Comprehensive-and-Unified-Policy For TB Control Philippines PDF

Comprehensive
and Unified Policy

for
TB Control
in the Philippines
(C.U.P. 2004)
Department of Health
Government of the Philippines
Philippine Coalition Against Tuberculosis
SEPTEMBER 2004
A publication of the Department of Health (DOH), Government of the Philippines,
in cooperation with the Philippine Coalition Against Tuberculosis (PhilCAT).
Published September 2004 in Manila, Philippines.
C.U.P. 2004 participating agencies:

Department of Health Social Security System
Department of the Interior and Local Employees Compensation Commission
Government
National Economic and Development
Department of Justice
Authority
Department of Agriculture
Occupational Safety & Health Center
Department of Science and Technology
Overseas Workers Welfare Administration
Department of Labor and Employment
National Commission on Indigenous Peoples
Department of Education
Philippine Coalition Against Tuberculosis
Department of National Defense
Philippine Medical Association
Department of Social Welfare and
Development
Employers Confederation of the Philippines
Department of Agrarian Reform
Trade Union Congress of the Philippines
Philippine Health Insurance Corporation
Association of Health Maintenance
Government Service Insurance System Organizations of the Philippines, Inc.
Published with assistance from Philippine Tuberculosis Initiatives for the Private Sector
(Philippine TIPS), a project supported by the U.S. Government through the Office of
Population, Health and Nutrition, U.S. Agency for International Development, under the
terms of Contract No. 492-C-00-02-00031. The opinions expressed herein are those of
the DOH and do not necessarily reflect the views of the U.S. Government and the U.S.
Agency for International Development.
Editorial Staff
Board of Advisers: Dr. Myrna C. Cabotaje - NCPDC, DOH

Dr. Rodrigo Romulo - PhilCAT
Dr. Jaime Lagahid - NCPDC, DOH
Dr. Charles Yu - PhilCAT
Editors: Dr. Marilyn N. Gorra - Philippine TIPS

Mr. Jose Ibarra Angeles - Philippine TIPS
Ms. Isabel Paula Patron - Philippine TIPS
Technical DOH: PhilCAT:

Working Dr. Rosalind Vianzon Ms. Amelia Sarmiento
Group: Dr. Angeles Hernandez Mr. Angelo Albert Concepcion
Dr. Vivian Lofranco
Dr. Anna Marie Celina Garfin
Dr. Ernesto Bontuyan, Jr.
Comprehensive
and Unified Policy
for
TB Control
in the Philippines
(C.U.P. 2004)
Comprehensive and Unified Policy for TB Control in the Philippines
Published by the Department of Health and the Philippine Coalition

Against Tuberculosis (PhilCAT)
All rights reserved. No part of this work which is copyright may be

reproduced or used in any form or by any means - graphic, electronic,
or mechanical, including photocopying, recording, taping or information
storage and retrieval systems - without the written permission of the
Publisher.
ISBNx-xxxxx-xxx-x
Foreword
Department of Health
Republic of the Philipines
The National Tuberculosis Control Program (NTP) of the Philippines, which put the Philippines
on the verge of achieving world targets, is considered by the World Health Organization (WHO)
and by other countries as one of the more progressive and admirable programs currently being
implemented. Central and integral to the success of the program is the cooperative and concerted
efforts of all the various stakeholders – “bayanihan”, taking into account the cultural diversity
and idiosyncrasies of the Filipinos to make it adaptable and acceptable to the local setting.
The bayanihan spirit has been a trademark for all Filipinos despite unique regional differences.
The spirit in itself has been embodied in the picture of people coming together, carrying the hefty
weight of a neighbor’ s house on their bare shoulders, helping their neighbor in his time of need.
Moving a whole house on a shoulder of one is unthinkable. The more people pitching in,
contributing to distributing the weight relieves those initially burdened with moving the house
around.
Now, imagine then all these people coming to help but eventually bumping with each other,
moving without cohesion or order! Or, imagine all that work of carrying a whole house and
realizing that you’
ve been going in the wrong direction all this time! Success is achieved with
direction, organization, and cooperation.
Admittedly, in the Philippines, TB has grown to epidemic proportions despite government

interventions for the past 50 years. The National TB Control Program was initially funded in
1954 by virtue of the Tuberculosis Law. Two national TB prevalence surveys had been conducted
since which showed the following: in 1981, TB infected more than half, or 27 million, of a 50
million population; while in 1987, it has infected 45 million of a 72 million population – 63%.
Government alone was unable to remove the problem. And as time slowly moved on, the weight
of the problem steadily increased.
Devolution of health services, including delivery of TB services, in 1991 did not help the cause
any. It probably even contributed to the gravity of the problem. The weight of TB was then
slowly becoming unbearable. Other contributing factors that further worsened an already awful
situation included social stigma for TB patients that made patients hide their ailments for fear of
societal alienation.
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It was in this environment of social stigma for patients with TB, a lack of definite direction of the
TB program due to devolution and strategic differences, and probably a pervasive indifference
in Government and private sector efforts for the past years, where the spirit of bayanihan was
finally felt missing and was badly needed. It was here when the need for improving and
strengthening collaboration and partnership with the private and other sectors was sought after.
Executive Order No. 187 series 2003 institutionalized the Comprehensive and Unified Policy for
Tuberculosis. This is to act as the roadmap on how the bayanihan will move. It is a script to
ensure that the collaboration among stakeholders – current and future, will continue to be in
synergy towards achieving the 70-85 goal. Presently, our CDR is 61% (2003) and cure rate is
77%. We are 61-77!
Bayanihan also enshrines another concept that probably is where the word bayanihan got its
roots. Bayanihan. Bayani. Heroes. Who are the heroes here? The Government? Maybe.
But it is also Government mandate. We are simply doing our job. The heroic thing is, our people
in Government are dedicated and committed in their work. They have been working doubly
hard. This is heroic. You, our stakeholders, our partners? Definitely heroes! Your generosity
in terms of fiscal, organizational, manpower, advocacy, and technical support is one of the most
important reasons why we are making headway today. The Health workers. Definitely heroes!
The leaps and bounds of the Program are due to the cumulative micro-efforts of each and every
health worker servicing each and every TB patient. Putting themselves at risk but nonetheless
doing their job well. And finally, the heroes of heroes are the patients and their families. How
could you describe the bravery of a TB patient as he faces societal stigma, as he and his family
endure each and every day of undergoing DOTS treatment.
Mabuhay kayong lahat!
MANUEL M. DAYRIT, MD, MSc

Secretary of Health
ii
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iv
Table of Contents
I. Executive Summary ....................................................................................................................... 1
II. Introduction ................................................................................................................................... 3

1. TB in the Philippines ......................................................................................................... 3
2. History of TB Control in the Philippines .......................................................................... 4
3. Development of the Comprehensive and Unified Policy for TB Control .......................... 8
III. The National Tuberculosis Program (NTP) ................................................................................ 11

1. Description ....................................................................................................................... 11
2. Vision, Mission, Goal of the NTP ......................................................................................12
3. Targets of the NTP .............................................................................................................12
4. NTP Strategies ................................................................................................................. 12
4-1. Political commitment. ....................................................................................... 13
4-2. Sputum microscopy. ..........................................................................................13
4-3. Standardized chemotherapy. ............................................................................ 13
4-4. Drug supply. ......................................................................................................13
4-5. Program management. ......................................................................................14
4-6. Data/information system. .................................................................................. 14
4-7. Case detection. ..................................................................................................14
5. Roles of Collaborating Agencies ....................................................................................15
5-1. Department of Health (DOH) and Center for Health Development (CHD) .... 15
5-2. Philippine Coalition Against Tuberculosis (PhilCAT) ................................... 15
5-3. Department of Interior and Local Government (DILG)/LGU ..........................16
5-4. Other Government Agencies ............................................................................. 16
5-5. Private Sector and NGOs ................................................................................. 17
5-6. Government Financial Institutions ..................................................................17
6. Functions of NTP Health Workers ................................................................................... 17
6-1. DOH TB Staff ......................................................................................................17
6-2. CHD NTP Core Team ..........................................................................................18
6-3. DOH Representatives ..........................................................................................18
6-4. Provincial and City NTP Core Team ..................................................................19
6-5 Health Officer / Medical Officer / Physician ........................................................ 19
6-6. Public Health Nurse/DOTS Nurse ...................................................................... 19
6-7. Midwives, Other Support Staff ............................................................................ 20
6-8. Medical Technologists or NTP Microscopists ......................................................20
6-9. Barangay Health Workers (BHWs) ..................................................................... 21
6-10. Hospital-based NTP Core Team .........................................................................21
IV. NTP Core Policies and Procedures ...........................................................................................23

1. Case Finding ..................................................................................................................23
1-1. Objective ............................................................................................................24
1-2. Policies ..............................................................................................................24
1-3. Procedures ........................................................................................................25
v
2. Case Holding ...................................................................................................................28
2-1. Objective ............................................................................................................ 28
2-2. Treatment Regimen ............................................................................................28
2-3. Fixed Dose Combination Anti-TB drugs ........................................................... 29
2-4. Policies ............................................................................................................... 29
2-5. Tuberculosis during Pregnancy and Lactation ................................................ 30
2-6. Procedures ......................................................................................................... 30
2-7. Outcome of Treatment ........................................................................................ 32
3. Recording and Reporting ................................................................................................ 33
3-1. Objectives ........................................................................................................... 33
3-2. Policies ............................................................................................................... 33
3-3. NTP Recording Forms ....................................................................................... 34
4. Logistics Management ..................................................................................................... 36
4-1. Recording/reporting of NTP logistics: .............................................................37
5. Monitoring, Supervision and Evaluation ....................................................................... 38
5-1. Objectives ........................................................................................................... 38
5-2. Policies ............................................................................................................... 38
5-3. Procedures ......................................................................................................... 39
6. Quality Assurance for Sputum Smear Microscopy ......................................................... 41
6-1. Objective ............................................................................................................ 42
6-2. Policies ............................................................................................................... 42
V. Guidelines for Implementation of the NTP by Private Physicians and Health Facilities ......... 43
1. Introduction ..................................................................................................................... 43
2. Policies and Guidelines ................................................................................................... 44
2-1. Case Finding (Diagnosis) ................................................................................. 44
2-2. Case Holding (Treatment) ................................................................................. 45
2-3. Recording and Reporting .................................................................................. 46
VI. Guidelines for Implementation of the NTP by Government Agencies ........................................ 47

1. Introduction ..................................................................................................................... 47
2. Profile of Participating Agencies .................................................................................... 48
2-1. Department of Education (DepEd) ...................................................................48
2-2. Department of Labor and Employment (DOLE) ............................................... 48
2-3. Department of Interior and Local Government (DILG) .................................... 49
2-4. Department of National Defense (DND) ........................................................... 49
2-5. Department of Justice (DOJ) ............................................................................. 50
2-6. Department of Social Welfare and Development (DSWD) ................................50
2-7. Department of Agriculture (DA) ........................................................................ 51
2-8. Department of Agrarian Reform (DAR) ............................................................ 51
2-9. Department of Science and Technology (DOST) .............................................. 51
2-10. National Economic and Development Authority (NEDA) ...............................51
2-11. National Commission on Indigenous Peoples (NCIP) .................................... 52
3. Policies and Guidelines ................................................................................................... 52
3-1. On Case Finding ................................................................................................ 52
3-2. On Case Holding ................................................................................................ 54
3-3. On Recording and Reporting ............................................................................ 55
3-4. On Training ........................................................................................................56
3-5. On Monitoring and Evaluation ........................................................................ 57
3-6. Health Education and Advocacy ...................................................................... 57
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VII. TB Benefits Policy of the ECC, SSS and GSIS ............................................................................59
1. Introduction .....................................................................................................................59
2. Policy, Benefits and Procedures for Claims ....................................................................60
2-1. Employees Compensation Program ..................................................................60
2-2. Social Security System .......................................................................................65
VIII. PhilHealth’s Outpatient TB DOTS Benefit Package ...................................................................73

1. Introduction .....................................................................................................................73
2. Definitions ........................................................................................................................73
2-1. Tuberculosis (TB) ..............................................................................................73
2-2. Pulmonary TB ....................................................................................................73
2-3. Symptomatic pulmonary TB ..............................................................................74
2-4. Asymptomatic pulmonary TB .............................................................................74
2-5. Extrapulmonary TB ...........................................................................................75
2-6. Qualified TB Patient ..........................................................................................75
2-7. Qualified Provider .............................................................................................75
2-8. Defaulter ............................................................................................................75
3. Policy ...............................................................................................................................75
3-1. NTP Manual of Procedures ...............................................................................75
3-2. Cases covered ....................................................................................................76
3-3. Standards for accreditation ..............................................................................76
3-4. Payment scheme .................................................................................................76
3-5. Monitoring .........................................................................................................76
4. Outpatient Anti-TB DOTS Benefit Package ....................................................................76
4-1. Coverage ............................................................................................................76
4-2. Providers ............................................................................................................77
4-3. Certification and Accreditation ........................................................................77
4-4. Payment ..............................................................................................................78
4-5. Reimbursement Process .....................................................................................78
4-6. National TB Registry .........................................................................................79
4-7. Monitoring .........................................................................................................79
ANNEXES:
Annex 1: Flow of NTP Activities ....................................................................................................83

Annex 2: Flowchart for the Diagnosis of Pulmonary TB ..............................................................84
Annex 3: Flowchart for the Diagnosis of Smear-Negative Pulmonary TB ...................................85
Annex 4: Approach to TB Asymptomatic .......................................................................................86
Annex 5: Guide to Case Finding ....................................................................................................87
Annex 6: Guide to Diagnosis and Initiation Of Treatment ............................................................88
Annex 7: Treatment Regimens ........................................................................................................89
Annex 8-A: Drug Dosage and Adjustment .........................................................................................90
Annex 8-B: FDC Composition ...........................................................................................................90
Annex 8-C: FDC Dosaging ................................................................................................................91
Annex 9: FDC Drug Samples .........................................................................................................92
Annex 10-A: Schedule of Sputum Smear Follow-Up Examination ....................................................93
Annex 10-B: Schedule of Sputum Smear Follow-Up Examination ....................................................94
Annex 11: Summary of Treatment Modification Based on Sputum Follow-Up ..............................95
Annex 12: Guide in Managing SCC Drugs Side Effects .................................................................96
Annex 13-A: Treatment Modifications Based on Sputum Results ......................................................97
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Annex 13-B: Treatment Modifications Based on Sputum Results ...................................................... 98
Annex 13-C: Treatment Modifications Based on Sputum Results ...................................................... 99
Annex 13-D: Treatment Modifications Based on Sputum Results ................................................... 100
Annex 14-A: Treatment Modifications for New Smear-Positive Cases ............................................ 101
Annex 14-B: Treatment Modification for Relapse and Failure Cases ............................................. 102
Annex 15: Guide to Case Holding ................................................................................................ 103
Annex 16: Guide to Ensure Treatment .......................................................................................... 104
Annex 17: Responsible Persons for the Recording Forms ........................................................... 105
Annex 18: Recording and Reporting Forms ................................................................................. 106
Annex 18-A: NTP Client List/Target Client List (TCL) .................................................................... 107
Annex 18-B: NTP Laboratory Request Form for Sputum Examination .......................................... 108
Annex 18-C: NTP Laboratory Register ............................................................................................. 111
Annex 18-D: NTP Treatment Card ..................................................................................................... 113
Annex 18-E: NTP Identification Card .............................................................................................. 116
Annex 18-F: TB Register .................................................................................................................... 118
Annex 18-G1: PPMD Referral Form, NTP .......................................................................................... 120
Annex 18-G2: PPMD Follow-up Form, NTP ...................................................................................... 121
Annex 18-H: Quarterly Report on NTP Laboratory Activities ........................................................ 122
Annex 18-I: Counting Sheet for Laboratory Activities Report ....................................................... 123
Annex 18-J: Quarterly Report on New Cases and Relapses of Tuberculosis.
.................................................... 124
Annex 18-K: Counting Sheet for Case Finding By Type / Drug Inventory ..................................... 125
Annex 18-L: NTP Quarterly Report on the Treatment Outcome of Pulmonary TB Cases ............... 126
Annex 18-M: Counting Sheet for Quarterly Report on the Treatment Outcome
of Pulmonary TB Cases ................................................................................... 126
Annex 19: Program Indicators ...................................................................................................... 127
Annex 20-A: Impairment Classification for Respiratory Disease Injuries
(Modified from American Thoracic Society Criteria) .................................. 129
Annex 20-B: ATS Functional Classification (of Dyspnea) .............................................................. 130
Annex 20-C: ATS Ratings of Respiratory Impairment by Spirometry ............................................. 130
Annex 21: SSS Guide to Functional Assessment .......................................................................... 131
Annex 22-A: TB Benefit Form (DOLE Guidelines) ........................................................................... 152
Annex 22-B: TB Benefit Form (Back) ............................................................................................... 153
Annex 23-A: TB Diagnostic Committee ............................................................................................ 154
Annex 23-B: TB Diagnostic Committee (TBDC) Referral Form ...................................................... 158
Annex 23-C: Quarterly TBDC Accomplishment Report Form ......................................................... 160
Annex 23-D: TBDC Masterlist Form ................................................................................................ 161
Annex 24: NTP Monitoring Checklist .......................................................................................... 162
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List of Acronyms Used
ACCP American College of Chest Physicians
AFB Acid-Fast Bacilli
AFP Armed Forces of the Philippines
AHMOPI Association of Health Maintenance Organizations of the Philippines, Inc.
AO Administrative Order
ARC Agrarian Reform Communities
AUSAID Australian Agency for International Development
BHS Barangay Health Stations
BHW Barangay Health Workers
BJMP Bureau of Jail Management and Penology
CAR Cordillera Administrative Region
CARP Comprehensive Agrarian Reform Program
CDR Case Detection Rate
CHD Center for Health Development
CHO City Health Office
CIDA Canadian International Development Agency
CME Continuing Medical Education
CPE Continuing Professional Education
CRUSH-TB Collaboration in Rural and Urban Sites to Halt Tuberculosis
CUP Comprehensive and Unified Policy ( for TB Control in the Philippines)
CXR Chest X-Ray
DA Department of Agriculture
DAR Department of Agrarian Reform
DepEd Department of Education
DILG Department of Interior and Local Government
DND Department of National Defense
DOH Department of Health
DOJ Department of Justice
DOLE Department of Labor and Employment
DOST Department of Science and Technology
DOT Directly Observed Treatment
DOTS Directly Observed Treatment Short Course
DSWD Department of Social Welfare and Development
EC Employees Compensation
ECC Employees Compensation Commission
ECOP Employers Confederation of the Philippines
EO Executive Order
EPI Expanded Program for Immunization
EPTB Extra Pulmonary Tuberculosis
EQA External Quality Assessment
FDC Fixed Dose Combination
FEFO First Expiring, First Out
FHSIS Field Health Service Information System
FIM Functional Independence Measure
GA Government Arsenal
GDF Global Drug Facility
GFATM Global Fund on AIDS, TB and Malaria
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GFI Government Financial Institution
GI Government Institution
GOCC Government-Owned and -Controlled Corporation
GSIS Government Service Insurance System
HC Health Center
HIV Human Immunodeficiency Virus
HMO Health Maintenance Organization
HR Isoniazid, Rifampicin
HRZE Isoniazid, Rifampicin, Pyrazinamide, Ethambutol
HRZES Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, Streptomycin
HSRA Health Sector Reform Agenda
ICD Italian Cooperation for Development
ID Identification Card
IEC Information Education and Communication
INH Isoniazid
ISHNP Integrated School Health and Nutrition Program
IUATLD International Union Against Tuberculosis and Lung Disease
JICA Japan International Cooperation Agency
LCE Local Chief Executive
LGU Local Government Unit
LTI Latent TB Infection
MC Memorandum Circular
MHO Municipal Health Office
MOH Ministry of Health
MOP Manual of Procedures
MTPIP Medium Term Public Investment Program
NCDPC National Center for Disease Prevention and Control
NCHF National Center for Health Facility
NCIP National Commission for Indigenous People
NDCP National Defense College of the Philippines
NEDA National Economic and Development Authority
NGO Non-Government Organization
NHIP National Health Insurance Program
NIT National Institute of Tuberculosis
NPC National Police Commission
NPS National TB Prevalence Survey
NSO National Statistics Office
NTCP National Tuberculosis Center of the Philippines
NTP National Tuberculosis Control Program
NTRL National TB Reference Laboratory
OCD Office of Civil Defense
ODA Official Development Assistance
OSG Office of the Surgeon General
OSHC Occupational Safety and Health center
OSND Office of the Secretary of National Defense
OWWA Overseas Workers and Welfare Administration
PA Philippine Army
PAF Philippine Air Force
PAS Para-amino salicylate
PCCP Philippine College of Chest Physicians
PCOM Philippine College of Occupational Medicine
PCSO Philippine Charity Sweepstakes Office
PD Presidential Decree
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PHIC/PhilHealth Philippine Health Insurance Corporation
PhilCAT Philippine Coalition Against Tuberculosis
PHO Provincial Health Office
PIDS Philippine Institute for Development Studies
PMA Philippine Medical Association
PMS Project Monitoring Staff
PN Philippine Navy
PNP Philippine National Police
PNVSCA Philippine National Volunteer Service Coordinating Agency
PPD Permanent Partial Disability
PPD Purified Protein Derivative
PPM Public-Private Mix
PPMD Public-Private Mix DOTS
PPP Public-Private Partnership
PSMID Philippine Society for Microbiology and Infectious Diseases
PTB Pulmonary Tuberculosis
PTD Permanent Total Disability
PTSI Philippine Tuberculosis Society, Inc.
PVAO Philippine Veterans Affairs Office
PZA Pyrazinamide
QAS Quality Assurance System
QC Quality Control
QI Quality Improvement
QI Quezon Institute
RA Republic Act
RAD Return After Default
RDCS Regional Development Coordinating Staff
RHU Rural Health Units
S&T Science & Technology
SCC Short-Course Chemotherapy
SDF Single Drug Formulation
SDS Social Development Staff
SHNC School Health and Nutrition Center
SR Standard Regimen
SRTC Statistical Research and Training Center
SSS Social Security System
TB Tuberculosis
TBCS TB Control Service
TBDC TB Diagnostic Committee
TC Tariff Commission
TCL Target Client List
TIUS Trade, Industry and Utilities Staff
TTD Temporary Total Disability
TUCP Trade Union Congress of the Philippines
UNICEF United Nations Children’s Fund
VMMC Veterans Memorial Medical Center
WB World Bank
WHO World Health Organization
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I. Executive Summary
T
UBERCULOSIS has been a major cause of illness and death in the Philippines.
Despite the significant advances that the National TB Control Program (NTP) of the
Department of Health (DOH) has made in improving the quality and extent of its control
efforts, still, by and large, TB control efforts have been fragmented and uncoordinated.
Historically, the private sector and even other departments of government have not been
integrated into overall TB control activities.
Recognizing the need for a more unified and concerted effort, the DOH, with the help of the
Philippine Coalition Against Tuberculosis (PhilCAT), organized various stakeholders into a
working group to develop this Comprehensive and Unified Policy (C.U.P.) for TB Control in
the Philippines. The organizing committee began in January 2002 a series of stakeholders’
meetings which culminated on World TB Day in March 2002 with the signing of a Memorandum
of Agreement wherein stakeholders committed their support and involvement in the policy
development process.
Two main working groups were formed to flesh out operational details using the NTP as the
core policy. The first group developed guidelines for the implementation of the NTP in
government agencies other than the Department of Health (DOH). This group was headed by
the DOH and the following as its members: the Departments of Education (DepEd), National
Defense (DND), Interior and Local Government (DILG), Justice (DOJ), Agriculture (DA),
Agrarian Reform (DAR), Social Welfare and Development (DSWD), Science and Technology
(DOST), the National Economic and Development Authority (NEDA) and the National
Commission for Indigenous Peoples (NCIP).
The second group established policies that would formalize the involvement of the private
sector, particularly private physicians, in TB control. This group consisted of the representatives
of the Social Security System (SSS), Government Service Insurance System (GSIS),
Employees Compensation Commission (ECC), the Philippine Health Insurance Corporation
(PHIC/PhilHealth), the Philippine Medical Association (PMA), Association of Health
CHAPTER I : EXECUTIVE SUMMARY 1

