung nabigyan ng pagkakataon ang kliyente na magtanong
5. Tignan kung naengganyo ang kliyente na magpakonsulta sa health
facility

192
TPT Success Story

“Salamat talaga kay Sir Jover sa pagturo niya sa

amin tungkol sa TB Preventive Treatment, Dahil
dito at kahit mahirap lang kami, nakuha namin
yung mga gamot na libre. Kampante kami na di
kami magkakaroon agad-agad ng TB.

(I am very thankful to Sir Jover for teaching us

what TB Preventive Treatment is. Because of this
and despite being poor, my family can take the
medicines for free. We are at ease that we will
not get TB anytime soon),”

-Elgen Tanghan, 41 yo (TPT Completer from

Pinamungahan, Cebu)

193
Post Test

Post Test: https://bit.ly/3Q78k09

194