TRICITY MEDICAL CENTER

TB-DOTS Committee

National Tuberculosis
Control Program Updates

Mikhael Earl S. Tacorda, RN

National Tuberculosis Control Program (NTP)
is a strategy adopted by the Department of
Health (DOH) through the internationally
endorsed strategy of Direct Observed Treatment
Short Course by the World Health Organization
(WHO).
Timeline of NTP

1996 - Direct Observed Short Course (DOTS) endorsed by World Health Organization
(WHO) and was adapted by the Department of Health (DOH).
2003 – All health centers (HC) and rural health units (RHU) implemented the strategy
1998 – Hospital were initially engaged with the issuance by DOH of an administrative
order instructing all DOH hospitals to adopt the DOTS under the Hospitals as Center
of Wellness initiative.
2004 – administrative order (DOH-AO 140-04) was amended and expanded to all
government hospitals.
mid-2000 - some public and private hospitals supported the TB control efforts
through the public-private mix DOTS (PPMD) strategy
2016 – RA 10767 (Comprehensive Tuberculosis Elimination Plan Act)
“All public and private health centers, hospitals and facilities shall observe
the national protocol on TB management arid shall notify the DOH of all TB cases as
prescribed under the Manual of Procedures of the National TB Program and the
Philippine Plan of Action on Tuberculosis Control.”
National Tuberculosis Program (NTP)
Manual of Procedure?

Basis for the implementation of the

tuberculosis control program in all DOTS
facilities in the Philippines.
National Tuberculosis Program (NTP)
Manual of Procedure?

Provides technical policies and guidelines on

the diagnosis, treatment, and counseling of
TB patients.
Updates in TB Management

1. Initial diagnostic tool for detection of TB is Direct Sputum Smear Microscopy

(DSSM),Xpert MTB/RIF Test , and Chest Xray.
2. No more Category 2 (2HREZ/1HRZE/5HRE) Treatment.
Treatment Regimen:
a. Category 1 (2HRZE/4HR) - PTB new, whether bacteriologically confirmed
(bc) or clinically diagnosed (cd)
b. Category 1a (2HRZE/10HR) - EPTB, new (CNS/bones or joints)
c. Conventional Treatment Regimen (CTR) 20-24months - Treatment regimen
recommended by TB Medical Advisory Council (TB MAC) to DR-TB patients who
do not meet the criteria for standard regimen.
d. Standard Short Treatment Regimen (SSTR) 9-11months – Treatment regimen
for DR-TB patients that meets several criteria.
Intensive phase: 4 – 6 Mfx-Km(Cm)-Pto-Cfz-Z-E-H
Continuation phase: 5 Mfx-Cfz-Z-E
 Definition of Terms

I - TB Disease Classification:
A. Bacteriological Status
1. Bacteriologically Confirmed - A TB patient from whom a biological specimen is positive by smear
microscopy, culture, or rapid diagnostic tests (such as Xpert MTB/RIF).
2. Clinically Diagnosed - A TB patient who does not fulfill the criteria for bacteriological confirmation
but has been diagnosed with active TB by a clinician or other medical practitioner who has
decided to give the patient a full course of TB treatment. This definition includes cases diagnosed
on the basis of Xray abnormalities or suggestive histology, and extrapulmonary cases without
laboratory confirmation.
B. Anatomical Site
1. Pulmonary (PTB) - Refers to a case of tuberculosis involving the lung parenchyma. A patient with
both pulmonary and extrapulmonary TB should be classified as a case of pulmonary TB.
2. Extrapulmonary (EPTB) - Refers to a case of tuberculosis involving organs other than the lungs.
(e.g. larynx, pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones,
meninges) Histologically diagnosed EPTB through biopsy of appropriate sites will be considered
clinically diagnosed TB. Laryngeal TB, though likely sputum smear-positive, is considered an
extrapulmonary case in the absence of lung infiltrates on chest x-ray.
 Definition of Terms

C. History of Previous Treatment

1.New Case - A patient who has never had treatment for TB or who has taken anti-TB drugs for less
than one month (less than 28 days). Isoniazid Preventive Therapy (IPT) or other preventive regimens
are not considered as previous TB treatment.
2. Retreatment Case - A patient who has been previously treated with anti-TB drugs for at least one
month in the past.
i. Relapse - A patient previously treated for TB, who has been declared cured or treatment
completed in their most recent treatment episode, and is presently diagnosed with
bacteriologically-confirmed or clinically diagnosed TB.
ii. Treatment After Failure (TAF) - A patient who has been previously treated for TB and whose
treatment failed at the end of their most recent course. OR, A patient (child or EPTB) for
whom sputum examination cannot be done and who does not show clinical improvement
anytime during treatment.
 Definition of Terms

iii. Treatment After Lost to Follow-up (TALF) - A patient who was previously treated for TB but
was lost to follow-up for two months or more in their most recent course of treatment and is
currently diagnosed with either bacteriologically-confirmed or clinically-diagnosed TB.

iv. Previous Treatment Outcome Unknown - Patient who have been previously treated for TB
but whose outcome after their most recent course of treatment in unknown or
undocumented.
Diagnosis and Management of TB on Adults
Diagnostic ALGORITHM for TB in Children (Below 15 years old)

Can Expectorate? Presumptive DSTB/DRTB

Follow Diagnostic Cannot Expectorate?