Maintenance Organizations of the Philippines, Inc. (AHMOPI), Employees Confederation of
the Philippines (ECOP), Trade Union Congress of the Philippines (TUCP), and Occupational
Safety and Health Center (OSHC) and the Overseas Workers and Welfare Administration
(OWWA) of the Department of Labor and Employment (DOLE). PhilCAT headed this second
group.
This resulting policy presents several significant achievements. First, the “Guidelines for
Implementation by Government Agencies” formalizes and operationalizes the collaboration
between the DOH and other departments of government with regard to the NTP. Second, the
“Guidelines for Implementation by Private Physicians” provides clear directions on the clinical
management of TB by private practitioners to comply with NTP policy. The “TB Benefits
Policy of the SSS/GSIS/ECC” unifies the policies of these different agencies and aligns them
with the NTP. The pioneer “TB Outpatient Benefits Package” of the Philippine Health Insurance
Corporation (PHIC) is presented for the first time in this policy.
The organizing committee concludes with three recommendations: (1) that a one-year grace
period for dissemination and training regarding the policy beginning August 2004 be implemented
prior to full implementation in August 2005; (2) that the organizing committee and all stakeholders
be reconvened after two full years of implementation to evaluate the policy and recommend
any necessary revisions; and (3) to revise and update the existing CUP in accordance with the
current and future thrusts and objectives of the NTP.
2 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
II. Introduction
1. TB in the Philippines
T
UBERCULOSIS (TB) is a chronic infectious disease caused by Mycobacterium
tuberculosis, a bacteria transmitted through airborne droplets from the sputum of
persons with pulmonary tuberculosis while coughing or sneezing. It is a curable disease.
However, if left untreated, it can lead to a disabling condition and even death. Also, partial
treatment of cases may cause multi-drug resistance that can lead to non-cure.
Tuberculosis is a major public health problem in the Philippines. In 1998 it ranked sixth among
the 10 leading causes of death and also sixth among the ten leading causes of illnesses. Although
the mortality rate of tuberculosis has fallen in the past 20 years, from 69 deaths per 100,000
population in 1975 to 38.3 deaths per 100,000 in 1997, still, at this rate, around 75 Filipinos
die every day from tuberculosis. Deaths were higher among males (66 %) and among the
productive age group 15-64 years old (60 %). The morbidity rate from tuberculosis shows a
more variable trend although it has fallen from 314 cases per 100,000 population in 1975 to
179.6 cases per 100,000 population in 1998. Globally, the Philippines is one of the 22 countries
identified by the World Health Organization (WHO) as having a high burden of tuberculosis
ranking at 8th worldwide. It ranks third in terms of new smear-positive TB notification rate in
the WHO-Western Pacific Region (WHO report 2003).
The 1997 National Tuberculosis Prevalence Survey (NPS) gave a more accurate measure of
tuberculosis in the country. The annual risk of tuberculosis infection (i.e. probability of a child
getting infected with TB within a year), which is generally accepted as a more sensitive indicator,
showed a very slight decline in 15 years: from 2.5 % in the 1981-1983 survey to 2.3 % in
1997.
CHAPTER II : INTRODUCTION 3
1981-1983 1997
1. Annual risk of TB infection 2.5% 2.3%
2. Prevalence of sputum smear positive cases 6.6/1,000 3.1/1,000
3. Prevalence of culture positive cases 8.6/1,000 8.1/1,000
4. Radiographic findings suggestive of TB 4.2% 4.2%
The same survey showed that TB cases are about three times more common among males
than females and most of these cases are in the 30 to 59 years of age that represents the
economically productive age group. Prevalence of sputum smear positive cases was at 3.1/
1000 population compared to 6.6/1000 population during the initial survey.
2. History of TB Control in the Philippines
1910–1929. Tuberculosis control in the Philippines was started in 1910 by a private

organization, the Philippine Islands Anti-Tuberculosis, now the Philippine Tuberculosis Society,
Inc. (PTSI). The head office was located at Santol area in Quezon City where a TB hospital
was established. The hospital was later named the Quezon Institute (QI) after President Manuel
Quezon who suffered from tuberculosis. The thrust of the control program was case finding
and in-patient services. At that time, no specific treatment regimen was available except bed
rest isolation or hospitalization.
1930–1949. Cognizant of the increasing incidence of the disease in the country, and to give
adequate attention, the TB Commission was created in 1932 under the Philippine Health Service
by virtue of Act No. 3743. Later in 1933, the powers and duties of the TB Commission were
transferred to the Bureau of Health. In 1934, Republic Act (RA) 4130, otherwise known as
the Sweepstakes Law, established the Philippine Charity Sweepstakes Office (PCSO) primarily
to raise funds to support the operations of the PTSI. This enabled the establishment of Chest
Clinics in selected areas of the country and provided accelerated in-patient activities.
In 1949, streptomycin injection was first used as part of the treatment for the illness. In 1950,
the TB Commission emerged as the Division of Tuberculosis under the Secretary of Health.
The Division established the TB Center at the DOH compound and collaborated with the TB
Ward of San Lazaro Hospital. Services included chest x-ray, sputum and bronchial washing
examinations and case holding. Treatment at this time consisted of streptomycin injection plus
oral Para-amino salicylate (PAS) tablets.
1950–1969. The BCG vaccination program was introduced for the first time in the country
between 1951 and 1952 as a preventive measure against tuberculosis. This program was
assisted by the United Nations Children’
s Fund (UNICEF).
In 1954, Congress passed the Tuberculosis Law (RA 1136) which became the basis for the
creation of both the Division of Tuberculosis under an appointed Director, and the National
Tuberculosis Center of the Philippines (NTCP) established at the DOH Compound. The
same law also mandated the provision of funds to support the operations of the National TB
Control Program.
In 1954, Triple therapy was initiated consisting of the following anti-tuberculosis drugs: isoniazid
(INH), Para-amino salicylate (PAS), and streptomycin.
The year 1964 marked the conduct of the Minglanilla Prevalence Survey in Cebu Province,
which showed the prevalence of smear positive cases at 4/1000. During this period, QI was
operating at its largest bed capacity at 1,350 beds. In 1968, the National TB Program
accelerated and expanded the control activities at the rural health units (RHUs), which were
established under RA 1086.
1970–1989. The mid 1970’s saw a vigorous nationwide expansion of the Program. The
RHUs were strengthened as the reponsibility for TB control efforts was increasingly passed on
to them. The domiciliary care program was launched in 1973 by PTSI, which eventually led to
the reduction of beds at QI to 700. In that same year, the Philippine College of Chest Physicians
(PCCP) was formed as an accredited non-governmental organization (NGO) society of the
Philippine Medical Association (PMA) with TB as one of its initial primary concerns.
The partnership between the DOH and PTSI grew intensely as they defined, complemented
and supported each other’ s roles in the field of TB control. The new thrust emphasized the
following: (1) importance of BCG vaccination, (2) case finding through sputum microscopy
and, (3) case holding/ treatment through domiciliary means.
Eventually, the new TB Control Program was implemented in all RHUs, thus limiting admissions
at QI only to those seriously ill cases. In 1976, the partnership also fostered the establishment
of the National Institute of Tuberculosis (NIT) in cooperation with WHO and UNICEF.
Focusing on human resource development, this Institute undertook operational researches and
provided training to local and foreign health workers on TB Control using the primary health
care approach. The year was also highlighted by the issuance of a Presidential Decree (PD)
requiring compulsory BCG vaccination. This became a prime component of the Expanded
Program for Immunization or EPI. In 1978, the PTSI adopted the NTP policies and guidelines
in its catchment areas.
The first National TB Prevalence Survey (NPS) was carried out in 1981-1983 by the NIT
through the assistance of the WHO and UNICEF. Also during this period, the Lung Center of
the Philippines (LCP) was established as a tertiary hospital and became a referral center for
pulmonary cases including TB.
In 1986, a new treatment regimen was introduced in the National TB Control Program. This is
the Short-Course Chemotherapy (SCC) which highlighted Rifampicin, 2HRZ/4HR. During
this period, a fourth drug, streptomycin or ethambutol, was also being used for the Intensive
Phase of the treatment regimen at the QI for confined or in-patients.
After the People Power revolution in 1986, the Ministry of Health (MOH) was renamed
Department of Health (DOH) and reorganized by Executive Order (EO) 119. The TB Control
Service (TBCS) was created under the Office for Public Health Services. A year later, the
Strengthened National TB Control Program was launched. Under this program, the TBCS
was provided P200 million-budget for drugs, and the SCC was adopted nationwide. To ensure
treatment compliance, the various drugs were packaged in blister-packs. This ingenuity was
later adopted by our neighboring countries. A revised Manual of Procedures (MOP) of NTP
was formulated and disseminated in 1988. This MOP provided SCC treatment for sputum
(+) and cavitary cases, and standard regimen, or SR, for the infiltrative cases.
PTSI adopted in 1987 the expanded community-oriented TB control program which established
microscopy centers in many provinces, and, with the exception of the Cebu Pavilion, led to the
conversion of TB Pavilions to Chest Clinics. In 1989, the Tri-Chest organization, led by the
PCCP and participated in by various agencies involved in TB prevention and control including
the DOH, released the first part of its consensus statements regarding the controversial issues
on TB. The remaining parts came out in 1990 and 1993.
1990–Present. The NTP got a big boost in 1990 with the financial and technical support
from the Italian government and World Bank (WB) under the 5-year Philippine Health
Development Project.
The Local Government Code of 1991 devolved the provision of health services from the
DOH to the local government units (LGUs), giving the latter the opportunity to manage the TB
program and deliver its activities to their constituents. The LGUs, thru the RHUs and the
Barangay Health Stations (BHSs), served as the implementers, while DOH was confined to
policy development, regulation and provision of technical and financial assistance.
Under this new paradigm of health service delivery, the Japanese International Development
Agency (JICA) provided the TB control project in Cebu with technical and financial support.
The following were accomplished by this project: (1) the WHO-recommended policies and
guidelines were tested; (2) laboratory facilities were improved with the establishment of the
Regional TB Laboratory in Cebu City and the upgrading of microscopy centers; and (3) TB
data recording and collection was systematized.
A council which was created in1993 by the PCCP to act as its working arm for TB, successfully
released in 1994 a set of algorithms on the diagnosis and treatment of tuberculosis. An external
evaluation of the NTP done in 1993 noted that while case-finding activities improved
tremendously, the problem in case holding persisted. In 1995, the TBCS issued through
Administrative Order (AO) No. 1-A s., 1995 the revised policies and guidelines on the diagnosis
and management of TB which, in essence, adopted the WHO recommended policies. The
thrust adopted by NTP was to improve case holding activities.
The era of the 90’s saw active interactions among the various sectors fighting TB. In 1994, the
Philippine Coalition Against Tuberculosis (PhilCAT) was organized under the initiative of the
PCCP, DOH, Philippine Society for Microbiology and Infectious Disease (PSMID), PTSI,
Cure TB, and the American College of Chest Physicians (ACCP)-Philippine Chapter. It was
entrusted with the main objective of serving as a coordinating body for the various government
and non-government agencies, private groups, academe, and other concerned institutions in
their fight against tuberculosis. By end of 2004, the membership of PhilCAT had grown to 61.
Mid 1990’s. The mid-1990’s witnessed an intensified national campaign to increase

awareness about the disease, and to mobilize support for its prevention and control. In 1995,
the TB Clinic of the University of Santo Tomas (UST) initiated the use of directly observed
treatment (DOT) in managing its out-patient TB cases. In 1996, DOH piloted the Directly
Observed Treatment Short Course (DOTS) strategy in three areas. WHO provided financial
and technical support to enhance the implementation of NTP, with DOTS as the primary
strategy. The Collaboration in Rural and Urban Sites to Halt Tuberculosis (CRUSH TB) Project
was pilot-tested in Iloilo City, Antique and Batangas. Results from this project paved the way
for the expansion of the new NTP to other areas and enabled the nationwide implementation of
DOTS.
The NTP officially adopted DOTS as a strategy with the issuance of A.O. No. 24 s., 1996. In
the same year, the President of the Philippines issued Proclamation No. 840: Proclaiming
August 19 of every year as the National TB Day. Additionally, March 24 is observed as
World TB Day. PhilCAT spearheads the observance of these special days aside from organizing
annual conventions on TB.
DOTS was subsequently replicated in 30 areas in 1997-1998 and in all public sector health
facilities of the country by year 2001. The DOTS expansion was facilitated by the active
participation of LGUs, the utilization of DOTS by BHWs as treatment partners, and by the
support from various international agencies such as the WHO, WB, JICA, World Vision-
Canadian International Development Agency (CIDA), Australian Aid (AUSAID) and Medicos
del Mundo.
The second national prevalence survey was conducted in 1997. In 1999, a new consensus on
TB diagnosis, treatment and control was forged through a consultative process coordinated by
the PSMID, PCCP and DOH under the auspices of PhilCAT.
In September 1998, the National TB Control Program became one of the flagships of the
DOH. Memorandum Circular (MC) No. 98-155 issued by the President, then the concurrent
Secretary of the Department of Interior and Local Government (DILG), pronounced the TB
Control Program as the highest priority health program of the LGUs and prescribed the DOTS
strategy.
In 1999, DOH embarked on the Health Sector Reform Agenda (HSRA) to improve delivery
of health services through the following:
· To secure funding for priority public health programs;
· To promote the development of local health systems and to ensure its effective performance;
· To provide fiscal autonomy to government hospitals;
· To strengthen the capacities of health regulatory agencies; and,
· To expand the coverage of the National Health Insurance Program (NHIP).
Under the HSRA, the National TB Control Program was one of the top priority among the
public health programs. The organizational reform attained through re-engineering, led to the
clustering of various public health programs, merging of offices, and significant reduction in
manpower. The regional office was renamed Center for Health Development (CHD).
Initiatives to strengthen the NTP included the delivery of quality DOTS services through expansion
of DOTS implementation in all government health facilities. The National TB Reference
Laboratory (NTRL) was established in 2001 to improve quality assurance of microscopy
through the established network of microscopy facilities. It is also spearheading the national
drug resistance survey (DRS). The current NTP has been in strong collaboration with other
government agencies and key private agencies to unify TB policies adaptable for implementation
in both sectors.
It has likewise gained access to international resources, such as the Global Drug Facility (GDF)
and Global Fund on AIDS, TB and Malaria (GFATM), to augment supply of anti-TB drugs.
In 2003, the NTP started the shift from single dose formulation (SDF) to Fixed Dose Combination
(FDC) drugs. This simplifies treatment, prevents development of drug resistance, and ensures
regular and complete drug delivery to DOTS centers. The NTP is also upgrading the various
CHD TB Reference Centers to improve its microscopy component.
3. Development of the Comprehensive and Unified Policy for TB

