REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF HEALTH
CENTER FOR HEALTH DEVELOPMENT
XII
Contents
 Identification of Presumptive TB
 Collection and Transport of Sputum Specimens
 Procedure for Direct Sputum Smear microscopy
 Procedure for Xpert MTB/RIF
 Tuberculin Skin Testing
 Diagnosis of Extrapulmonary TB (EPTB)
 Decision on Diagnosis based on laboratory results
 Intensified Case Finding
2013 NTP
MANUAL OF
PROCEDURES
Case Finding
 Early
identification and
Objective
diagnosis of TB
cases
Definition of
Terms
Definition of Terms

DOTS facility – healthcare facility,

whether public or private, that provides
TB-DOTS services in accordance with
the policies and guidelines of the NTP
DOH
Definition of Terms
2 Types of Case Finding
Passive Active
case case
finding finding
is identifying TB a healthworker’s
among the purposive effort to
symptomatic find TB cases in the
patients who are community or
screened for among those who do
disease activity not consult with
upon consultation at personnel in a
health facility. DOTS Facility
Turnaround time – collection
of first sputum sample to
initiation of treatment for TB.

Intensified case finding –

active case finding among
individuals belonging to
special or defined populations
 • Close contact – a person who shared an
enclosed space for extended periods within
the day with the index case
• High-risk Clinical groups – with clinical
conditions that puts them at risk of
contracting TB disease, particularly those
with immunocompromised states
VULNERABL • High-risk populations – persons with
E known high incidence of TB,
POPULATIO
particularly those in closed
NS
environments or living in
congregate settings that promote
easy disease transmission
• Inmates
• Elderly
• Indigenous People
• Urban/rural poor
Definition of Terms
High-risk Clinical groups
◦ HIV/AIDS
◦ Diabetes
◦ End-stage renal disease
◦ Cancer
◦ Connective tissue diseases
◦ Autoimmune diseases
◦ Silicosis
◦ Gastrectomy
◦ Solid organ transplantation
◦ Prolonged systemic steroids
Definition of Terms
Presumptive TB – any person whether adult
or child with signs and/or symptoms
suggestive of PTB whether pulmonary or
extrapulmonary, or those with CXR findings
suggestive of active TB
Presumptive DRTB – any person whether
adult or child, who belongs to any of the
DRTB high risk groups such as retreatment
cases, new tb cases that are contacts of
confirmed DRTB cases and PLHIV w/ signs
and symptoms of TB.
Definition of Terms
TB exposure
• close contact with an active adult TB case
• without any signs and symptoms of TB
• with negative TST reaction
• no radiologic and laboratory findings suggestive of TB.

TB infection or latent TB infection (LTBI)

• as above BUT with a positive TST reaction.
TB disease – A presumptive TB who after
clinical and diagnostic evaluation is confirmed to
have TB.
Definition of Terms
Tuberculin Skin Testing (TST)

Isoniazid Preventive Therapy (IPT)

Drug Susceptible TB (DSTB)

Drug Resistant TB (DRTB)

Programmatic Management of Drug Resistant

TB (PMDT)
Classification of TB Disease
1. Based on bacteriological status

◦ Bacteriologically confirmed - a biological specimen

is positive by smear microscopy, culture or rapid
diagnostic tests (Xpert MTB/RIF).

◦ Clinically diagnosed – a Presumptive TB patient

who does not fulfil the criteria for bacteriological
confirmation but has been diagnosed with active TB
Classification of TB Disease
2. Based on anatomical site

◦ Pulmonary TB

◦ Extrapulmonary TB
Classification of TB Disease
Classification based on history of
previous treatment
◦ New case – pt. who has never had
treatment for TB or has been treated for
less than 1 month.
◦ Retreatment case – pt. who has been
treated with anti TB drugs for at least 1
month in the past
Classification of TB Disease
Classification based on drug-susceptibility
testing
◦ Monoresistant TB
◦ Polydrug resistant TB
◦ Multidrug resistant TB (MDRTB)
◦ Extensive drug-resistant TB (XDRTB)
◦ Rifampicin resistant TB (RR-TB) - resistance to
rifampicin detected using phenotypic or genotypic
methods, with or without resistance to other anti-
TB drugs.
Policies
A. Both passive and intensified case
finding activities shall be implemented

B. Intensified case finding shall be done

among close contacts, high risk clinical
groups and high-risk populations.
Policies
C. Direct Sputum Smear Microscopy (DSSM), whether by light
or fluorescence microscopy, shall be the primary
diagnostic tool in NTP case finding.