Algorithm for Adult

Positive TST Perform Tuberculin Negative TST

(>10mm) Skin Testing (TST) (<10mm)

Decide to treat as active TB if

the child has any of the 3 of 5 Do Chest-Xray
clinical criteria for diagnosis of
TB in children

Clinically At least 3 out of 5 Less than 3 out of 5 Investigate

Diagnosed further or
PTB refer to
specialist
1. Positive exposure to an adult/adolescent with active
TB disease.
2. Positive tuberculin test (a positive TST confirms TB
exposure).
3. Positive signs and symptoms suggestive of TB.
4. Abnormal chest radiograph suggestive of TB.
5. Laboratory findings suggestive or indicative of TB.
 Diagnostic ALGORITHM for TB in PLHIV

PLHIV
With at least 1 of 4
symptoms: No Symptoms
1. Cough Suggestive of TB
2. Fever
3. Weight Loss
4. Night Sweat
Clinically/Chest Xray (TB/EPTB)

Xpert MTB/RIF Test

Findings Suggestive Findings not
of TB Suggestive of TB
MTB Detected; MTB Detected; MTB not
RIF Resistance RIF Resistance Detected
Detected not Detected Isoniazid Preventive
Therapy
Bacteriologically Clinically/Chest
Bacteriologically
Confirmed TB Xray (TB/EPTB) Findings not
Confirmed RR-TB
Refer to PMDT Suggestive of TB

Clinically Findings
Diagnosed TB Suggestive of TB
 REFERRAL ALGORITHM
Patient seen at the Clinics/OPD/In-patient who are:
Presumptive TB
Presumptive DRTB
Recently Clinically Diagnosed or Bacteriologically
Confirmed TB

INTERNAL REFERRAL
Each Clinic, Station including OPD, ER, ICU, and Ward will be provided Hospital
Internal Referral Forms to be filled out by the Attending Physician (AP) or Resident.

Out-Patient Services In-Patient Services Patients from other

Treatment Center

Attending Physician offers the option of The TB Team Representative will

treatment in COLLABORATION with perform initial evaluation and Resident evaluates the patient
patient’s choice of treatment center (Health will provide a reply slip to the and assesses which treatment
Centers, Satellite Treatment Clinics). referral. center the patient came from.

AP refers the patient to The Team Physician shall The Team Representative will
TB Team. recommend diagnostic procedure perform initial evaluation and
and treatment regimen. confirms the referral from the
treatment center.
The Team Representative will
perform initial evaluation and will DS-TB patients For DR-TB patients, The Team Representative will
provide a reply slip to the referral. may start the TB Team perform initial evaluation and
treatment Representative will confirms the referral from the
regimen until refer or coordinate treatment center.
discharge. the patient to
PMDT.
 REFERRAL ALGORITHM
The Team Representative educates the patient
about TB and refer which treatment center (TC)
they would like to have their treatment.
The Team reinforces that the patient will
have their checkup with their Attending
Physician and will have their free medication
from their treatment center of choice.
The Team Representative refers
the patient to TC of choice.
The Team Representative receives response
from TC via Integrated Tuberculosis
Information System (iTIS).
TB Team informs AP
the outcome of referral.
The Team Representative
Upon discharge, the patient
communicates the information
will be assess by the Team
regarding the patient treatment
Representative and refer which
to the AP.
treatment center they would
like to have their treatment.
Patient continues treatment at
our facility.
Upon discharge, the patient
will be referred back to
their TC.
INTERNAL REFERRAL FORM
Thank you!
Hospital TB Team

Chair: Dr. Bernadette Olmo Head, Department of Pulmonology

NTP Medical Coordinator
Members: Dr. Joseph Macalla Chairman, Infection Control Committee
Dr. Concepcion Alfonso Chief of Clinics
Pediatrician, Department of Pediatrics
Dr. Radiologist, Department of Radiology
Dr. Salome Elnora Fortu Head, Department of Out-Patient Services
Mr. Mikhael Earl Tacorda NTP Nurse Coordinator (ICU)
Ms. Jade Loriane Mari NTP Nurse Coordinator (5A)
Ms. Ann Charisse Vargas Medical Technologist, NTP Microscopist
Ms. Marlyn Aloy Head Nurse, Infection Prevention and Control
Ms. Maria Shiela Tabisola Radiologic Technologist, Radiology Department
Ms. Head Pharmacist, Pharmacy Department
Ms. Head, Medical Records Department