Control
Despite efforts by the Philippine Coalition Against Tuberculosis (PhilCAT), a standard national
policy to guide all stakeholders was still perceived to be lacking. Most of the large government
institutions that have their own health programs and those in the private health sector failed to
follow the NTP. To address this concern, PhilCAT obtained the approval from the DOH to
initiate the development of the Comprehensive and Unified Policy (CUP) for Tuberculosis
Control in the Philippines. Through a Department Order signed by the Secretary of Health, the
DOH created a Committee to develop the policy. The committee was headed by the past
chairman of PhilCAT and included the head of the National Center for Disease Prevention and
Control and representatives from the government and the private sectors.
Two subcommittees were formed. The Government Institution (GI) Subcommittee was tasked
to identify government agencies that were conducting, or in need of, TB control activities, and
to assist them in adopting the NTP in their respective institutions. The second subcommittee,
the Public-Private Partnership (PPP) Subcommittee, was tasked to identify the stakeholders
involved in the care of TB patients, to consult private physicians, and to work with them in
establishing mechanisms for the sustained participation of private physicians in the NTP.
Headed by the DOH, the subcommittee working with government agencies included
representatives from the Departments of Education (DepED), Interior and Local Government
(DILG), Justice (DOJ), National Defense (DND), Agriculture (DA), Agrarian Reform (DAR),
Labor and Employment (DOLE), Social Welfare and Development (DSWD), Science and
Technology (DOST), the National Economic and Development Authority (NEDA), and the
National Commission on Indigenous Peoples (NCIP).
The PPP subcommittee was headed by the PhilCAT and included representatives from the
Philippine Medical Association (PMA), Association of Health Maintenance Organizations of
the Philippines, Inc. (AHMOPI), the Social Security System (SSS), Government Service
Insurance System (GSIS), the Philippine Health Insurance Corporation (PHIC/PhilHealth),
Employers Confederation of the Philippines (ECOP), Occupational Safety and Health Center
(OSHC), Employees Compensation Commission (ECC), Trade Union Congress of the
Philippines (TUCP), the Philippine College of Occupational Medicine (PCOM) and the
Overseas Worker and Welfare Administration (OWWA).
III. The National Tuberculosis Program
(NTP)
1. Description
T
HE National Tuberculosis Program (NTP) is a nationwide control
program spearheaded by the Department of Health (DOH) and implemented by the
local government units (LGUs) in accordance with the devolution of health services as
mandated under the Local Government Code of 1991. Other government agencies, government-
owned and -controlled corporations (GOCCs), government financial institutions (GFIs), non-
governmental organizations (NGOs) and the private sector are also involved in the
implementation of the program.
The DOH retains the function of policy formulation and technical provision through monitoring
and supervision of program plans, policies and guidelines. Through its regional offices now
called the Center for Health Development (CHD), the DOH also ensures the provision of
technical assistance, monitoring of the program, provision of anti-TB drugs and other TB
supplies. The Philippine Coalition Against Tuberculosis (PhilCAT) supports TB control activities
to strengthen private sector participation in TB control by providing the venue for interaction
between the public and the private sectors.
Program implementation is based on the DOTS strategy recommended by the World Health
Organization (WHO) and the International Union Against Tuberculosis and Lung Disease
(IUATLD), which depends on the implementation of a five-point package:
· Sustained political commitment to increase human and financial resources;
· Quality-assured TB sputum microscopy for case detection among persons
presenting with or found to have symptoms of TB;
· Standardized short-course chemotherapy (SCC) to all cases of TB under
proper case-management conditions including direct observation of
treatment or supervised treatment;
CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM 9

· Uninterrupted supply of quality-assured anti-TB drugs with reliable
procurement and distribution systems, and,
· Standardized recording and reporting system enabling assessment of every

patient and of the overall program performance.
Tuberculosis case finding services using sputum microscopy as the primary diagnostic tool and
case holding using directly observed treatment (DOT) are now available in DOTS centers
located nationwide. A DOTS Center is a health facility providing the five key elements of
DOTS Strategy. It can be a public, a private or a public-private mix. TB-DOTS services are
provided in this Center or can be outsourced from a nearby health facility (i.e., sputum microscopy
or directly observed treatment) through a referral system. The flow chart describing the NTP
Activities is shown in Annex 1: Flow of NTP Activities (page 83).
2. Vision, Mission, Goal of the NTP
Vision A country where TB is no longer a public health problem.
Mission Ensure that TB-DOTS services are available, accessible

and affordable to TB clients through the health services
provided by the government agencies, non-governmental
organizations and the private sector involved in TB control.
Goal Reduction of the prevalence of sputum smear positive TB

cases and TB mortality to half in 2015.
3. Targets of the NTP

a) Cure at least 85% or more of new sputum smear-positive TB cases detected
in all DOTS Centers.
b) Detect at least 70% of the total estimated new sputum smear-positive TB cases.
c) Achieve 100% DOTS coverage in both public and the private sectors.
4. NTP Strategies
To achieve its objectives, the NTP shall focus on the following strategies and activities:
4-1. Political commitment.

Advocate for political commitment at all levels of the health system including the private
sector by:
a) Mobilizing additional human, financial, and technical resources for TB control;
b) Fostering local, national and international partnerships;
c) Fostering communication among all health care providers, patients and the public
at large;
d) Providing opportunities for strengthening the NTP in relation to its clients; and,
e) Involving key leaders in the overall implementation of the NTP.
4-2. Sputum microscopy.

Provide access to quality-assured TB sputum microscopy by:
a) Providing functional microscopes

b) Conducting training programs for microscopists on basic sputum microscopy;
c) Maintaining and sustaining a Quality Assurance System (QAS) on TB microscopy;
and,
d) Organizing a network of all TB laboratories.
4-3. Standardized chemotherapy under DOT.

Provide standardized chemotherapy to all confirmed cases of TB under Directly
Observed Treatment (DOT)/ supervised treatment by:
a) Providing policies and guidelines for the treatment of TB cases;

b) Monitoring treatment response and progress and assessing treatment outcomes
through quality-assured sputum microscopy;
c) Establishing a mechanism or a referral system for DOT;
d) Ensuring client health education at initiation and continuation of treatment; and,
e) Providing enablers and recognition of DOTS centers and cured TB patients.
4-4. Drug supply.

Ensure uninterrupted supply of quality-assured anti-TB drugs through reliable
procurement and distribution system by:
a) Establishing a drug procurement and distribution system at all levels;
b) Regularly monitoring the availability of anti-TB drugs;

c) Supplementing the drugs from other sources (e.g., LGUs, Private Sectors); and,
d) Developing a public-private referral system to enable clients to access NTP drugs.
4-5. Program management.

Improve the program management capability of health workers by:

a) Provide technical assistance to all DOTS centers, including the TB Diagnostic
Committee;
b) Providing training on service provision and TB management; and,
c) Monitoring and supervising DOTS implementation at all levels.
4-6. Data/information system.

Improve the data/information system by:
a) Implementing the standardized DOTS recording and reporting system;
b) Developing an effective and efficient information processing system;
c) Analyzing the NTP data in relation to their DOTS implementation; and,
d) Strengthening public-private referral system.
4-7. Case detection.

Improve TB case detection by :
a) Establishing an effective public-private mix DOTS (PPMD) strategy;
b) Developing and disseminating effective IEC materials for community; and,
c) Improving and expanding hospital-based NTP.
5. Roles of Collaborating Agencies

5-1. DOH-NCDPC and CHD
a) Formulate plans, policies and standards for the NTP.
b) Provide technical assistance, including training to DOTS implementing levels.
c) Advocate for political commitment and alerts the community for mobilization.
d) Oversee program implementation in coordination with the other TB partners (e.g.,
LGUs, other government organizations, private agencies, international partners).
e) Provide the necessary logistics such as: anti-TB drugs, laboratory supplies, NTP
recording forms (registers, treatment cards), and educational/IEC materials
(prototypes).
f) Monitor regularly, supervise and evaluate the NTP activities, including Quality
Assurance System (QAS) to ensure quality implementation, incorporating client-
centered values in DOTS service delivery.
g) Collate and analyze data from the regularly submitted quarterly reports and provide
feedback of findings and recommendations to all concerned agencies.
h) Forge partnerships with other government agencies, NGOs, private entities and
international communities for a more comprehensive NTP implementation.
i) Develop PPM-DOTS in communities in partnership with PhilCAT and other private
groups.
j) Coordinate with CHD’s and Sentrong Sigla in the conduct of DOTS Center
Certification.
k) Initiate resource-generation campaigns for TB-DOTS and facilitate access to
international donor assistance.
5-2. PhilCAT
a) Participate in the development of policies for NTP and strategies for private sector
participation.
b) Develop local coalitions in support of Public-Private Mix DOTS (PPM-DOTS)
in communities.
c) Provide technical assistance in the development of PPM-DOTS in communities,
including training of private sector on DOTS.
d) Provide a venue for interaction between the Department of Health, non-government
agencies, other private organizations and the private sector.
e) Conduct advocacy activities in support of the NTP.
f) Participate in the certification of private DOTS facilities and DOTS referring
physicians.
g) Participate in the monitoring/evaluation of the NTP activities.
5-3. DILG / Local Government Units (LGUs)

a) DILG
· Implement measures to undertake TB control among members of the PNP,

inmates in jails nationwide and its employer, staff and clientele.
· Issue corresponding orders, memo circulars mandating LGUs to implement
NTP-DOTS in all health centers and hospitals under their jurisdiction.
· Participate in NTP activities and events at central and regional levels.
b) LGUs
· Develop a local health plan in consultation with DOH/CHD/PHO/CHO/MHO.

· Advocate for political commitments and community alertness.
· Create the TB Core Team composed of the Physician, Nurse and Medtech/
Microscopist that will oversee and implement the NTP as planned, in their
locality.
· Provide funds for monitoring, supervision, evaluation, training, NTP drugs and
supplies.

· Prepare, submit and analyze all required NTP quarterly reports.
· Implement a standardized Quality Assurance System for microscopy work.
· Build partnerships with other government agencies, NGOs, private entities
and international communities for a more comprehensive NTP implementation.
· Invest in continuing quality improvement and certification of LGU health facilities
as DOTS centers.
· Promote and maintain a client-centered DOTS service delivery system.
· Provide enablers to local community health volunteers and TB Diagnostic
Committee (TBDC) activities to sustain private sector interest and participation
in the NTP.
5-4. Other Government Agencies

a) Implement program components of NTP at all levels in accordance with the core
policies for case finding, case holding, recording and reporting.
b) Provide effective health education services to their respective clients.
c) Integrate facts and information about TB and the DOTS strategy into their
respective policies and health programs.
d) Spearhead TB research in consultation with the DOH.
e) Ensure capacity development of staff about NTP in coordination with the DOH
and other key TB agencies.
f) Ensure the timely release of funds for efficient NTP implementation within their
agency.
g) Initiate the forging of partnerships with the DOH, NGOs, private entities and
international communities for a more comprehensive NTP implementation.
h) Refer problematic cases to experts as the case may be.
5-5. Private Sector and NGOs

a) Ensure the implementation of the DOTS strategy in their respective areas, in
accordance with the Comprehensive and Unified Policy (CUP) on TB.
b) Advocate the implementation of the DOTS strategy in accordance with the CUP
on TB.
c) Establish access to the appropriate DOTS center in the public sector, through
standardized referral mechanism.
d) Allow access to relevant NTP records for data analysis.
e) Participate in NTP activities involving partnerships for community mobilization and
advocacy.
f) Coordinate with, and consult the public sector regarding NTP activities as necessary.
5-6. Government Financial Institutions (GFIs) and
Government-owned and -Controlled Corporations (GOCCs)
a) Provide reimbursable TB benefit packages for income loss and cost of diagnosis
and treatment.
b) Ensure the timeliness and regularity of payments to the accredited DOTS facilities
(PhilHealth).
c) Conduct regular DOTS accreditation services for availment of the TB benefit
DOTS package (PhilHealth).
6. Functions of NTP Health Workers
6-1. DOH TB Staff

a) Participate in the program planning of activities, policy-making and budget
preparation at national level.
b) Promote advocacy activities for political commitment at the national and local
governments.
c) Coordinate the overall NTP implementation among participating stakeholders.
d) Ensure the regular availability of all NTP supplies.
e) Provide regular technical assistance including training, monitoring, supervision, and
evaluation to all TB partners in the government and private sectors.
f) Collate and analyze pertinent data for future planning and policy development.
g) Coordinate with Sentrong Sigla all activities related to the certification of DOTS
centers.
6-2. CHD NTP Core Team

(NTP Medical, Nurse and Supervising Medtech Coordinators)
a) Participate in program planning of activities and budget preparation at CHD level.
b) Promote advocacy activities for political commitment at LGUs and for community
awareness.
c) Coordinate the overall NTP implementation within the region in consultation with
the DOH (Central Office), including private sector activities (i.e., PPM-DOTS).
d) Ensure the regular availability of all NTP supplies.
e) Provide regular technical assistance to other government agencies, NGO’s and
the private sector, including training and planning.
f) Monitor, supervise, evaluate the implementation of NTP; and recommend
appropriate remedial measures as necessary.
g) Collate and analyze pertinent data for future planning.

h) Submit on time the required NTP reports to the DOH (Central) level for
consolidation and analysis.
i) Participate in Sentrong Sigla as certifiers/assessors of DOTS centers.
j) Update periodically the directory of DOTS facilities for use as reference in
networking and other purposes.
6-3. DOH Representatives (Provincial, City, and Municipal)

a) Liaise with the CHD and the Provincial/City NTP Core Teams on issues pertaining
to the implementation of NTP in their respective assigned areas.
b) Participate in the monitoring of NTP implementation in coordination with the
Provincial/City NTP Core Team and concerned health center staff.
c) Assist in the conduct of other key NTP activities, like training, in coordination with
the CHD/Provincial/City NTP Core Teams.
d) Monitor regularly the quality of DOTS implementation in the DOTS units.
e) Collect quarterly NTP data from the DOTS Centers (public, private, PPM-DOTS)
and analyze these together with the health center staff.
f) Submit and analyze data to the respective Provincial/City Core Team and discuss
results as necessary.
g) Submit and analyze the provincial/city data to the CHD Core Team and discuss
results as necessary.
h) Provide technical assistance to facilitate certification of LGU health facilities as
DOTS centers.
6-4. Provincial and City NTP Core Team

(Medical, Nurse, Medtech Coordinators)
a) Coordinate all NTP activities within the Province/City, including that of the private
sector.
b) Implement advocacy activities to strengthen political commitments and intensify
community awareness.
c) Ensure regular availability of all NTP supplies at the health centers.
d) Monitor, supervise and evaluate the implementation of NTP and ensure the
implementation of corrective or remedial measures as necessary.
e) Implement Quality Assurance System (QAS) on laboratory to maintain the quality
microscopy service of the microscopy centers. Act as the validator/controller for
QAS (for the medtech coordinator).
f) Ensure the timely preparation and submission of NTP reports to CHD.
g) Provide technical assistance to facilitate certification of LGU health facilities as
DOTS centers.
6-5. Health Officer/Medical Officer/Physician (Public and
Private)
a) Supervise respective health workers when applicable to ensure the proper and
quality implementation of NTP core policies such as:
· Case finding
· Case holding
· Analysis and timely submission of NTP reports
· Referral of TB cases to other health services as needed
· Management of NTP logistics
b) Participate in Continuing Medical Education (CME) related to TB-DOTS.
c) Provide continuous health education to all TB patients, their families and to the
community to strengthen their participation in TB control activities.
d) Coordinate with the local chief executives (LCEs), other government agencies,
locally existing TB organizations, private sector and NGOs in the area to ensure
support for the TB program.
6-6. Public Health Nurse/DOTS Nurse (Public and Private)

a) Assign, educate and supervise the designated treatment partner of a TB patient.
b) Supervise support staff like Midwives, to ensure the proper implementation of the
DOTS strategy/NTP core policies.
c) Maintain and update the NTP Case Register.
d) Facilitate the timely requisition and distribution of drugs and supplies.
e) Provide continuous health education to all TB patients, their families and to the
community to strengthen their participation in the TB control.
f) Prepare the NTP reports and analyze date together with the Physician and other
staff to improve implementation and to plan for future activities.
g) Facilitate the conduct of meetings and consultations among center staff.
h) Act as Treatment Partner.
6-7. Midwives, Other Support Staff (i.e., Field Treatment

Supervisor / Field Treatment Coordinator)
On Case Finding:
· Identify TB symptomatics and collect sputum specimens for microscopy.
· Maintain and update the relevant NTP forms (Treatment Cards, ID Cards,
NTP Client List).

b) On Case Holding:
· Supervise the daily treatment of TB patients or the patient’s treatment partner
to ensure proper implementation of DOTS strategy/NTP core policies.
· Provide continuous health education to all patients placed under treatment,
their family members and to the community, to strengthen their participation in
the TB control program.
· Consult/Update weekly the Physician or Nurse while the patient is on his/her
course of treatment.
· Collect sputum specimen for follow-up examinations as scheduled.
· Report and retrieve defaulters within two (2) days.
· Refer patients with adverse drug reactions to the Physician for evaluation and
management.
· Refer all diagnosed TB cases to the medical officer or nurse for clinical evaluation
and initiation of appropriate treatment.
6-8. Medical Technologists or NTP Microscopists

a) Do sputum smear examination for diagnosis and follow-up.
b) Submit the results of the sputum smear examination to the requesting staff.
c) Maintain and update the NTP Laboratory Register.
d) Prepare and analyze the laboratory reports in coordination with the other Staff to
improve/maintain quality of microscopy services and to plan for future laboratory
activities.
e) Submit quarterly slides to the designated sputum smear validator for quality assurance
check.
6-9. Barangay Health Workers (BHWs)

BHWs are key-role players in the NTP especially since they contribute voluntary
health services to the community.
a) Refer TB symptomatics to health staff for sputum collection.
b) Act as Treatment Partner and undertake the Directly Observed Treatment (DOT).
c) Keep and update the NTP ID Cards of assigned TB patients.
d) Report and retrieve defaulters within two (2) days from time of default.
e) Consult/Update the Midwife weekly while the patient is on his/her course of
treatment.
f) Attend the patient’s weekly consultation with the Midwife.
g) Refer any patient’s complaint or any untoward reaction while on treatment to the
health staff.
h) Provide health education to the patient and family members. Participate in the
health education of the community.
6-10. Hospital-based NTP Core Team (Physician, Nurse,
Medical Technologist)
a) Coordinate NTP activities within the hospital with the assistance of any of the
following: TB Staff, DOH-NCHF Staff, CHD NTP Core Team, Provincial/City
NTP Core Team.
b) Implement the hospital-based NTP-DOTS policies.
c) Advocate to hospital management the provision of resources to maintain and sustain
implementation of hospital-based NTP DOTS.
d) Supervise the NTP implementation of other hospital staff/workers to ensure the
proper implementation of the DOTS strategy/NTP core policies such as:
· Identification and initial examination of TB symptomatics through sputum smear
examination.
· Undertaking of the directly observed treatment (DOT) for TB cases applicable
within the hospital setting.
· Availability and regularity of NTP drugs and supplies for those cases to be
treated within the hospital.
· Referral of patients to health centers/other health facilities, for diagnosis, initiation/
continuation of treatment or for supervised treatment using NTP Referral /
Transfer Form which should be properly filled-up by the hospital-based NTP
coordinator.
· Prepare and submit NTP reports to the PHO/CHO levels.
e) Conduct regular health education and advocacy activities to TB patients.