D. All presumptive TB should undergo DSSM unless it is not

possible due to the following situations:
 mentally incapacitated as decided by a specialist or medical
institution
 debilitated or bedridden
 children unable to expectorate
 patients unable to produce sputum despite sputum induction
Policies
E. Two sputum specimens of good quality shall be collected,
either as frontloading (i.e., spot-spot one-hour apart) or
spot – early morning specimens, based on the patient’s
preference.
◦ The two specimens should be collected at most within 3
days.
Policies
F. Available rapid diagnostic test (e.g., Xpert MTB/RIF) shall be
used for TB diagnosis among
◦ presumptive DRTB
◦ persons living with HIV (PLHIV) with signs and symptoms of TB
◦ smear negative children
◦ smear negative adults with CXR findings suggestive of TB.

G. If Xpert MTB/RIF is inaccessible….evaluated by the DOTS

physician who shall decide using his/her best clinical
judgment.
Policies
H. Tuberculin skin test (TST) shall not be used as sole basis
for TB diagnosis. It shall be used as a screening tool for
children.
◦ A 10mm induration is considered a positive TST reaction.
Policies
I. All DOTS facilities, whether public or private are
encouraged to establish their own in-house
microscopy unit.
J. All municipalities and cities shall ensure access to
quality-assured microscopy services.
◦ One microscopy center shall cater to at most 100,000
population.
◦ In difficult to access areas, remote smearing stations
(RSS) manned by trained volunteers could be
established.
Policies
K. All laboratories providing DSSM services or other TB
diagnostic tests, whether public or private, shall participate
in the External Quality Assessment (EQA) system of the
NTP.
L. All presumptive DRTB -- referred to the nearest
Programmatic Management of Drug-resistant TB (PMDT)
facility for screening and management.
M. All Persons living with HIV (PLHIV) shall be screened for TB
co-infection.
Procedures
Identification of Presumptive TB
A. For 15 years old and above,

1. Cough of at least 2 weeks duration with or without other

symptoms
2. Unexplained cough of any duration in:
◦ a close contact of a known active TB case
◦ high-risk clinical groups
◦ high risk populations
Procedures
B. For below 15 years old
◦ at least three (3) of the following clinical criteria:
1. Coughing/wheezing of 2 weeks or more
2. Unexplained fever of 2 weeks or more
3. Loss of weight/ failure to gain weight/ weight faltering/ loss of appetite;
4. Failure to respond to 2 weeks of appropriate antibiotic therapy
5. Failure to regain previous state of health 2 weeks after a viral infection
6. Fatigue, reduced playfulness, or lethargy (child has lost his/her normal
energy)
◦ Any of the above in a child who is a close contact of
a known active TB case
Procedures
C. Chest x-ray findings suggestive of PTB, with or
without symptoms regardless of age
 Procedures (Identification of
Presumptive TB)
D. Presumptive extrapulmonary TB
 Gibbus, especially of recent onset (resulting from vertebral TB);
 Non-painful enlarged cervical lymphadenopathy with or without fistula
formation;
 Neck stiffness (or nuchal rigidity) and/or drowsiness suggestive of meningitis
that is not responding to antibiotic treatment, with a sub-acute onset or raised
intracranial pressure;
 Pleural effusion;
 Pericardial effusion;
 Distended abdomen (i.e., big liver and spleen) with ascites;
 Non-painful enlarged joint; and
 Signs of tuberculin hypersensitivity (e.g. phlyctenular conjunctivitis, erythema
nodosum).
Procedures (Identification of
Presumptive TB)
Once identified as presumptive TB, register patient in
Form1. Presumptive TB Masterlist
Form 1. Presumptive TB Masterlist
Procedures (Collection and
Transport of Sputum Specimens)
All presumptive TB should undergo DSSM
(exceptions discussed previously). PLHIV with signs
and symptoms should be referred to a PMDT
treatment center or an Xpert Site.

Collect spot-spot at least 1 hour apart OR spot-early

morning

Specimen should be approximately 5-10ml for DSSM

and 1ml for Xpert MTB/RIF
Procedures (Collection and
Transport of Sputum Specimens)
Transport sputum specimen to a microscopy center
or Gene Xpert center together with the completely
filled up Form 2a. NTP Laboratory Request Form.

If specimen cannot be sent to a microscopy unit

early enough, prepare the smears immediately and
then store them appropriately.
Form 2a. NTP Laboratory Request
Form
Procedures (Direct Sputum
Smear Microscopy)
Fluorescence Microscopy
IUATLD/ Conventional Light
200x magnification; 400x magnification;
WHO Scale Microscopy
1 length = 30 fields 1 length = 40 fields
No AFB seen in 300
No AFB observed / 1 No AFB observed / 1
0 oil immersion field
length length
(OIF)
Confirmation
1-4 AFB / 1 length 1-2 AFB / 1 length
required*
1-9 AFB seen in 100
+n 5-49 AFB / 1 length 3-24 AFB / 1 length
OIF
10 – 99 AFB seen in
1+ 3-24 AFB / 1 field 1-6 AFB / 1 field
100 OIF
1-10AFB /OIF in at
2+ 25-250 / 1 field 7-60 / 1 field
least 50 fields
>10 AFB/OIF in at
3+ >250 / 1 field >60 / 1 field
least 20 fields
Procedures (Direct Sputum
Smear Microscopy)
Interpret as positive if at least one sputum smear is
positive for AFB

Record the result in:

◦ Form 2a. NTP Laboratory Request Form
◦ Form 3a. NTP Laboratory Register (Microscopy and GX).