IV. NTP Core Policies and Procedures
1. Case Finding
C
ASE finding is an essential component of tuberculosis control. Its purpose is to
identify the sources of infection in the community, that is, to find the persons
discharging the tubercle bacilli and initiate proper treatment to render them non-infectious
initially and ultimately cure them.
The basic step in TB control is the identification and diagnosis of TB cases among individuals
with suspected signs and symptoms of TB. This is referred to as case finding. Fundamental to
case finding is the detection of infectious cases through direct sputum smear examination as
smear positive TB cases are about 20 times more infectious than the smear negative patients.
One undiagnosed and untreated smear positive patient can infect 10 persons in one year and
half of them will die within two years.
Sputum examination is the principal diagnostic method adopted by the NTP because of the
following reasons: (1) it provides a definitive diagnosis of active TB; (2) procedure is simple;
(3) economical and (4) a microscopy center could be organized even in remote areas. Studies
through the years have established its high specificity (97.5 percent to 99.8 percent). Sputum
examination is done prior to initiation of treatment, regardless of whether they have readily
available x-ray results or whether symptomatics are suspected of having extrapulmonary
tuberculosis. TB cannot be diagnosed with certainty by x-ray. Other diseases often look very
similar. It is a major error to diagnose TB based on x-ray alone and fail to examine the sputum.
The result of the sputum examination is crucial not only for diagnosis but is also one of the
bases, together with history of treatment in categorizing TB patients for treatment. It is also
used to monitor the patient’s response to treatment.
Sputum quality is very important. Three sputum specimens should be collected under the
supervision of a health worker. This should come from the lungs and patients should be given
proper instructions on sputum induction. Increasing yield were observed in terms of findings
CHAPTER IV : NTP CORE POLICIES AND PROCEDURES 21

with the second and third smears.
Microscopy centers are available in Rural Health Units (RHUs) and other non-governmental
agencies nationwide. Sputum microscopy services are offered for free as part of the NTP
services in all RHUs even to patients of private practitioners.
There are two types of case finding, passive and active case finding. Passive case finding
refers to finding TB cases from among the TB symptomatics who present themselves at the
health facility while active case finding is a purposive effort by a health worker to find TB
cases from among the TB symptomatics in the community who do not seek consultations
related to TB in the health facility.
N.B. Refer to Annex 2: Flowchart for the Diagnosis of Pulmonary TB to Annex 4: Approach
to TB Asymptomatic, pages 84 to 86.
1-1. Objective
The general objective of case finding is the early identification and diagnosis of TB
cases.
1-2. Policies
a) Direct sputum smear examination (primary diagnostic tool in NTP case finding):
1) Sputum smear examination is the preferred method for the diagnosis of TB.
All symptomatics identified shall be made to undergo smear examination for
diagnosis prior to initiation of treatment, regardless of whether they have
available X-ray results or whether they are suspected of having extra-pulmonary
TB. The only contraindication for sputum collection is massive hemoptysis.
It is only after a pulmonary TB symptomatic has undergone a sputum
examination for diagnosis with three sputum specimens and subsequently yielded
negative results that he shall be made to undergo other diagnostic tests such as
X-ray, culture and others, if necessary.
2) All health facilities shall be encouraged to establish and maintain a microscopy
unit in their areas of jurisdiction. In areas where this is not possible, referral to
an NTP microscopy service provider shall be encouraged.
3) Quality of sputum microscopy shall be maintained and sustained through the
regular quality assurance system at the provincial/city level.
b) Chest X-ray:
1) Chest x-ray examination shall be the secondary diagnostic tool for TB case
finding. However, no diagnosis of pulmonary tuberculosis shall be made based
of the result of X-ray examinations alone.
2) Smear negative cases whose chest x-ray examination result is suspected to be
positive for TB lesions shall be referred to the TB Diagnostic Committee that
shall decide on the appropriate action to take. Comparative reading of previous
and current X-rays is highly recommended for confirming diagnosis of TB in
such situations.
3) In each province/city, the creation of a TB Diagnostic Committee (TBDC) is
recommended. The TBDC shall provide diagnostic services to TB smear
negative cases whose chest x-ray results are consistent with active TB.
c) Skin test for TB infection (PPD skin tests) should NOT be used as a basis for the
diagnosis of TB in adults.
d) Passive case finding shall be implemented in all health facilities.
e) Sputum smear examination (smearing, fixing and staining of sputum specimens,
reading the smear) shall be performed only by adequately-trained medical
technologist or NTP microscopist.
1-3. Procedures
a) Identification of TB Symptomatics is the responsibility of the staff of all health
facilities involved in NTP.
1) The responsible person shall identify TB symptomatics among patients consulting
at the health facility. These are persons having continuous cough, for two or
more weeks, and those with or without the following signs and symptoms:
· Fever
· Sputum expectoration
· Significant weight loss
· Hemoptysis or recurrent blood-streaked sputum
· Chest and/or back pains not referable to any musculo-skeletal disorders
· Other symptoms such as sweat with chills, fatigue, body malaise, shortness
of breath
2) The responsible person shall educate and encourage identified TB symptomatics
for sputum examination.
3) The responsible person shall encourage household members of identified TB
cases, who are also TB Symptomatics, to undergo sputum examination.
4) The responsible person shall utilize the NTP client list for providing service to
TB clients.
b) Collection and transport of sputum specimens to the Microscopy Center are the
responsibilities of the health staff.
1) The responsible health staff member who is in-charge of the initial consultation
shall explain the purpose of the sputum examination to the TB symptomatics
before collecting his/her sputum. It is crucial for the TB symptomatics to
understand the importance of submitting three sputum specimens during their
consultation.
2) The responsible health staff shall label the body of the sputum cup with the
patient’scomplete name and the serial number, seal each sputum specimen

container, pack it securely and transport it to a microscopy unit or laboratory
as soon as possible or not later than four days from collection. Otherwise, the
specimens should be properly stored in cool, dark and safe place. No specimen
shall remain unexamined over the weekend. The specimen should be sent
together with the NTP Laboratory Request Form for Sputum Examination
to the microscopy center.
3) The responsible health staff shall demonstrate how to produce good sputum.
It is essential to obtain quality sputum specimen for proper diagnosis of TB.
Good sputum could be obtained by asking the patient to do the following
steps:
· Rinse his/her mouth;
· Breathe deeply two times, holding the breath for few seconds after each
inhalation and then exhaling slowly; and
· After inhaling deeply on the third time, at the height of inspiration, cough
strongly and spit the sputum in the container.
4) The responsible health staff shall supervise the patient from behind during the
procedure and observe contamination precautions. It is recommended to collect
sputum specimen outside where aerosols containing TB bacilli are diluted and
sterilized by direct sunlight in order to prevent health workers from inhalation
hazards.
5) The responsible health staff shall collect three specimens within two days
according to these procedures:
· First specimen, which is also referred to as first spot specimen, is collected
at the time of consultation, or as soon as the TB symptomatics is identified.
· Second specimen, or early morning specimen, is the very first sputum
produced in the morning and is collected by the patient according to the
instructions given by the midwife.
· Third specimen, which is also referred to as second spot specimen, is
collected at the time TB symptomatics comes back to health facility to
submit the second specimen.
· If the responsible health worker fails to collect 3 sputum specimens within
2 days, he or she is given 1 week to complete the 3 specimen collections.
c) Smearing, fixing, staining and reading of sputum specimens are the responsibilities
of the trained medical technologist or TB microscopist at the microscopy centers.
They will do the following:
1) Record the information in the NTP Laboratory Register.
2) Smear, fix, stain and read the slides.
3) Interpret smear examination result or the individual readings of the three
specimens and the final written laboratory diagnosis in the sputum microscopy
results portion of the returned Laboratory Request Form for Sputum
Examination to determine the diagnostic classification such as:
· A smear positive result occurs when at least two sputum smear results are
positive. When the sputum collection unit receives this positive result, the
responsible health staff shall inform the patient of the results of the sputum
examination and refer him/her to the doctor for assessment and initiation
of treatment.
· A doubtful result occurs if there is only one positive sputum smear result
out of the three sputum specimens examined. The responsible health staff
shall inform the patient of the results of the sputum examination and explain
the collection of another three sputum specimen within one week.
If at least one specimen from the second set of specimens turns out to be
positive, the laboratory diagnosis is positive. Refer the patient to the doctor
for assessment and initiation of treatment.
If all three specimens from the second set of specimens turn out to be negative,
the laboratory diagnosis is negative. Refer the patient to the doctor for further
assessment. The physician may request for chest X-ray to confirm diagnosis.
If the chest X-ray is suggestive of TB, the physician may recommend treatment
and classification of patient as smear positive. Further observation is
recommended when chest X-ray results are not suggestive of active TB (see
Annex 2: Flowchart for the Diagnosis of Pulmonary TB, page 84).
A smear negative result shows that all three sputum smear results are negative.
The responsible health staff shall inform the TB symptomatic about the results
of the sputum examination and refer the patient to the doctor for further
assessment. The doctor may treat the patient symptomatically/empirically or
with antibiotics and or other medications as necessary. If the symptom
persists, collect another set of three sputum specimens for repeat smear
examinations.
4) Record the examination results in the NTP Laboratory Register and in the
lower portion of the NTP Laboratory Request Form for Sputum Examination.
5) Inform the responsible person of the results of the examination as soon as
these are available by sending back the accomplished Laboratory Request
Form for Sputum examination.
6) Refer to the TB Diagnostic Committee smear negative CXR positive TB
suspects.
The physician shall decide on the referral of smear negative patients to the TB
Diagnostic Committee for further diagnosis and management (see Annex 23-
A: TB Diagnostic Committee, page 154).
N.B. Refer to Annex 5: Guide to Case Finding (page 87), and Annex 6: Guide to
Diagnosis and Initiation Of Treatment (page 88).
2. Case Holding
The procedure that ensures that patients complete treatment is referred to as case holding.
Chemotherapy is the only way to stop the transmission of TB. It is senseless to search for
cases if they could not be treated properly after they have been found. It would only encourage
false hopes on the part of the patient. While effective anti-TB drugs are available in the country,

there are still many TB patients who are not cured. This is due to irregular or complete
stoppage of TB drug intake by many patients. The long duration of treatment, six months on
the average, makes it most likely for patients to be remiss in drug intake. Treatment compliance
is necessary to cure TB and avoid drug resistance.
Poor treatment compliance may lead to the following outcomes: chronic infectious illness,
death or drug resistance. Second line anti-TB drugs for drug resistant cases are very expensive
and most are not available in the country. The best way to prevent the occurrence of drug
resistance is through regular intake of drugs for the prescribed duration. The only proven way
of ensuring adherence is through direct observation of treatment (DOT), one of the elements of
DOTS strategy which is the WHO recommended policy package for TB control. DOT works
by assigning a responsible person to observe or watch the patient take the correct medications
daily during the whole course of treatment.
All TB cases, especially the smear positive TB cases, should undergo DOT for the whole
duration of treatment. Anyone of the following could serve as a treatment partner:
· Staff of a health facility.

· Member of the community such as the BHW, local government official, religious group, or
former (cured) TB patient.
· Member of the patient’
s family
Supervised treatment can be done in any accessible and convenient place (e.g. health facility,
treatment partner’s house, patient’
s place of work, patient’s house) as long as the treatment partner
can effectively ensure the patient’
s daily intake of the prescribed drugs and monitor his/her response
to the treatment regimen. For those without a mechanism to do supervised treatment, patients
may be referred to the nearest DOTS Center.
2-1. Objective
The general objective of chemotherapy is to treat TB cases effectively and completely,
especially pulmonary sputum smear positive cases.
2-2. Treatment Regimen

The treatment regimen to be followed according to the type of TB case is shown in
Annex 7: Treatment Regimens (page 89). The different first-line anti-TB drugs under
the NTP are the following:
H – ISONIAZID (75 mg) E – ETHAMBUTOL (275 mg),
R – RIFAMPICIN (150mg), S – STREPTOMYCIN (750 mg).
Z – PYRAZINAMIDE (400 mg),
2-3. Fixed Dose Combination Anti-TB drugs

The fixed dose combination (FDC) drugs are anti-TB drug preparations, whereby
two or more first line anti-TB drugs are combined in one tablet. There are 2, 3, or 4
FDCs. The NTP utilizes the 4 and 2 drug combinations which are called FDC-A and
FDC-B respectively.
The World Health Organization (WHO) and the International Union Against Tuberculosis
and Lung Disease (IUATLD) have endorsed the use of FDCs by the NTP since 1994.
The 4-drug and 2-drug combinations are included in the WHO Model List of Essential
drugs since 1999.
For the composition of FDCs, categories of treatment regimens and drug dosages
using FDCs, see Annex 7: Treatment Regimens (page 89) and Annex 8-A: Drug
Dosage and Adjustment (page 90), Annex 8-B: FDC Composition (page 90), and
Annex 8-C: FDC Dosaging (page 91).
2-4. Policies
a) Treatment of all TB cases shall be primarily based on reliable diagnostic technique,
namely, sputum smear examination aside from clinical findings. Chest x-ray
examination is used only as a secondary diagnostic tool.
Treatment of all sputum smear negative CXR positive cases shall be based upon
the decision of the TB Diagnostic Committee.
b) Domiciliary treatment shall be the preferred mode of care.
c) Patients recommended for hospitalization are those with the following conditions:
1) Massive hemoptysis
2) Pleural effusion obliterating more than half (1/2) of a lung field
3) Miliary TB
4) TB meningitis
5) TB pneumonia
6) Those requiring surgical intervention
7) Those with complications
d) No patient shall initiate treatment unless the patient and health workers have agreed
upon a case holding mechanism for treatment compliance.
e) For all patients to be started on treatment, provision of the complete drug
requirement should be ensured. The complete drug allocation of each patient shall
be secured before treatment is started.
f) The DOH shall ensure the provision of FDC drugs to the health centers, including
PPMD units and other health facilities giving priority to sputum smear positive
cases. However, the health facilities (including LGUs) shall be encouraged to procure
SDF preparations (at least 5% of the expected cases), intended for those who
may develop adverse reactions to FDCs.
g) Quality of FDCs shall be ensured by ordering them from a source with track
record of producing FDCs according to World Health Organization (WHO)
prescribed standards.
h) The dosage for FDCs shall be in accordance to the WHO recommended dosages.

i) Chemoprophylaxis is not recommended by the NTP.
2-5. Tuberculosis during Pregnancy and Lactation

Pregnant women and lactating or breastfeeding mothers suffering from tuberculosis
should also be treated with anti-TB drugs. It is even more harmful if they are left
untreated, as the fetus may also be affected with tuberculosis. Based on the National
TB Consensus in 1999, the following are the recommendations to manage tuberculosis
among these special conditions:
a) For sputum AFB smear (+) and/or TB culture (+)cases, with or without CXR
evidence of active PTB, the regimen should consist of rifampicin, isoniazid and
ethambutol for at least nine months or at least six months beyond culture conversion
whichever is longer. However, if the organisms are proven sensitive to both
rifampicin and isoniazid, ethambutol could be instituted during the initial three months
only.
The use of pyrazinamide must be avoided except in situations where resistance to
rifampicin or isoniazid is highly suspected and resistance to pyrazinamide is unlikely.
If ever it is to be utilized, it must be given after the first trimester of pregnancy.
Streptomycin should not be used as previously stated in the National TB Consensus
Part I because it is potentially hazardous not only during the first trimester but
throughout gestation. It induces ototoxicity.
b) Women who are taking rifampicin, and who need contraceptive precautions, are
advised not to use oral contraceptive steroids. They should consider using an
alternative method of contraception because of observed drug interaction between
oral contraceptives and rifampicin.
2-6. Procedures (for the health worker)

a) Registration and Initiation of Treatment:
1) Inform the patient that he/she has TB and motivate the patient to undergo
treatment.
2) Refer the patient to a physician for pre-treatment evaluation and initiation of
treatment.
3) Refer to the NTP Treatment Card and prepare two NTP ID Cards (one is for
the treatment partner and the other is for the patient). Start the treatment
using any of the three treatment regimens best suited to the patient’s disease
classification, type and previous history of treatment.
4) Register the patient in the NTP TB Register. Refer the patient to the most
accessible health facility where he/she can have his/her treatment supervised.
b) Ensuring Treatment Compliance through DOT:

Directly Observed Treatment (DOT). DOT is a strategy developed to ensure
treatment compliance by providing constant and motivational supervision to TB
patients. DOT works by having a responsible person, referred to as treatment
partner, who watches the TB patient take the medicines everyday during the whole
course of treatment. The following are the responsibilities of the treatment partner:
2) Administer the patient’s drugs at their agreed treatment facility everyday, and
ensure that the patient swallows his/her drugs daily. After intake of the drugs,
the treatment partner shall check and sign the patient’s NTP ID Card and his/
her own copy of the NTP ID Card.
3) Ensure that on Saturdays, Sundays and holidays when the health facility is
closed, treatment is done at home but shall be supervised by a family member.
The family member shall sign the patient’s NTP ID Card.
4) Regularly motivate the TB patient to continue treatment by emphasizing key
messages, such as:
· TB can be cured but requires regular drug intake for the prescribed
duration.
· The patient should report any adverse reaction of the drugs to his/her
treatment partner immediately.
· The patient should undergo follow-up sputum examination on specified
dates (see Annexes 10-A and 10-B: Schedule of Sputum Smear Follow-
up Examination, pages 93-94).
5) Regularly confer (preferably weekly) with the treatment partner and the patient
for treatment evaluation at the health facility.
6) Exert effort together with all health workers to immediately retrieve a patient
who fails to report on the day the patient is expected.
7) Monitor the response to treatment and ensure that follow-up sputum
examination is done on the specified date (see Annexes 10-A and 10-B:
Schedule of Sputum Smear Follow-up Examination, pages 93-94). Sputum
smear examination for follow-up requires only one specimen collection,
preferably collected in the early morning.
c) Management of Chronic TB Cases, and HIV Co-Infected Cases:
1) Chronic case: a patient who is still sputum smear positive at the end of a re-
treatment regimen. He/she should be referred to a higher facility for proper
evaluation and management.
2) For those HIV co-infected cases, work up the patient for TB and start TB
treatment accordingly in accordance with the agency’s protocol.
d) Management of Adverse Reactions to Drugs:
Closely monitor the occurrence of minor and major reactions to drugs, especially
during the intensive phase (see Annex 12: Guide in Managing SCC Drugs Side
Effects in page 96). There are major side effects that necessitate withdrawal of the
responsible drug. In this case, FDC must be changed to SDF.
e) Monitoring Patient Response to Treatment:
Monitor the sputum smear status of all patients under treatment, including initially
sputum smear negative patients, according to the standard schedule (see Annexes
10-A, 10-B, and 10-C: Schedule of Sputum Smear Follow-Up Examination, pages

93-94) and modify treatment based on the sputum follow-up examination results
(see Annexes 13-A to 13-D: Treatment Regimen Modifications for Category I
and II, with and without modifications, pages 97 to 100).
f) Management of Defaulter and Referred Cases:
1) Perform routine smear examination to defaulted/lost cases that come back for
chemotherapy. Refer patients to a physician for re-evaluation and re-treatment.
2) New smear positive patients who interrupted treatment should be managed
according to the recommended schedule (see Annex 14-A: Treatment
Modifications for New Smear Positive Cases Who Interrupted Treatment,
page 101).
3) Relapse and failure cases that have interrupted treatment shall be managed
according to recommended schedule on Annex 14-B: Treatment Modification
for Relapse and Failure Cases Who Interrupted Treatment (page 102).
4) Treatment shall be continued for patients who were properly referred or
transferred using the NTP referral slip. However, sputum smear examination
for diagnosis should be performed for patients without an accompanying
properly accomplished NTP referral/transfer form.
2-7. Outcome of Treatment

A patient who undergoes treatment may achieve any of the following treatment outcomes:
a) Cure: A sputum smear positive patient who has completed treatment and is sputum
smear negative in the last month of treatment and on at least one previous occasion.
(Note: We have changed the definition of “cure” as above, however, we have not
changed the policy to collect follow-up sputum specimen with three occasions for
smear positive case: (a) at the end of the Intensive Phase, (b) at the middle of the
Maintenance Phase, and (c) at the end of the Maintenance Phase.)
b) Treatment Completed: A patient who has completed treatment but does not meet
the criteria to be classified as cure or failure. This group includes:
· An initially sputum smear-positive patient who has completed treatment without
follow-up sputum examinations during the treatment, or with only one negative
sputum examination during the treatment, or without sputum examination in
the last month of treatment;
· A sputum smear-negative patient who has completed treatment.
c) Died: A patient who died for any reason during the course of treatment.
d) Treatment Failure:
· A patient who is sputum smear-positive at five months or later during the
treatment.
· An initially sputum smear-negative patient before starting treatment and
becomes smear-positive during the treatment.
(Note: This case will be re-registered as “other” with a new TB case number.)
e) Defaulter: A patient whose treatment was interrupted for two consecutive months
or more and remains unreached for continuing treatment.
f) Transfer Out: A patient who has been transferred to another facility with properly
accomplished NTP referral/transfer form for continuation of current treatment.
3. Recording and Reporting

Records that contain accurate, complete and up-to-date information on patient diagnosis,
treatment, follow-up examinations and treatment outcome must be made available to ensure
the provision of appropriate and effective patient’s care. Such records are also important in
the implementation of a successful TB control program.
Records enable health workers to ensure that each TB symptomatic found is examined and
more importantly, that TB patients get cured. Reports are important sources of information on
patient coverage and care; program efficiency and effectiveness; and availability of drugs and
other NTP supplies at health service units. In this manual, recording and reporting is designed
to generate and provide the minimum set of information required for program planning at
different levels.
3-1. Objectives
a) To provide program implementers with information to serve as basis for planning
on how best to assist their clients and patients.
b) To provide program supervisors with information to serve as basis for planning on
how best to assist TB control program implementers.
3-2. Policies
a) Recording and reporting for NTP shall be implemented at all health facilities, including
PPMD units, government and private hospitals.
b) Reporting TB cases should be made mandatory to private physicians and private
clinics after agreement with parties concerned shall have been made.
c) Recording and reporting shall include all cases of TB, classified according to
internationally accepted case definitions.
d) Recording and reporting for NTP shall use, as much as possible, the Field Health
Service Information System (FHSIS) network for routine reporting and feedback.
e) Records and reports should allow for the calculation of the main indicators for
program evaluation (see Annex 19: Program Indicators, page 127).
f) All four quarterly reports should be sent to DOH through the CHD. PPMD reports
should be disaggregated to reflect additions to total cases reported in the province/
city/municipality where PPMDs are installed.
g) The DOH shall make an Annual consolidation, analysis, interpretation and
dissemination of information to all partners, stakeholders and general public as
necessary.

3-3. NTP Recording Forms
Note: Refer to Annex 17: Responsible Persons for the Recording Forms (page 105).
a) NTP Client List (Target Client List/TCL):
The NTP client list is a record of all clients in the health facility who were assessed
for TB. This includes clients who are for sputum microscopy or for referral to the
TBDC. At the RHU, this corresponds to the Target Client List or the TCL. This is
a tool to confirm the three sputum collection at the sputum collection unit (RHU /
BHS / Private Health Facility). This list is maintained by the health staff in the
facility to keep track of accomplished sputum-smear examinations for three
specimens and confirmed diagnosis of TB Symptomatics (see Annex 18-A: NTP
Client List/Target Client List (TCL), page 107). The Target Client List of FHSIS
would be used in facilities where this is already available such as the RHUs and
BHSs.
b) NTP Laboratory Request Form for Sputum Examination:
The nurse and the midwife shall accomplish this form when they request for sputum-
smear examination (diagnosis or follow-up). Laboratory Request Form shall be
attached to all specimen sent to the microscopy center. The NTP medical
technologist and microscopist shall fill-in the form with the result of the sputum
smear examinations which has to be returned to the referring unit. (see Annex 18-
B: NTP Laboratory Request Form for Sputum Examination, page 108).
c) NTP Laboratory Register:
This register contains all information on sputum-smear examinations done by the
NTP trained medical technologist and microscopist on TB Symptomatics (for
diagnosis) as well as TB patients undergoing treatment (for follow-up). It can be
used to check microscopy data recorded on the NTP TB Register. The NTP
medical technologist and microscopist shall maintain the forms at the microscopy
center or referral laboratory unit (see Annex 18-C: NTP Laboratory Register,
page 111).
d) NTP Treatment Card:
All TB patients admitted to the treatment program should have an NTP treatment
card. This card should be filled-in completely with all the necessary information
about the TB patient and the treatment he/she is receiving including daily drug
intake as well as the results of sputum follow-up examinations. This NTP Treatment
Card is maintained and updated by the health staff /PPMD treatment coordinator
/responsible person at the health facility where the patient is receiving treatment.
This is kept at the facility (see Annex 18-D: NTP Treatment Card, page 113).
e) NTP Identification Card:
Once a patient is diagnosed as a TB case, he will be issued an NTP Identification
Card. The NTP ID Card is a handy source of information on the patient’s diagnosis,
treatment regimen, schedule of daily drug intake and follow-up results of sputum
smear examinations. The treatment partner initials the NTP ID Card each time he/
she sees the patient take his/her drugs. In addition, the treatment partner keeps
and maintains the same NTP ID Card for him/her to monitor the patient’s compliance
to treatment. Both the TB patient and the treatment partner has a copy of the NTP
ID Card. The treatment partner signs on both copies of the NTP ID cards (see
Annex 18-E: NTP Identification Card, page 116).
f) NTP TB Register:
The nurse assigned at the health facility/PPMD unit maintains this register. It gives
information on the type and classification of TB cases, treatment regimen, monitoring
of sputum follow-up and treatment outcomes of all patients in a catchment area.
This is one of the main sources of data in the calculation of the treatment outcome
and other main epidemiological indicators in NTP (see Annex 18-F: TB Register,
page 118).
g) NTP Referral / Transfer Form:
The nurse or the physician/PPMD coordinator fills-in this form in duplicate (one
copy is for the receiving unit and the other is for the referring unit). This form is
needed when a patient is referred to another health unit for continuation of treatment.
The receiving unit completes the lower portion of the form upon receipt from the
patient, and sends it back to the referring unit. It is recommended that the referring
unit ask for the treatment outcome of the patient from the receiving unit afterwards,
in order to confirm the final outcome (see Annex 18-G2: PPMD Follow-up Form,
page 121).
h) NTP Reporting Forms:
1) Quarterly Report on Laboratory Activities:
This report is made by the NTP trained medical technologist or microscopist
at the microscopy center. It provides information on the total number of TB
symptomatics examined, the total number of TB symptomatics collected three
sputum specimens and the total number smear-positive cases discovered every
quarter (see Annex 18-H: Quarterly Report on NTP Laboratory Activities,
page 122).
This Quarterly Report is sent from the health facility/PPMD unit to the Provincial
or City NTP Coordinators quarterly. Then the Provincial or City NTP
Coordinators consolidate and analyze the data and send them to the CHD
NTP Coordinators. The CHD NTP Coordinators consolidate and analyze the
data prior to submission to DOH.
2) Quarterly Report on New TB Cases and Relapses:

This report is prepared by the nurse/PPMD coordinator and noted by the
physician of the health facility and submitted to the Provincial or City NTP
Coordinators quarterly. It is the summary report on the NTP case finding on
new smear-positive cases (age and gender specific), relapses, new smear-
negative cases and extra-pulmonary cases.
The information is used by the provincial, city, CHD, central NTP Coordinators
to evaluate case finding of new smear-positive, relapse cases, new smear-
negative cases and extra-pulmonary cases (see Annex 18-J: Quarterly Report
on New Cases and Relapses of Tuberculosis, page 124).

Treatment failure cases are not included in this report as they have already
been reported when they were then new cases. Transfer-in patients are counted
in the health facility where they came from.
This data is consolidated and analyzed prior to submission by the respective
levels.
3) Quarterly Report on Treatment Outcome:

This report shows information on the outcome of treatment of a group of
patients who were treated 13-15 months earlier. It serves as the basis for
evaluating the effectiveness of chemotherapy through the cure rate (see Annex
18-L: NTP Quarterly Report on the Treatment Outcome of Pulmonary TB
Cases, page 126).
This report is made by the nurse and noted by the physician of the health
facility and submitted to the provincial/city NTP coordinators every quarter.
The provincial and city NTP coordinators consolidate and analyze the data
prior to submission to the CHD NTP coordinators.
4. Logistics Management
Health facilities/PPMD units should have an adequate supply of anti-TB drugs and other NTP
supplies in order to provide quality NTP services. The latter includes sputum cups, glass
slides, syringes, reagents and recording and reporting forms. The buffer stock must also be
maintained at all levels to avoid stock-outs. The adequate reserve level are prescribed as
follows:
DOH / CHD level Six months
Provincial / City level Three month
Rural Health Unit / City Health Unit / PPMD unit Three months
Anti-TB drugs and laboratory supplies shall be procured by the DOH. These will be sent
directly to the CHD and distributed to the provinces or cities that will in turn distribute them to
the DOTS centers. To avoid stock-outs or oversupply, the Quarterly Report on New Cases
and Relapses of Tuberculosis and on Drug Inventory and Requirement (see Annex 18-J: Drug
Inventory and Requirement, page 124) must be carefully prepared and submitted on time by
the implementing units to the provincial or city NTP Coordinators and the consolidated data
are sent to the CHD NTP Coordinator on time.
The number of FDC Blister Packs to be requested can be determined using the Quarterly
Report on New Cases and Relapses of Tuberculosis and on Drug Inventory and Requirement
as guide to compute for the quarterly drug requirement. This is accomplished as follows:
a) Compute the total number of FDCs blister packs (FDC-A, FDC-B, PZA, Ethambutol)
and Streptomycin Vials needed, based on the number of patients registered in the previous
quarter.
b) Multiply this by two (include the buffer stock).
c) Deduct the drugs from the stock on hand, to come up with the number of drugs to be
ordered.
Number of FDC Blister Packs Required per Patient per Regimen
FDC-A RHZE FDC-B RH Z E Streptomycin

No. of blister packs No. of vials
Regimen 1 6 12
Regimen 2 9 15 10 56
Regimen 3 18 6
Reminders:
· Drugs must be stored in a secure, clean and cool place at all times.
· Always observe the First Expiring, First Out (FEFO) rule.
· Secure and give the entire supply of drugs required for the entire duration of treatment per
TB patient to the midwife in charge of the patient.
4-1. Recording/reporting of NTP logistics:

The logistics for the NTP shall be reported using the Quarterly Report on New Cases
and Relapses of Tuberculosis and on Drug Inventory and Requirement (see Annexes
18-J: Quarterly Report on New Cases and Relapses of Tuberculosis and on Drug
Inventory and Requirement, page 124). This is the summary report on the number of
cases according to the regimen applied, namely, Regimen I, Regimen II, and Regimen
III. The information is used by the provincial, city and CHD NTP coordinators to
calculate the number of anti-TB drugs needed at the health facility. The CHD NTP
coordinator distributes anti-TB drugs to each province and city. The provincial or city
NTP coordinators in turn, distribute the drugs to their catchment health facilities.
This report is made by the nurse and noted by the physician of the health facility and
submitted to the provincial/city NTP coordinators every quarter. The provincial and
city NTP coordinators consolidate and analyze the data prior to submission to the
CHD NTP coordinators.
5. Monitoring, Supervision and Evaluation

Monitoring is an ongoing process of collecting and analyzing information about program
implementation. It involves regular assessment of whether activities are being carried out as
planned and how the activities are being done. Monitoring goes beyond following up on the
progress of planned activities to identifying problems and implementation bottlenecks. Data
and information gathered through monitoring should be immediately processed, analyzed and
disseminated to people who can act and react. Monitoring is not completely separable from
evaluation, except that monitoring focuses on ongoing implementation, while evaluation focuses
on effectiveness, results and impact.

Supervision is an essential management tool to ensure that the implementers correctly,
effectively and efficiently carry out policies, standards and procedures of the program. It is
also an opportunity for supervisors to do the following:
· Discuss with health workers important issues related to the program.

· Check records and reports.
· Acknowledge and re-enforce good performance.
· Help health workers identify and correct inadequacies or weaknesses in performance.
· Provide exit feedback with corresponding recommendations to the problems identified to
improve program implementation.
· Provide on-the-job training
Evaluation is the regular assessment of the process or development of any program or

project with particular focus on its effectiveness and impact. This process is carried out by
each of the NTP Coordinators by analyzing indicators, data and relevant information from
records and reports and feedbacks from field health implementers, surveys and studies from
other agencies.
5-1. Objectives
a) To supervise and monitor on a regular basis, the health status of patients from
records and reports in order to improve and maintain the NTP activities at all level.
b) To evaluate on a regular basis, all NTP activities by using indicators derived from
records and reports in order to identify problems recommend and institute possible
solutions.
5-2. Policies
a) The provincial or city NTP coordinators are the NTP supervisors of the health
facilities, PPMD units and accredited DOTS centers. They shall visit regularly (at
least quarterly) these implementing facilities to monitor the progress and
performance of NTP. This activity shall be done in coordination with the DOH/
CHD NTP Coordinators.
b) The physician and nurse are the NTP supervisors at the health facility levels. They
shall visit their catchment areas regularly. Regular supervisory visits to the health
facilities will create good working relationships between the supervisors and the
health workers. The frequency of the visit will depend on the level of performance
of the health unit as well as the performance of the health workers.
c) Relative to Quality Assurance System (QAS) , the CHD/PHO/CHO shall monitor
regularly (at least quarterly) the performance of laboratory services and functionality
of the TB Diagnostic Committee.
d) The health staff concerned with NTP implementation at each level shall regularly
analyze the data of quarterly reports using standard program indicators and provide
feedback of findings with corresponding recommendations to the staff or authorities
concerned.
e) Advocate on commitment for counterpart share in the purchase of anti-TB drugs,
other NTP logistics and costs of NTP operations.
5-3. Procedures
a) Procedures for the Conduct of Monitoring and Supervision Activities:
Identify the areas to be visited and determine the frequency of the visits. Those
with problems should be visited more frequently. Use the following guidelines for
supervisory visits:
1) Compare and verify the 3 key records of NTP implementation, namely, (1)
NTP TB Case Register, (2) NTP Treatment Cards and (3) NTP Laboratory
Register. Check for correctness and consistency of written data.
2) Review the NTP treatment cards.
· TB Case Number
· Previous TB treatment history
· Type and classification of patient
· Regimen /category of treatment
· Sputum examination results on diagnosis and on follow-up
· Drug collection
· Treatment outcome
3) Review the NTP TB Register.
· TB Case Number
· Type and classification of patient
· Sputum examination results on diagnosis and for follow-up
· Conversion rate at the end of the 2nd and 3rd month of treatment
· Treatment outcome
4) Review NTP Laboratory Register.
· TB Case Number for the follow-up examination
· Rate of three sputum specimen collection
· Positivity rate
5) Observe health workers.
6) Interview health workers and patients.
7) Conduct physical inventory of NTP drugs and other logistics.
After gathering all relevant information, the supervisor must inform or advise
the health worker of the findings from the visit. Recommendations should
preferably be furnished in writing. Courses of action to address deficiencies,
mistakes and negligence must be discussed and solutions agreed upon by both
supervisor and the concerned health worker.

b) Procedures for evaluation:
1) During the first week of each quarter, the nurse at the health facility shall prepare
the Quarterly Report on New Cases and Relapses of Tuberculosis and the
Quarterly Report on the Treatment Outcome of Pulmonary TB Cases. The
medical technologist or microscopist shall also prepare the Quarterly Report
on NTP Laboratory Activities of the cases registered during the previous
quarter.
The physician, nurse and medical technologist/NTP microscopist shall analyze
all the quarterly reports to evaluate the performance of the NTP activities at
their health facility. All staff concerned shall evaluate their performance by
analyzing indicators such as the proportion of pulmonary smear positive cases
out of all pulmonary cases; three sputum collection rate; positivity rate; case
detection rate (CDR), sputum conversion rate at the end of two (three) months
of treatment for new smear positive cases and cure rate.
Treatment Failure cases are not included in the Quarterly Report in New Cases
and Relapses of TB, as they have been already reported, when they were then
typed as new cases. Transfer-in cases are counted in the health facility where
they were referred from.
The NTP reports prepared by the Provincial/City NTP Coordinator should
be disaggregated as to public and private contribution, to reflect the additions
in the PPMD units to the total cases reported in the province/city/municipality,
where the PPMD is being implemented.
2) All quarterly reports are prepared from the NTP TB Register and the NTP
Laboratory Register. Therefore, the information in the report is only as accurate
as the information recorded in these registers. The quarterly reports are based
on the following coverage period:
1st Quarter January 1- March 31
2nd Quarter April 30 - June 30
3rd Quarter July 1 - September 30
4th Quarter October 1 - December 31
The provincial and city NTP Coordinators shall consolidate and analyze all
quarterly reports coming from the implementing health facilities. The
consolidated data by province and city reports shall be sent to the CHD NTP
Coordinators for analysis. The CHD NTP Coordinators shall consolidate and
analyze all quarterly reports prior to submission to the DOH. Recommended
alternative courses of action anchored on relevant findings and based on
standard program indicators (see Annex 19: Program Indicators, page 127)
shall be used or applied to ensure the effective implementation of the TB control
program.
c) Monitoring Forms:
A standardized monitoring tool/checklist based on the established program indicators

shall be used during the monitoring and supervision activities. This contains the
basic program indicators that measure the status and progress of program
implementation (see Annex 24: NTP Monitoring Checklist, page 162)
6. Quality Assurance for Sputum Smear Microscopy

For a laboratory to maintain high quality results, its overall performance should be monitored
through a series of regular activities, which in combination, make up the laboratory’s quality
assurance system (QAS).
In NTP, the sputum smear microscopy result is used to categorize a symptomatic patient
according to standard definition. In addition, it is utilized to monitor progress of patient who
have positive sputum smears while they are receiving anti-TB treatment and to confirm the
cure of the patient at the end of treatment.
Such is the importance of microscopy; it follows that errors will be highly significant – not only
for the patient but also for the NTP. It is therefore essential that the QA system (1) ensures that
the reported results are accurate, (2) identifies any practices that are potential sources of error
and (3) ensures that appropriate corrective actions are initiated.
QA for sputum smear microscopy includes the following:

· Quality control (QC);
· External quality assessment (EQA); and
· Quality improvement (QI).
6-1. Objective
The general objective of quality assurance in sputum microscopy is to ensure high
quality of sputum smear examination services in the NTP.
6-2. Policies
a) In the health facility, the NTP medical technologist/microscopist shall maintain quality
routine work or quality control (QC).
b) Provincial/City health offices are responsible for the external quality assessment
(EQA) which includes blinded slide rechecking and on-site evaluations.
c) CHDs and other regional TB laboratories shall support provincial/city QA centers.
d) The National TB Reference Laboratory (NTRL) has a key role in ensuring the
quality of the services provided by microscopy centers.
e) (For procedures and forms, refer to the Manual on the Quality Assurance for
Sputum Smear Microscopy, NTP, March 2004.)