Send the results back within 3 working days.

Form 2a. NTP Laboratory Request
Form
Procedures (Xpert MTB/RIF)
Xpert
Interpretation
MTB/RIF result
T MTB detected, Rifampicin resistance not detected

RR MTB detected, Rifampicin resistance detected

TI MTB detected, Rifampicin resistance indeterminate

N MTB not detected

I invalid/ no result/ error

Record the result in:

◦ Form 2a. NTP Laboratory Request Form
◦ Form 3a. NTP Laboratory Register (Microscopy and GX).

Send the results back within 2 working days.

Form 3a. NTP Laboratory Register
(Microscopy and GX)
Procedures (Tuberculin skin
testing)
For patients less than 15 years old who cannot submit
sputum or with negative sputum results

Standard set of procedures (no change)

A positive TST is an area of induration of the skin with

diameter of 10mm or more
Procedures (Diagnosis of
Extrapulmonary TB)
Extrapulmonary TB can be diagnosed clinically by
the DOTS physician or a specialist

Extrapulmonary TB can also be confirmed

bacteriologically using Gene Xpert for body fluids
such as cerebrospinal fluid (CSF) and gastric
aspirate.
Procedures (Intensified Case
Finding)
• Household contacts
◦ Susceptible TB cases
◦ DR-TB cases
• Jails and prisons
• Urban and Rural poor
• PLHIV
• TB during disasters
Procedures (Household contacts- susceptible)

 list all household contacts in Form 4.TB

Treatment/ IPT Card.
 household contacts should be evaluated within 7
days from treatment initiation of index case to
ensure prompt diagnosis.
 If CXR is available and feasible, perform CXR on
all household members whether symptomatic or
not.
Form 4. TB Treatment-IPT Card
Form 4. TB Treatment-IPT Card
Procedures (Household contacts- susceptible)

 All household contacts identified to be a

presumptive TB based on signs and symptoms
and/or chest Xray findings shall be evaluated based
on the NTP case finding procedures.
 All asymptomatic household contacts 5 years old
and above (with normal chest Xray findings, if
done) are advised to seek consult immediately if
signs and symptoms of TB develop.
Procedures (Household
contacts- susceptible)
 All asymptomatic household contacts <5 years old of a
clinically-diagnosed index case
◦ undergo Tuberculin Skin Testing (TST)
◦ If TST is positive, give Isoniazid Preventive Therapy (IPT)
◦ If TST is negative, do not give IPT and advise to seek
consult immediately if signs and symptoms of TB develop.
 All asymptomatic household contacts <5 years old of a
bacteriologically-confirmed index case :
◦ undergo Tuberculin Skin Testing (TST)
◦ If TST is negative, these contacts should be given IPT.
◦ If TST is positive, rule out TB disease with CxR before giving
IPT.
Procedures (Household
contacts- DR-TB cases)
 Evaluate all household contacts of diagnosed DR-
TB cases by screening for signs and symptoms
and chest X-ray.
 If identified as presumptive TB, refer to a DOTS
facility with PMDT services for DR-TB screening.
 If no signs and symptoms nor Chest X-ray
findings, advise to immediately return to the DOTS
facility if signs and symptoms of TB develop.
Procedures (Jails and Prisons)
 Same as current policies and procedures of BJMP, BuCor
and DOH
 Consider “unexplained cough of any duration in a high risk
population.”

 TB case finding activities among inmates:

◦ upon entry to the jail or prison;
◦ during detention through cough surveillance;
◦ prior to transfer of inmates to another jail or prison; and,
◦ prior to release of inmates back to the community
Procedures (Urban/Rural Poor)

 Volunteers should be oriented on how to identify

possible signs and symptoms of TB.
 For presumptive TB identified by the volunteer, a
referral form recognized by the local DOTS facility
should be accomplished.
 Once the patient consults the DOTS facility, the staff
should follow the routine diagnostic procedure for TB.
 Referred patients who do not consult the DOTS
facility should be followed-up by the community
volunteer.
 Procedures (Persons Living
with HIV)
 All PLHIV (Social Hygiene Clinic or Treatment Hub) shall
undergo TB screening:
◦ symptomatic screening
◦ Chest X-ray.
◦ If symptomatic, sputum for Xpert MTB/RIF
 TB screening for PLHIV shall be done upon HIV diagnosis
and annually during follow-up visit.
 TB treatment shall start once the patient is found to have
active TB (referral to PMDT if RR-TB)
Procedures (Persons Living
with HIV)

PLHIV with no active TB shall be given

Isoniazid Preventive Treatment (IPT) for 6
months
Thank you.

Done with Case Finding.

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