V. Guidelines for Implementation of the
NTP by Private Physicians and Private
Health Facilities
1. Introduction
P
RIVATE physicians in the Philippines have not always been in agreement with the
Department of Health regarding the management of tuberculosis. However, since
the formation of the Philippine Coalition Against Tuberculosis (PhilCAT) in 1994 and
the development of the Philippine Clinical Practice Guidelines on the Diagnosis, Treatment and
Control of Pulmonary Tuberculosis (National Consensus on TB) in 2000, representatives of
the public and private sectors have worked closely to unify the approach to managing TB in
the country.
The 1997 National TB Prevalence Survey highlighted the importance of private physicians in
TB control in the Philippines when it showed that 46 percent of individuals with TB-like
symptoms who sought health care consulted private physicians. This was greater than the 30
percent that consulted at public health centers.
Despite the large proportion of TB patients consulting private physicians, the appropriate
infrastructure for TB control has yet to be established in the private sector. This refers to a
system using standardized diagnostic criteria and supervised treatment regimens, recording
and reporting and access to an uninterrupted supply of anti-TB drugs, all of which are included
in the World Health Organization-recommended strategy of Directly Observed Treatment,
Short-course (DOTS).
These guidelines developed in 2002 hope to link private physicians more closely to the National
TB Program by aligning the diagnostic criteria and treatment regimens used and by promoting
DOTS. In so doing, these guidelines will lay the foundation for the TB control infrastructure in
the private sector. These guidelines cover the management of TB in older children, adolescents
and adults. A multi-sectoral “Task Force for TB in Children” was organized by the DOH,
which included representatives from the private sector. The Task Force developed
recommendations for the Management of TB in Children, which now requires validation in
CHAPTER V : GUIDELINES FOR IMPLEMENTATION OF THE NTP BY PRIVATE PHYSICIANS

AND HEALTH FACILITIES 41
pilot projects. Once validated, these recommendations may potentially be integrated into the
comprehensive policy for TB control.
2. Policies and Guidelines

2-1. Case Finding (Diagnosis)
Case finding is the identification and diagnosis of TB cases among individuals with
suspected signs and symptoms of TB. Sputum examination for acid-fast bacilli (AFB)
or direct microscopy is the most important diagnostic test to request for a patient
clinically suspected to have PTB. It is reliable, economical and may be made available
even in remote areas where a microscopy center could be organized. Patients must be
made aware of the importance of sputum quality. The chances of obtaining a good
specimen are better when patients are supervised either by their doctor or by laboratory
personnel. At least three sputum specimens should be submitted for direct microscopy.
Ideally, specimens should be submitted to the laboratory within 24 hours from the time
of collection.
A chronic cough, significant weight loss, sweat and chills, fatigue and body malaise,
and fever are found in over half of patients suffering from PTB. These clinical signs and
symptoms should raise the possibility of PTB. Only a chronic cough consistently indicates
PTB over non-TB respiratory disease. No other sign is discriminative for PTB. PTB
does not have to be symptomatic. Even among culture proven PTB cases, a small
percentage (5-14 percent) may have no symptoms. Asymptomatic PTB is more
frequently observed in older age groups.
Approach to an asymptomatic individual suspicious for TB is more difficult. This scenario

is often encountered in persons who had chest x-rays taken in relation to employment
or for other reasons like an annual check-up or part of a pre-operative evaluation. A
single chest film can only suggest the presence of PTB. It cannot confirm the diagnosis
nor establish disease activity; the physician should ask for and compare previous CXR
films. Any previous treatment for PTB should be asked, the regimen as well as the
treatment duration. The patient should be subjected to sputum collection.
N.B.Refer to Annexes 2- 6, pages 84 to 88.
a) Policies:
1) Direct sputum examination shall be the primary diagnostic tool for case finding.
· Patients with TB symptoms shall be made to undergo smear examination

regardless of whether they have available x-ray results or whether they
are suspected of having extra-pulmonary TB. Three sputum specimens
shall be collected.
· Individuals without TB symptom, but who for some reasons (e.g. screening
for employment, annual employment check-up, medical clearance for a
surgical procedure, etc.) obtained a chest x-ray which shows abnormalities
consistent with pulmonary TB, shall also be subjected to sputum
examination. Sputum induction may be done as necessary.
· No diagnosis of TB shall be made based on the result of x-ray examination
alone. Skin test for TB infection (PPD) should not be used as a basis for
the diagnosis of TB in adults.
2) Only trained medical technologist or NTP microscopist shall perform sputum

examination.
2-2. Case Holding (Treatment)

Case holding does not only refer to treatment per se, but also means making sure that
the TB patient religiously takes all their anti-TB drugs everyday without fail until they
complete their treatment. Adherence to treatment regimen is a key factor in cure and
success. The strategy developed to ensure treatment compliance is Directly Observed
Treatment (DOT). It is one of the five key elements of the DOTS strategy, which is the
WHO recommended policy package for TB control. This means that a responsible
person, referred to as the treatment partner, will observe or watch the patient take the
correct medications daily during the course of treatment.
With direct observation of treatment, the patient doesn’t bear the sole responsibility of
adhering to treatment. The treatment partner may be a health worker or a community
member who is willing, trained, responsible, acceptable to the patient and accountable
to the TB control services. Actual observation of treatment can be done in any accessible
and convenient place (e.g. health facility, treatment partner’s house, patient’s
place of work, patient’s house) as long as the treatment partner can effectively ensure
the patient’s intake of the prescribed drugs and monitor his/her reactions to the drugs.
a) Policies:
1) Treatment of TB cases shall consist of at least four anti-TB drugs during the
intensive phase and two (2) drugs in the maintenance phase.
· Symptomatic PTB – Treatment to be given shall be the same as in NTP
(see Annex 7: Treatment Regimens, page 89).
· Asymptomatic PTB – Category III (see Annex 7: Treatment Regimens,
page 89).
· Extrapulmonary TB – as in NTP.
N.B. For a patient classified as relapse or failure case, the culture and sensitivity
test should be done by a reputable laboratory whose fees are affordable for
the patient. This, however, is not reimbursable by PhilHealth or the National
TB Program.
2) Drugs to complete the full course of treatment shall be ensured for each patient.
3) Direct observation of treatment shall be adopted in the treatment of a TB

patient. Private physicians who are unable to provide direct supervision
themselves are encouraged to refer the patient to the nearest DOTS center or
to establish a new DOTS service in their community.
CHAPTER V : GUIDELINES FOR IMPLEMENTATION OF THE NTP BY PRIVATE PHYSICIANS

AND HEALTH FACILITIES 43
4) Sputum follow-up examination shall be done to all TB cases, as scheduled to
monitor treatment response (see Annexes 10-A and 10-B, pages 93-94).
Latent TB Infection (LTBI): The diagnosis and treatment of LTBI is presently
NOT a priority of the NTP or this comprehensive policy for TB control. If a
private physician wishes to carry out such diagnosis and treatment, neither the
National TB Program nor the Philippine Health Insurance Corporation is
authorized to subsidize it at this time.
2-3. Recording and Reporting

The recording and reporting system is used to systematically evaluate patient progress
and treatment outcome, as well as overall program performance. The system consists
of: a laboratory register that contains a log of all patients who have had a smear test
done; patient treatment cards that detail the regular intake of medication and follow-up
sputum examinations; and the TB register, which contains the list of patients starting
treatment and the record of their individual and collective progress towards cure. The
quarterly reports give managers timely, concrete indicators of achievement or problems
requiring action.
a) Policies:
1) Records and reports shall be adopted from the National TB Control Program.
2) The prescribed NTP treatment card shall be used for each TB patient for
individual assessment of treatment response of patient and as a proof of
treatment of TB patients.
3) The standard NTP referral form shall be used in referring TB symptomatics
for diagnosis or for treatment to a public health facility.
4) Patients diagnosed with TB disease shall be reported to the DOH, the LGUs,
or other bodies designated to manage the National Data Base.
VI. Guidelines for Implementation
of the NTP by Other Government
Agencies
1. Introduction
T
HE problem of tuberculosis is a national concern. Both the private sector and
government agencies, other than the Department of Health, play a vital role in the
control of tuberculosis. Tuberculosis case finding and treatment services are delivered
largely through the health services provided by the local government administered rural health
units (RHUs) and health centers nationwide under the supervision of the Department of Interior
and Local Government (DILG). On top, other government agencies - e.g., Department of
Education (DepEd) and Department of National Defense (DND)– also provide tuberculosis
case finding and treatment services to their employees and dependents. Tuberculosis disease
may also be occurring among the employees of other government agencies such as DSWD,
DOJ, DAR, DA, DOST, NEDA and NCIP as well as among their dependents and clienteles,
hence the need for the establishment of TB Control Program in the said agencies.
One of the problems identified in the implementation of the tuberculosis control program by
government agencies is the lack of uniformity in the procedures applied for case finding and
treatment. This lack of uniformity often times has resulted in both inaccurate diagnosis and
poor treatment. Standardizing the approach to tuberculosis control will make the program
more efficient. This will result in accurate diagnosis of TB disease, proper treatment
regimentation, higher cure rates and ultimately a greater reduction in the TB problem.
A government agency could participate in the implementation of the National Tuberculosis

Control Program (NTP) in various ways. First is by establishing a DOTS Center, which will
provide two TB services: (1) case finding by direct sputum microscopy and (2) TB treatment
using DOT (Direct Observed Treatment) to employees, dependents and their clientele.
Secondly, those agencies that may not be able to set up a DOTS Center, employees, dependents
and clientele with symptoms of TB may establish referral links with the nearest local government
DOTS center for sputum microscopy and/or proper treatment.
CHAPTER VI : GUIDELINES FOR IMPLEMENTATION OF THE NTP BY GOVERNMENT AGENCIES 45

Moreover, a government agency, like DOLE, may also participate in the NTP by developing,
implementing and monitoring policy and guidelines in relevant settings like the workplace.
2. Profile of Participating Agencies

2-1. Department of Education (DepEd)
DepEd through its School Health and Nutrition Center (SHNC) provides effective
health and nutrition services to their students, teachers and non-teaching personnel.
The SHNC takes charge of the over-all management of the Integrated School Health
and Nutrition Program (ISHNP), which is a comprehensive education and service
package delivered to the schools, eventually to the homes and communities. The main
objective of ISHNP is to promote, protect and maintain the health and nutritional
status of students and school personnel through the provision of various health and
nutrition services and education.
Among the communicable disease programs presently implemented by DepEd is

tuberculosis control. The program components implemented are case finding, treatment,
information education and communication (IEC), capability building, and monitoring
and evaluation. TB case finding and treatment services are provided to elementary,
secondary teachers and non-teaching personnel through the DepEd Division and School
Clinics nationwide.
2-2. Department of Labor and Employment (DOLE)

DOLE is the agency mandated to formulate policies, implement programs and serve
as the policy-coordinating arm of the Executive Branch in the field of labor and
employment. Its vision is to ensure decent and productive employment for every
Filipino worker. Its primary responsibilities are: (1) the promotion of gainful employment
opportunities and the optimization of the development and utilization of the country’s
manpower resources; (2) the advancement of worker’s welfare by providing for just
and humane working conditions and terms of employment; and (3) the maintenance of
industrial peace by promoting harmonious, equitable, and stable employment relations
that assure equal protection for the rights of all concerned parties.
An attached agency to the DOLE is the Occupational Safety and Health Center (OSHC)
which is responsible for undertaking: (a) continuing research and studies on occupational
safety and health; (b) the development and implementation of programs, policies and
standard in the field of occupational safety and health; and (c) medical examination of
workers and necessary testing for safe use of personal protective and other safety
devices for the prevention of occupational accidents and diseases. In particular, OSHC
assists government agencies and institutions in the formulation of policies and standards
on occupational safety and health and other matters related thereto and issue technical
guidelines for the prevention of occupational diseases and accidents.
2-3. Department of Interior and Local Government (DILG)
authority over 108,000 members of the Philippine National Police (PNP), the National
Police Commission (NPC), the Bureau of Fire Protection, the Philippine Public Safety
College and the Bureau of Jail Management and Penology.
The main function of DILG is to oversee and monitor the implementation of the Local
Government Code of 1991, enhance the capabilities of the LGUs for self-governance,
and implement plans and programs for local autonomy. As part of its overall function,
DILG undertakes relevant measures regarding fire protection and jail management
and penology; ensure humane treatment and rehabilitation of inmates. Among the relevant
measures that may be undertaken, is tuberculosis control among the members of the
Philippine National Police, the inmates in jails nationwide and employees and clientele
of the other attached agencies.
A Memorandum Circular 98-155 had been signed which mandates the local government
units to implement DOTS strategy in the control of TB in their respective areas.
2-4. Department of National Defense (DND)

DND was formally organized on November 1, 1939 pursuant to Executive Order
No. 230, to implement the National Defense Act (Commonwealth Act No. 1) passed
by the National Assembly on December 31, 1935 and Commonwealth Act No. 340
creating the Department.
DND is tasked with the responsibility of providing the necessary protection of the
State against external and internal threats; directing, planning and supervising the National
Defense Programs; and performing other functions as may be provided for by law.
It exercises supervision over the Armed Forces of the Philippines (AFP), the Office of
Civil Defense (OCD), the Philippine Veterans Affairs Office (PVAO), the National
Defense College of the Philippines (NDCP), and the Government Arsenal (GA).
Its mission is to provide and maintain the conditions of security, stability and peace and
order conducive to economic growth and national development. It envisions a modern,
technology-driven national defense force in the 21st century capable of providing a
secure and stable internal and external security environment.
Health service delivery is one of the major concerns in effectively realize this vision.
Health service is primarily distributed to 3 categories of beneficiaries, namely: the
soldiers, veterans and civilian employees, to include their dependents. Each group is
provided with healthcare facilities to address their medical concerns.
The AFP has its own medical system, under the supervision of the Office of the Surgeon
General (OSG), that caters to the health needs of the soldiers and their dependents.
The three major services of the AFP namely: Philippine Army (PA), Philippine Navy
(PN), and the Philippine Air Force (PAF) have their own Chief Surgeon’s Office that
supervises the delivery of medical services to the respective units. The flagship medical

facility in the AFP is the AFP Medical Center where V. Luna General Hospital is
located. This is allied with 31 other hospitals (8 PAF, 3 PN, 9 PA and 11 AFP Wide
Service Support Units) and 28 medical dispensaries strategically located around the
archipelago.
Catering to the country’

s living heroes is the sprawling and tranquil Veterans Memorial
Medical Center (VMMC) in Quezon City. Supervised by the Philippine Veterans
Affairs Office, this medical facility addresses the health concerns of the more than
240,000 veterans, AFP retirees and their dependents. The Office of the Secretary of
National Defense (OSND) Clinic also keeps the Department employees’ and their
dependents health in check. And finally, the Government Arsenal has its own hospital
facilities.
2-5. Department of Justice (DOJ)

The different agencies and offices of the DOJ serve as the instrumentalities by which
programs and services instituted by the Department are delivered to the people. Among
the eleven (11) agencies under the DOJ is the Bureau of Corrections that is charged
with custody and rehabilitation of national offenders sentenced to serve a term of
imprisonment of more than three (3) years. Among its mandate is to provide humane
treatment by supplying the inmates’ basic needs and implementing a variety of
rehabilitation programs designed to change their pattern of criminal and anti-social
behavior. Headed by a Director, the Bureau has a strength of 2,362 employees, 61
percent of whom are custodial officers, 33 percent are administrative personnel and 6
percent are members of the medical staff.
The Bureau of Correctional has seven (7) operating units located nationwide, namely:
The New Bilibid Prison in Muntinlupa, the Correctional Institution for Women in
Mandaluyong City, Iwahig Prison and Penal Farm in Puerto Princesa, Sablayan Prison
and Penal Farm in Occidental Mindoro, San Ramon Prison and Penal Farm in
Zamboanga City, Leyte Regional Prison in Abuyog, Leyte and Davao Prison and
Penal Farm in Panabo, Davao Province. A TB control program among inmates in the
New Bilibid Prison in Muntinlupa is presently being implemented.
2-6. Department of Social Welfare and Development (DSWD)

DSWD is the lead government agency in formulating national social welfare and
development policies, plans and statistics, especially as these relate to family
development and poverty groups. DSWD is an advocate for social welfare and
development concerns, to include disadvantaged families, children/youth, women, senior
citizens, persons with disabilities and similarly situated individuals.
DSWD provides assistance to local government units, non-government organizations,

and other members of civil society in effectively implementing programs including health,
projects and services that will alleviate poverty and empower disadvantaged individuals,
families and communities for an improved quality of life. Among the attached agencies
are: the Council for the Welfare of Children, Inter-country Adoption Board and the
National Council for the Welfare of Disabled Persons.
2-7. Department of Agriculture (DA)
The DA is the principal agency of the Philippine government responsible for the promotion
of agricultural development and growth. In pursuit of this, it provides the policy
framework, helps direct public investments, and in partnership with local government
units (LGUs) provides the support services necessary to make agriculture and agri-
based enterprises profitable and to help spread the benefits of development to the
poor, particularly those in rural areas. There are 21 agencies affiliated with the DA and
these include the National Food Authority, the National Nutrition Council, the National
Tobacco Administration, and the Philippine Coconut Authority.
2-8. Department of Agrarian Reform (DAR)

DAR is the principal agency responsible for implementing the Comprehensive Agrarian
Reform Program (CARP). Its mission is to improve land tenure through better access
to and more equitable distribution of land and the fruits thereof. It shall also enhance
the welfare and promote the development of Program beneficiaries through coordinated
delivery of essential support services. DAR has a grand total workforce of 13,574,
974 from the central office and 12,590 from Regions I to XII including CAR and
CARAGA. DAR also has a total of 1,452 Agrarian Reform Communities (ARCs)
and a grand total of 749,275 Agrarian Reform beneficiaries.
2-9. Department of Science and Technology (DOST)

DOST is the premier science and technology body in the country charged with the
twin mandate of providing central direction, leadership and coordination of all scientific
and technological activities. In pursuit of its vision of a competent and competitive
science and technology community with a social conscience, DOST works with the
S&T community.
DOST has five (5) Sectoral Planning Councils, seven (7) Research and Development
Institutes, seven (7) Service Institutes, two (2) Collegial bodies, fourteen (14) Regional
Offices and seventy three (73) Provincial S&T Centers.
2-10. National Economic and Development Authority (NEDA)

NEDA is the country’ s independent social and economic development planning and
policy coordinating body. NEDA’ s task is to formulate development plans and ensure
that plan implementation achieves the goals of national development. Five government
agencies are attached to the NEDA for purposes of administrative supervision. These
are: Tariff Commission (TC), Philippine National Volunteer Service Coordinating Agency
(PNVSCA), National Statistical Coordination Board (NSCB), National Statistics
Office (NSO), and Statistical Research and Training Center (SRTC). Moreover, the
Philippine Institute for Development Studies (PIDS) is attached to the NEDA for policy
and program coordination.
The following committees as well as sector staffs are tasked to look into the specific
concerns of the NTP: a) Social Development Staff (SDS) – evaluates program and

projects, facilitates the inclusion of program and projects in the Mid-Term Public
Investment Program (MTPIP), including those in support of the NTP; b) Project
Monitoring Staff (PMS) – monitors the progress of the implementation of ODA-
assisted TB Control Program, identifies the bottlenecks and proposes solutions to
problems of implementation, prepares integrated reports on the status of approved
TB Control Project; c) Trade, Industry & Utilities Staff (TIUS) – provides technical
and legal advise and assistance in the formulation and implementation of developing
policies, plans and programs particularly on request for inclusion in the National Priority
Plan to avail of full tax deductibility of donations on TB control Program and Projects;
and d) Regional Development Coordination Staff (RDCS) & Regional Offices –
monitors and evaluate regional policies, plans and programs related to the NTP.
2-11. National Commission on Indigenous Peoples (NCIP)

NCIP is an agency created under R.A. 8371, otherwise known as the Indigenous
Peoples Rights Act. Its mandate is to protect and promote the interest and well being
of the indigenous peoples with due respect to their beliefs, customs, traditions and
institutions. As such, it shall serve as the primary government agency responsible for
the formulation and implementation of pertinent and appropriate policies, plans and
programs to carry out the policies set forth in the new law.
It caters to more than 12 million indigenous peoples of 110 ethnic tribes spread out all
over the country. It has 12 Regional Offices, 46 Provincial Offices, and 108 community
service centers.
NCIP intends to support the NTP through TB health education and information
dissemination and referral of TB patients to the nearest health center/rural health unit/
barangay station for case finding and treatment.
3. Policies and Guidelines

3-1. On Case Finding
Case finding is an essential component in the control of tuberculosis. Its objective is to
identify the sources of infection in the community, that is to find the persons discharging
the tubercle bacilli and initiate treatment to render them non-infectious initially and
ultimately cure them (see Annexes 2-6, pages 84 to 88).
Among the agencies’ employees, identification of patients with TB disease may be

done during consultation at the agency clinic for those manifesting TB symptoms or
during the annual check-up. All those found with TB symptoms or those with Chest X-
ray shadows consistent with active PTB during annual check up but are asymptomatic
shall be made to undergo sputum microscopy at the agency clinic by a trained medical
technologist/microscopist. If the agency does not have the facility for sputum
examination, a referral may be made to the nearest microscopy center (Rural Health
Unit (RHU)/Health Center (HC)/Health Maintenance Organization (HMO)) or any
accredited DOTS Center.
Other clienteles of the different agencies may be referred to the agency clinic or to
other health facility nearest them.
a) Policies and Guidelines:
1) Direct Sputum Microscopy shall be the primary diagnostic tool in NTP case
finding.
· Employees consulting the agency clinic, e.g., DOJ, DepEd, DILG (PNP,
BJMP, BF), DA, DAR, DND (AFP & VMMC) with signs and symptoms
of TB shall be made to undergo sputum examination regardless of whether
they have available chest x-ray results.
The employee shall be referred for sputum examination to the nearest

health facility (Rural Health Unit (RHU)/Health Center (HC)/ Health
Maintenance Organization (HMO)) for agencies without a facility for
sputum microscopy (e.g., DOST, DSWD, NEDA, and NCIP). Referral
shall be made using the appropriate NTP form (see Annex 18-B: NTP
Laboratory Request Form for Sputum Examination, page 108).
· Employees found to have chest x-ray findings compatible with TB during

their annual check-up whether symptomatic or asymptomatic shall also be
referred to the agency clinic e.g. DOJ, DepEd, DILG (PNP, BJMP, BF),
DA, DAR, DND (AFP and VMMC) or the nearest health facility for
sputum microscopy in the case of agencies with no facility of their own
e.g. DOST, DSWD, NEDA, NCIP. For those without cough, induction
of the same shall be done.
· Employees of government agencies without a treatment facility or clinic,

nor annual medical check-up benefit who develop TB symptoms, shall be
referred to the nearest health facility for diagnosis. Referral shall be made
using the appropriate NTP form (see Annex 18-B: NTP Laboratory
Request Form for Sputum Examination, page 108).
· Dependents of employees (e.g. DND) and clientele (persons served by

the other government agencies e.g. DSWD, DA, DAR) with symptoms of
TB shall be referred to the nearest health facility for diagnosis. Referral
shall be made using the appropriate NTP form (see Annex 18-B: NTP
Laboratory Request Form for Sputum Examination, page 108).
2) Only an adequately trained medical technologist or NTP microscopist shall

perform sputum examination (smearing, fixing and staining of sputum specimens,
reading the smear). The procedure for identification of TB symptomatics,
collection and transport of sputum specimen, and smearing shall follow the
NTP procedures (see Chapter IV. NTP Core Policies and Procedures, pages
24-27).

· Training of medical technologist/microscopist shall be coordinated with
the TB Unit-Infectious Disease Office, Department of Health.
· Training of the agency medical technologist/microscopist shall be
undertaken by the National TB Reference Laboratory, Research Institute
of Tropical Medicine, Department of Health at Alabang, Muntinlupa, Metro
Manila or any other laboratory designated by the Department of Health.
3-2. On Case Holding

Case holding does not only refer to treatment per se, but also means making sure that
the TB patient religiously takes all his/her anti-TB drugs everyday without fail until he/
she completes treatment. This would ensure cure of TB patients, prevent deaths due
to TB and most importantly prevent multi-drug resistance.
The DOTS strategy is a comprehensive strategy to ensure the correct diagnosis and
cure of TB patients and treatment compliance. It has the following five elements:
· Political Commitment – funding and support from the local executives and other
government agencies and private sectors to execute.
· Microscopy – to confirm whether or not TB bacilli are present in the sputum.
· Drugs for TB – complete drug requirement for each patient should be available
at all times in the health facility.
· DOT (Directly Observed Treatment or Supervised Treatment) – a health worker
called a “Treatment Partner” is assigned to each patient to make sure that the
patient is swallowing all his/her drugs everyday until completion of treatment. DOT
is just one of the components of the strategy.
· Reporting Books – part of the system that documents the progress of each
patient until totally cured.

1) Treatment of TB cases shall consist of at least four anti-TB drugs during the
intensive phase and two drugs in the maintenance phase. Treatment Regimen
shall follow the recommendation of the NTP (see Annex 7: Treatment
Regimens, page 89, and Annex 8-A: Drug Dosage and Adjustment and Annex
8-B: FDC Composition, page 90).
2) DOT (Directly observed treatment or supervised treatment) shall be adopted
in the treatment of TB patients. It shall be done at the agency clinic, supervised
by the clinic nurse/attendant. On Saturdays, Sundays and Holidays, anti-TB
drugs shall be taken at home by the patient himself/herself supervised by a
family member. For agencies without treatment facility (e.g. DOST, NEDA)
patients shall be referred for DOT to the nearest DOTS center.
· Each participating government agency that will be treating their own patients
(e.g., DepEd, DILG-PNP, DA, DAR, DSWD, DND, and DOJ) shall
ensure that all patients started on treatment are assured of a complete
course of anti-TB drugs.
Patients of agencies with no facility to do DOT treatment of their employees
shall be referred to the health facility nearest the patient.
For dependents of employees and clientele of the different agencies who
need treatment shall likewise be referred to the health facility nearest him/
her.
· No newly diagnosed patient shall be admitted for treatment if there is
shortage of drugs in the clinic. Borrowing of drugs from the ongoing patients
shall not be allowed since the arrival of the next batch of drugs is not clear
/ guaranteed.
· Daily intake of drugs shall be recorded in the treatment card and
identification card of the patient as proof of treatment.
· Health Education shall be done during initiation of treatment and on
continuous basis during the daily supervision of treatment. Messages shall
include the importance of daily intake of drugs and completing treatment.
It should also include the schedule of sputum follow-up examination as
well as its importance. Information about the possible side effects (drug
reaction) shall also be included (see Annex 12: Guide in Managing SCC
Drugs Side Effects, page 96).
· Sputum follow-up examination shall be done to all TB cases as scheduled
to monitor treatment response (see Annex 10-A: Schedule of Sputum
Smear Follow-Up Examination for Category I and Annex 10-B: Schedule
of Sputum Smear Follow-Up Examination for Categories II and III, page
93 and 94).
· Patients who fail to come to the clinic for daily administration of treatment
shall be followed-up / reminded, for him/her to report back to the clinic
within two (2) days during the intensive phase and within a week during
the maintenance phase.
· Treatment outcome shall be determined and analyzed for each patient
(see page 32 for the various treatment outcomes and definition).
3-3. On Recording and Reporting

a) Participating government agencies (e.g., DepEd, DILG, DA, DAR, DND, and
DOJ) shall adopt the NTP records and reports in the implementation of the TB
program (see Annexes 18-A to 18-M, pages 107 to 126).
b) Treatment Card shall be used for each TB patient for individual assessment of
treatment response of patient and as proof of treatment of TB patients (see Annex
18-D: NTP Treatment Card, page 113).
c) Identification Card (ID) shall be provided each TB patients on treatment (see
Annex 18-E: NTP Identification Card, page 116).
d) A register of TB symptomatic called the NTP Laboratory Register (see Annex 18-
C: NTP Laboratory Register, page 111) and NTP TB Case Register (see Annex
18-F: TB Register, page 118) for TB patients put to treatment shall be maintained
for program assessment and individual’s treatment outcome.

e) The standard referral form shall be used in referring TB symptomatics for diagnosis
and of TB patients for continuation of treatment in another facility whenever
applicable. (Refer to Annex 18-G1: PPMD Referral Form / NTP, page 120).
f) Quarterly report on New Cases and Relapses (see Annex 18-J: Quarterly Report
on New Cases and Relapses of Tuberculosis and on Drug Inventory and
Requirement, page 125) and Treatment Result (see Annex 18-L: NTP Quarterly
Report on the Treatment Outcome of Pulmonary TB Cases, page 127) shall be
sent to the respective Regional Health Office. For central office clinics, such reports
shall be sent to the TB Unit, Infectious Disease Office of the DOH as these shall
be the basis for drug allocation and inclusion in the case notification on tuberculosis.
3-4. On Training
Training of health personnel of all agencies participating in the implementation of the
NTP is an important support component of the program. A good knowledge of the
tuberculosis control program policies, guidelines and procedures is necessary to
implement an effective TB program. Health workers such as doctors, nurses and
midwives should have the knowledge and skills to identify TB symptomatics, give the
appropriate treatment regimen, monitor treatment response, and maintain the necessary
NTP records and reports. Medical technologists and/or TB microscopists should be
skilled in sputum microscopy and maintain its quality. Barangay Health workers should
likewise be trained on identification of TB symptomatics as well as on DOT. Without
these knowledge and skills, there will be a poor program implementation, which may
ultimately lead to non-cure of TB patients and possible development of drug resistance.

1) Participating government agencies (DepEd, DILG-PNP, LGU, DA, DAR,
DSWD, DND, and DOJ) shall conduct NTP orientation at their regional/
provincial offices in coordination with the DOH Regional Health Office whenever
necessary.
2) Participating government agencies (DepEd, DILG-PNP, LGU, DA, DAR,
DND, DOJ) shall conduct sputum microscopy training for medical technologists
and nurses (DepEd) in coordination with the Regional and TB Unit, Central
Office of the DOH.
3) DepEd shall conduct orientation of school principal and administrators and all
school health personnel on DOTS Strategy.
4) DepEd shall conduct communication skills training on TB messages for health
personnel.
3-5. On Monitoring and Evaluation

Monitoring is a process of collecting and analyzing information about the program
implementation. It also involves dissemination of and providing feedback on findings
and recommendations to improve program implementation. Evaluation is the assessment
of the program focusing on its effectiveness and impact (see “Monitoring, Supervision
and Evaluation”, page 38).
a) Policies and Guidelines (DepEd, DOLE, DILG, DA, DAR, DND, DOJ):
The Technical Working Group Member of each agency shall:

1) Monitor and evaluate the NTP program in their respective agency.
2) Monitor implementation of policy and program on TB prevention and control
in the workplace (see Annex 22-A: TB Benefit Form (DOLE Guidelines),
page 152).
3) Conduct physical inventory of drugs and other logistics necessary for the
program implementation and issue requisition for the needed logistics quarterly,
if applicable.
4) Ensure accomplishment and analysis of the quarterly reports (on casefinding
and cohort analysis) by their respective regional offices, and routing of the
same to the corresponding Regional Health Office on the second month of the
succeeding quarter. Reports of the agencies at the central level shall be sent
directly to the TB Unit, Infectious Disease Office of the DOH.
5) Conduct annual evaluation of the program implementation in collaboration with
the Regional Health Office (NTP Coordinators).
6) Participate in the monitoring of the ODA-assisted TB project implementation
(NEDA).
3-6. Health Education and Advocacy

a) Develop modules for elementary and secondary students on the prevention and
control of tuberculosis. (DepEd)
b) Support information campaign of the programs. (all agencies)
c) Develop campaign materials (DepEd, DILG-LGU) and other agencies.
d) Conduct health education and information dissemination about tuberculosis disease,

its prevention and control to their respective clientele. (all participating agencies)

DIAGRAM OF NTP IMPLEMENTATION
GOVERNMENT AGENCIES
Employees Clients
Dependents
With shadows suggestive

of TB With TB symptoms
(Annual Checkup)
Sputum Examination
Agency Clinic Health Facility

(DOTS Center) (DOTS Center)
TB Disease
Directly Observed Treatment
Agency Clinic Health Facility

(DOTS Center) (DOTS Center)
VII. TB Benefits Policy
of the ECC, SSS, and GSIS
1. Introduction
T
UBERCULOSIS is listed among the occupational diseases that may be compensable
under the Employees’ Compensation (EC) Program of the Employees’
Compensation Commission (ECC), subject to applicable criteria for its diagnosis and
compensability.
The ECC program provides compensation package for public and private sector employees
and their dependents in the event of work-related contingencies. The primary aim of the EC
program is to help workers and their dependents, in the event of work-related injury, sickness,
or death, to promptly receive meaningful and adequate income benefits, medical or related
services, and rehabilitation services.
The ECC program is administered by the Social Security System (SSS) in the case of workers
in the private sector, and by the Government Service Insurance System (GSIS) in the case of
workers in the public sector.
In addition to the ECC program of ECC, the SSS also implements its Social Security Protection
program which, under RA 8282, or the Social Security Act of 1997, basically provides for the
replacement of income lost in times of sickness, disability, and death. SSS benefits for sickness,
disability, and death applies to injuries or diseases that are work-related and those that are not
work-related. In the case of work-related injuries, SSS members may claim for both ECC
program benefits and SSS program benefits.
The GSIS also provides for the replacement of income lost in times of sickness and disability
as well as other benefits due to an illness as provided for under RA 8291, or the GSIS Act of
1997. By virtue of its provision for mutual exclusiveness of benefits, however, GSIS members
may not claim for both EC program benefits and GSIS program benefits for the same illness.
Among the conditions to entitlement are the following: (a) has been duly reported to the System;
CHAPTER VII : TB BENEFITS POLICY OF THE ECC, SSS AND GSIS 57

(b) sustains the disability as a result of the TB disease; and (c) the System has been duly
notified of the sickness which caused his disability.
2. Policies, Benefits and Procedures for Claims

2-1. Employees Compensation Program
a) Policy:
1) The ECC shall provide Initial Temporary Total TB Disability (TB Sickness)
for 30 days to be given in the form of income benefit and reimbursement of
medical expenses to qualified GSIS and SSS members diagnosed with work-
connected TB disease. The member may apply for extension of this benefit to
a maximum of 90 days extension if he/she meets the acceptable criteria.
2) The ECC shall provide Permanent TB Disability Benefit to separated GSIS

and SSS members with work-connected TB disease who shall remain to be
sputum positive at the end of 120 days and/or with impairment classification of
class 2 or higher (see Annexes 20-A to 20-C, pages 129 to 130). Those with
impairment classification of Class 1 and with at least mildly impaired respiratory
function by spirometry or peak flow determination shall also be entitled to
Permanent Disability Benefit. Qualified members with TB of extrapulmonary
site may apply for Permanent TB Disability Benefit based on the severity of
functional impairment of the organ involved (Annex 21, page 131).
b) EC Program Benefits:
1) Temporary Total Disability Benefit. This is an income benefit paid to an

eligible GSIS/SSS member who suffers work-connected TB starting on the
very first day. It shall not exceed 90% of the employee’s daily salary credit as
determined by the System. Presently, this income benefit is set at not more
than Pesos 200 per day for private workers and Pesos 90 per day for
government employees to be paid beginning on the first day the worker is
diagnosed with TB but shall not be paid longer than 120 days. At the same
time, the member with a work-connected TB is entitled to reimbursement of
his/her medical and related expenses.
· Requirement for Eligibility:
An eligible SSS member is qualified to avail of the EC benefit simultaneously

with benefits under the regular social security program of SSS regardless
of whether he/she has or has not exhausted his/her sick leave credits if he/
she satisfies the following conditions:
i. He/she has been duly reported to the System
ii. He/she has work–connected tuberculosis
iii. The system has been duly notified of his/her TB disease. His/her
employer shall be liable for the benefit if the illness occurred before
the employee is duly reported to the System.
· Medical Requirements for Entitlement to EC-TTD:
i. Initial Temporary Total TB Disability (TB Sickness) Benefit

Requirements:
- Pulmonary Tuberculosis:
• Attending physician report (initial portion of the TB Benefit
Form
• Results of 3 separate sputum examinations for AFB or culture
• Chest x-ray result with findings consistent with pulmonary TB
diagnosis
• Verification of TB diagnosis by GSIS/SSS physician
- Extrapulmonary Tuberculosis:
• Referral from attending physician with history and physical

examination
• Positive TB culture result of fluid or tissue from involved site
or histological evidence from the site involved
• Certification from the attending physician attesting to the
diagnosis of TB of the extrapulmonary site concerned
• Verification of the TB diagnosis by GSIS/SSS physician
Entension of Temporary Total TB Disability (TB Sickness) Benefit

Package. An extension of 30 days beyond the initial TTD benefit
already granted may be given to a member with TB who fulfills the
following requirements:
- Pulmonary TB:
Still sputum (+) or becomes sputum positive on the basis of three
sputum follow–up examinations at least 3 weeks from the previous
examination or impairment classification of class 1 or higher.
- Extrapulmonary TB:
A certification from the attending physician that the patient has
extrapulmonary tuberculosis and still needs time off from work
while continuing treatment.
2) Permanent Partial Disability Benefit. This is a cash benefit paid to an EC

beneficiary for his TB who at the end of 120 days TTD is found to be partially
disabled due to his TB disease. It is given beginning the end of his TTD Benefits
and shall continue for a period as may be warranted by his/her medical condition
as determined by the ECC rating on compensation benefits. The benefits include
reimbursement of his/her medical and related expenses which may be enjoyed
simultaneously with benefits under the social security program. The monthly

income benefit that is given for the PPD will be suspended if the employee
recovers from his/her partial disability or fails to submit quarterly medical
progress report certified by his/her attending physician. Failure to submit the
quarterly report will mean suspension/forfeiture of the said benefit based on
the policy on non-submission of medical progress report.
A GSIS/SSS member is qualified to avail of this benefit from the ECC if

he/she satisfies the following conditions:
i. He/she has been duly reported to the System;
ii. He/she sustained the permanent partial disability as a result of a work
– connected TB disease; and,
· Medical Requirements for Entitlement to EC - PPD:
i. Pulmonary Tuberculosis:
- He/she met the criteria for PTB and has proof of at least 100 days
of documented treatment
- He/she is still sputum positive at the end of the Temporary Total
Disability
- He/she has an impairment classification of Class 1 to 3 (Annexes
20-A to 20-C, pages 129 to 130) and Functional Independence
Measure (FIM) classification for permanent partial disability
(Annex 21, page131).
ii. Extrapulmonary Tuberculosis:

- He/she met the criteria for extrapulmonary TB and has proof of
at least 100 days of documented treatment
- He/she satisfies functional impairment classification for Permanent
Partial Disability of organ System involved and Functional
Independence Measure (FIM)
3) Permanent Total Disability Benefit. The Permanent Total Disability is a

cash benefit in monthly pension paid to a qualified GSIS/SSS member found
with Permanent Total Disability due to TB disease. The benefit includes
reimbursement for medical, rehabilitation and related expenses and a monthly
pension plus 10 percent for each of the five dependent children beginning with
the youngest and without substitution, which may be enjoyed simultaneously
with benefits under the social security program. A permanent total disability
pensioner is also given a monthly supplemental allowance for his/her extra
needs depending on his physical condition arising from his/her TB. The monthly
pension will be suspended if the employee is gainfully employed, recovers
from his/her permanent disability, or fails to present himself/herself for
examination at least once a year upon notice by the GSIS/SSS or fails to
submit a quarterly report certified by his/her attending physician. The suspension/
forfeiture of the said benefit will be based on the policy on non–submission of
medical progress report.

i. He/she has been duly reported to the System;
ii. He/she sustained the permanent total disability as a result of a work-
connected TB disease;
· Medical Requirements for Entitlement to EC – PTD:
i. Pulmonary Tuberculosis:
of documented treatment
Disability
- He/she has an impairment classification of Class 4 (Annexes 20-
A to 20-C, pages 129 to 130) and Functional Independence
Measure (FIM) classification of permanent total disability (Annex
21, page131).
ii. Extrapulmonary Tuberculosis:

- He/she met the criteria for extrapulmonary TB and has proof of at
least 100 days of documented treatment
Total Disability of organ System involved and Functional
Independence Measure (FIM) of total disability
c) Procedure for Claims:
1) All claims for work-connected TB shall be filed using the prescribed form
furnished by either the GSIS or SSS and endorsed by the employer or his
duly authorized representative together with the following supporting documents:
· Completed TB Benefits Form initial portion with the following as

attachments:
i. For application for Temporary Total TB disability (TB sickness),

Initial Claim:
- Pulmonary TB:

Official results of 3 AFB sputum examination, x-ray films and official
results of mycobacterial or TB culture examination if available.
History and physical examination of attending physician,
histopathology examination result of involved tissue or results of
culture of fluid or tissue from involved site and certification from
the attending physician attesting to the diagnosis of TB of the
extrapulmonary site concerned.
ii. For extension of Temporary Total TB Disability:

- Pulmonary TB:
Results of sputum examination or culture taken three weeks from
the previous sputum examination or culture, evidence of at least
mild respiratory impairment by spirometry or peak flow and
certification by the attending physician that he/she has at least Class
1 respiratory impairment.
histophathology examination results of involved tissue or results of
culture of fluid or tissue from involved site and certification from
extrapulmonary site concerned.
iii. For Permanent Total or Partial TB Disability:

- Pulmonary TB:
Results of sputum examination or culture taken at the end of the
temporary total disability, respiratory impairment result by
spirometry or peak flow and proof of at least 100 days of
documented treatment.
histopathology examination result of involved tissue or results of
culture of fluid or tissue from involved site, certification from the
attending physician attesting to the diagnosis of TB of the
extrapulmonary site concerned and proof of at least 100 days of
documented treatment.
· Supporting documents:
i. Updated service record
ii. Statement of duties and responsibilities
iii. Pre-employment x-ray
iv. Official receipts in payment of laboratory bills
v. Professional fees and medicines purchased from the drugstore
· Proof of treatment or treatment record where the daily dose of the patient’s
anti-TB drugs taken under supervised treatment is recorded.
2) The GSIS/SSS physician shall evaluate the application within twenty (20)
calendar days from the submission of all required documents and shall render
a decision denying or awarding compensation benefits.
3) The claimant shall be notified in writing by the GSIS or SSS of its award or
decision on the action taken on his claim. The claimant shall be informed of his
right to appeal and that the decision shall become final and executory if no
appeal or motion for reconsideration is filed within the prescribed period.
4) The claimant shall file with the GSIS or SSS, as the case may be, only one
motion for reconsideration within ten (10) calendar days from receipt of the
decision. When a motion for reconsideration is denied by the GSIS or the
SSS, the claimant may appeal to the Commission within (30) calendar days
from receipt of the decision or the notice of denial of the motion for
reconsideration.
5) The claimant shall file with the GSIS or the SSS, a notice of appeal within
thirty (30) calendar days from receipt of the decision.
2-2. Social Security System

a) Policy:
1) The SSS shall provide Initial Temporary Total TB Disability (TB Sickness)
Benefit of thirty (30) days to qualified members diagnosed with TB disease.
The member may apply for extension of this benefit to a maximum of ninety
(90) days if he/she meets the acceptable criteria.
2) The SSS shall provide Permanent TB Disability Benefit to members with

tuberculosis whose sputum acid-fast stain remains positive at the end of 120
days and/or with impairment classification (Annexes 20-A to 20-C, pages
129 to 130) of class 2 or higher. Those with impairment classification of Class
1 and with at least mildly impaired respiratory function shall also be entitled to
Permanent Disability Benefit. Qualified members with extrapulmonary TB may
apply for Permanent TB Disability Benefit based on the severity of functional
impairment of the organ system involved (Annex 21, page 131).
3) SSS shall report members who applied for Temporary Total Disability (TB
Sickness) Benefit to the body designated to manage the National TB Data
Base.
b) Benefits:
The SSS administers two programs: the Social Security Protection and the
Employees Compensation (EC) Program of the Employees’ Compensation
Commission to workers in the private sector. Basically, the SSS provides for the

replacement of income lost in times of sickness, disability, and death under RA
8282, the Social Security Act of 1997.
1) TB Sickness Benefit:
It is a daily cash allowance paid to an eligible SSS member for the number of
days he is unable to work due to TB sickness. Such allowance shall begin only
after all company sick leaves of absence with full pay to the credit of the
employee for the current year have been exhausted. The member is also
entitled to EC TB sickness under the EC Program if he suffers a work-related
TB and the period of compensability shall be counted from the first day of
such sickness.
The member may enjoy simultaneously both SS and EC sickness benefit

provided he meets all the qualifying conditions in the availment of such benefit
as required by both Agencies.
· Packages:
i. SSS - The sickness benefit is given in the form of a daily cash allowance.
The amount of benefit is computed as: the daily sickness allowance
times the approved number of days (the daily sickness allowance is
90 per cent of the average daily salary credit).
ii. EC - The sickness benefit is an income cash benefit equivalent to 90
per cent of the employee’s average daily salary credit with a minimum
of P90.00 and a maximum of P200.00. The TB sickness can be paid
for a continuous period of 120 days and may go beyond up to 240
days if sickness requires more treatment. If it persists after this period,
the sickness can be considered a disability.
· System Requirements for Eligibility:
i. SSS -- A member is qualified to avail of sickness benefit if he/she:

- Is unable to work for more than 3 days due to TB sickness;
- Has paid at least three monthly contributions within the 12-month
period immediately preceding the semester of sickness;
- Has used up all current company sick leaves with pay for the
current year; and,
- Has notified the employer or SSS if separated, voluntary or self-
employed member of his confinement within 5 calendar days after
the start of such confinement unless such confinement is in a
hospital.
ii. EC -- A member is qualified to avail of sickness benefit if he/she:
- Has been duly reported to the SSS;
- Has work-connected tuberculosis; and,
- SSS has been duly notified of his TB disease.
His/her employer shall be liable for the benefit if such TB illness
occurred before the employee is duly reported for coverage to the
system.
· Medical Requirements:
i. Initial TB Sickness Benefit Package:
- Pulmonary TB:
• Attending physician’s report (initial portion of the TB Benefit
Form (refer to Annexes 22-A and 22-B, pages 152-153).
• Results of three separate sputum examinations for AFB or
culture.
• Chest x-ray film and result with findings consistent with
pulmonary TB.
• Verification of TB diagnosis by SSS physicians.
• Referral from attending physician with history and physical
examination report.
• Positive TB culture result of fluid or tissue from involved site
or histological evidence from the site involved.
• Certification from the attending physician attesting to the
diagnosis of TB of the extrapulmonary site concerned.
• Verification of TB diagnosis by SSS physician.
ii. Extension of TB Sickness Benefit Package:
An extension of 30 days or more (until maximum of 120 days) beyond

the initial benefit maybe given to a member with TB disease who fulfills
the following requirements:
- Pulmonary TB:
• Still sputum (+) or becomes sputum (+) on the basis of three

sputum follow-up examinations at least 3 weeks from the
previous examination or impairment classification of class 1
or higher.
• Certification from the Attending Physician attesting the

presence of the above-mentioned signs and symptoms. The
certification shall be written in the Sickness Notification Form.

• Certification from the attending physician that the patient has
extrapulmonary tuberculosis and still needs time off from work
while continuing treatment.
• Verification of TB diagnosis by SSS physician.
· Procedure for Claim
i. Initial TB Sickness Benefit Package:
- Members diagnosed with TB disease are required to submit the

following:
• TB Sickness Notification Form for employed members or
Sickness Benefit Claim for separated, self-employed, or
voluntary members.
• Sickness Benefit Reimbursement Application Form (for the
employer)
• Completed TB Benefit Form (refer to Annexes 22-A and 22-
B, pages 152-153) with the following as attachments:
(a) Pulmonary TB:
Official result of three (3) AFB sputum examinations,
x-ray films and official result showing PTB,
mycobacterial or TB culture examination if available.
(b) Certification from attending physician attesting to the
diagnosis of pulmonary TB.
(c) Extrapulmonary TB:
histopathology examination result of involved tissue or
results of culture of fluid or tissue from involved site and
certification from the attending attesting to the diagnosis
of TB of the extrapulmonary site concerned.
- The application shall be evaluated by the SSS physician who shall

return the basic TB Sickness Notification form with the appropriate
recommendation to the employee/employer except in the case of
voluntary, self-employed or separated SSS members who shall
receive direct payment of benefit.
• The TB Sickness Benefit Form shall be collected by SSS and

submitted to the Philippine Coalition Against Tuberculosis or
other body designated to manage the National TB Data Base
on a monthly basis.
• The employer shall advance the approved benefits and have

this reimbursed by SSS.
ii. Extension of TB Sickness Benefit Package:
- Members diagnosed with TB disease who shall remain sputum

positive after thirty (30) days are required to submit the following:
• TB Sickness Notification Form for employed members or

Sickness Benefit Claim for separated, self-employed, or
voluntary members.
• Sickness Reimbursement Application Form (for the employer).
• Completed TB Benefit (Extension Portion) Form with the
following as attachments:
(a) Pulmonary TB
(1) Results of sputum examination or culture or

evidence of at least mild respiratory impairment
by spirometry or peak flow and certification by a
physician that he/she has at least Class 1 respiratory
impairment.
(2) Certification by the attending physician attesting
to the diagnosis of Pulmonary Tuberculosis.
(3) Verification by SSS physician of member’s health
condition to warrant granting of extension.
(b) Extrapulmonary TB
(1) History and physical examination of attending

physician, histopathology examination result of
involved tissue or results of culture of fluid or tissue
from involved site.
(2) Certification from the attending physician attesting

to the diagnosis of TB of the extrapulmonary site
concerned.
- The application shall be evaluated by the SSS physician who shall

return the basic TB Sickness Benefit form with the appropriate
recommendation back to the employee/employer except in the
case of voluntary, self-employed or separated SSS members who
shall receive direct payment of benefit.
- The employer shall advance payment of the approved benefits to
employees and have advances reimbursed by SSS.
2) TB Disability Benefit
SSS pays cash benefit in monthly pension or lump sum to eligible members
with permanent partial or total disability due to TB disease. In addition to the

monthly pension, a supplemental allowance of P500.00 is paid to provide
additional financial assistance to meet his/her extra needs arising from the
disability.
For permanent total disability, each dependent child of the pensioner, (not
exceeding five and without substitution starting from the youngest), will receive
a dependent’s pension equivalent to 10 per cent of the member’s monthly
pension or Pesos 250 whichever is higher. The dependent pension stops when
the child reaches 21 years old, gets married, gets employed or dies.
For work-connected TB disability, the ECC pays cash benefit in monthly

pension to eligible members. Also, it provides a supplemental allowance of
P575.00 (15% higher than SSS) and a dependent’s allowance equivalent to
10 per cent of the member’s monthly pension. In addition, the eligible member
is also entitled to medical and related services and rehabilitation services and
dependent pension for each of his dependent child (not exceeding five and
without substitution starting from the youngest).
The EC disability benefit may be enjoyed simultaneously with SS disability

benefit.
· Packages:
i. SSS -- It is a cash benefit paid to a member who becomes permanently
disabled due to TB, either partially or totally. The disability benefit
may either be in lump sum or monthly pension and the amount and
duration of benefit is based on the current policy of the System, which
are subject to change.
ii. EC -- It is a monthly cash income benefit paid to a member who
becomes permanently disabled due to a work-connected TB disease,
either partially or totally. The amount and duration of the benefit is
based on the policy of the System.
· System Requirement for Eligibility:

i. SSS -- A member who suffers partial or total permanent disability,
with at least one monthly contribution paid to the SSS prior to the
semester of contingency, is qualified.
ii. EC -- A member is qualified to disability benefit if he satisfies the
following conditions:
- He has been duly reported to the System; and,
- He has sustained the permanent partial or total disability as a result
of work-connected TB disease.
· Medical Requirements:
i. Pulmonary TB
of documented treatment.
Disability.
- He/she has an impairment classification of Class 1 to 3 (Annexes
20-A, 20-B, and 20-C on pages 129-130 and Functional
Independence Measure (FIM) classification for permanent partial
disability (Annex 2, page 84).
ii. Extrapulmonary
- He/she met the criteria for extra pulmonary TB and has proof of at
least 100 days of documented treatment.
Partial Disability of organ system involved and Functional
Independence Measure (FIM).
· Procedure for Claim:
i. SSS members with TB disease should submit the following:

- Claim for Disability Benefit Form
- Medical certificate form
- Other documents that might be required to support the disability
claim:
* Pulmonary TB
Chest x-ray result indicating PTB and results of sputum
examination or culture taken at the end of the temporary total
disability, respiratory impairment result by spirometry or peak
flow and proof of at least 100 days of documented treatment.
* Extrapulmonary TB
histopathological examination result of involved tissue or results
of culture of fluid or tissue from involved site, certification from
extrapulmonary site concerned and proof of at least 100 days
of documented treatment.
The application shall be evaluated by the SSS physician who

shall give the appropriate recommendation.

VIII. PhilHealth’s Outpatient TB
DOTS Benefit Package
1. Introduction
T
he outpatient TB DOTS benefit package is the response of the Philippine Health
Insurance Corporation (PhilHealth) to the need to provide accessible and quality
health care services to its members and their qualified dependents who are suffering
from TB. This package was included in PhilHealth’s Benefits Package pursuant to Board
Resolution Nos. 485 and 490, Series of 2002, as embodied in Circular No. 19, Series of
2003. The DOTS (Directly Observed Treatment, Short-course) strategy, which is reported to
have an 85% or higher cure rate, is highly recommended to effectively deliver this benefit
package.
2. Definitions
2-1. Tuberculosis (TB)
TB is an infectious disease caused by the microorganism called Mycobacterium
tuberculosis or the TB bacillus. The microorganism enters the body by inhalation
through the lungs. They spread from the initial location in the lungs to other parts of the
body via the blood stream, the lymphatic system, via the airways or by direct extension
to other organs.
2-2. Pulmonary TB
A pulmonary TB case refers to disease involving the lung parenchyma. It is the most
frequent form of the disease, occurring in over 80 percent of cases. This form of
tuberculosis may be infectious. A “case” of TB is a patient in whom the diagnosis has
been confirmed bacteriologically or a patient in whom a presumptive diagnosis of
active TB is made on the basis of radiological evidence and a decision by the TB
Diagnostic Committee to treat with a full course of anti-TB therapy.
CHAPTER VIII : PHILHEALTH’S OUTPATIENT ANTI-TB DOTS BENEFIT PACKAGE 71

2-3. Symptomatic pulmonary TB
Symptomatic pulmonary TB case refers to an individual with symptoms of
pulmonary TB and is found to have one of the following:
a) At least two sputum specimens positive for AFB, with or without radiographic
abnormalities consistent with active PTB; or
b) One sputum specimen positive for AFB and with radiographic abnormalities
consistent with active PTB as determined by the TB Diagnostic Committee; or
c) One sputum specimen positive for AFB with sputum culture positive for M.
tuberculosis; or
d) All three sputum specimens negative for AFB with radiographic abnormalities
consistent with active PTB as determined by the TB Diagnostic Committee, with
no history of anti-TB treatment and with a normal previous chest x-ray.
Signs and symptoms of pulmonary TB include cough for two weeks duration or
more with one or more of the following:
· Fever
· Sputum expectoration
· Significant weight loss
· Hemoptysis or recurrent blood streaked sputum
· Chest and/or back pains not referable to any musculo-skeletal disorders
· Other symptoms such as chills, fatigue, body malaise, shortness of breath
2-4. Asymptomatic pulmonary TB

An asymptomatic pulmonary TB case refers to an individual without symptoms of
pulmonary TB and is found to have one of the following:
a) Radiographic abnormalities consistent with active PTB and at least one sputum
specimen positive for AFB, OR
b) Previous chest x-ray normal and current chest x-ray show abnormalities consistent
with active PTB as determined by the TB Diagnostic Committee and three sputum
AFB smears are negative, OR
c) Previous chest x-ray showed abnormality consistent with active PTB, three sputum
AFB smears previously negative, current chest x-ray shows progression of
radiographic abnormality.
N.B. If current CXR shows abnormality consistent with TB and 3 sputum specimens
are negative for AFB, but no previous CXR is available and the patient does not fulfill
the criteria for PTB, follow-up CXR and sputum examination should be done at least
a month after.
2-5. Extrapulmonary TB
Extrapulmonary TB (EPTB) affects organs other than the lungs, more frequently the
pleura, lymph nodes, spine, joints, genitourinary tract, nervous system or abdomen.
Tuberculosis, moreover, may affect any part of the body.
N.B. Diagnosis for extra-pulmonary tuberculosis should be based on one culture positive
specimen, or histological or strong clinical evidence consistent with active extra-
pulmonary tuberculosis, followed by a decision by a clinician to treat with a full course
of tuberculosis chemotherapy.
2-6. Qualified TB Patient

A qualified TB patient is any of the following:
a) A new case of smear positive pulmonary TB;

b) A new smear negative pulmonary TB as recommended for treatment by the TB
Diagnostic Committee;
c) A new extrapulmonary TB;
d) Children diseased with TB.
In order to qualify, the abovementioned patients shall have been seen and worked up
by a qualified TB/DOTS Provider. Once this requirement has been met, a qualified TB
patient shall be eligible to avail of the outpatient anti-TB DOTS benefit package.
2-7. Qualified Provider

A qualified provider is an outpatient clinic duly accredited by PhilHealth.
2-8. Defaulter
Qualified TB patient who starts the treatment but who for any reason discontinues
treatment and could no longer be retrieved is considered a defaulter.
3. Policy
3-1. NTP Manual of Procedures
Implementation of the DOTS Strategy shall be based on the Manual of Procedures of
the National Tuberculosis Control Program, 2004. The PhilHealth outpatient TB DOTS
benefit package shall cover follow-up diagnostic work-up, follow-up consultation
services and anti-TB drugs in an out-patient set-up.

3-2. Cases covered
The DOTS Benefit Package shall cover new cases of pulmonary and extra-pulmonary
tuberculosis only. It shall not cover the following types of tuberculosis cases: relapse,
failure and return after default (RAD).
3-3. Standards for accreditation

Accreditation of DOTS Centers as providers of DOTS services shall be based on
standards developed by the Corporation in consultation with other stakeholders. Quality
Assurance Standards shall be based on the PhilHealth Benchbook.
3-4. Payment scheme

The accredited DOTS Center shall be paid on a case-based reimbursement payment
scheme. Two payments shall be released to the accredited DOTS Center as determined
by the Corporation.
3-5. Monitoring
The Health Finance Policy and Services Sector, specifically, the Utilization Review
Unit of the Quality Assurance Research and Policy Development Group shall spearhead
the monitoring of the implementation and impact of the outpatient anti-TB DOTS benefit
package.
4. Outpatient Anti-TB DOTS Benefit Package

4-1. Coverage
a) All PhilHealth members and their qualified dependents may avail of the outpatient
TB DOTS benefit package if they satisfy the “Criteria for Eligibility” and are not
excluded by the “Criteria for Exclusion.”
Criteria for Eligibility:

· New cases of smear positive or smear negative pulmonary
tuberculosis.
· New cases of extra pulmonary tuberculosis
· TB disease in children
Criteria for Exclusion:

The PhilHealth outpatient TB DOTS benefit package shall not cover the following
types of TB cases:
· Failure cases (On previous treatment)
· Relapse cases
· Return After Default cases (RAD)
All members and dependents who are qualified to avail of the outpatient TB DOTS
benefit package may avail of services in the DOTS center where he/she is registered.
Transfer to another accredited DOTS center during the course of treatment shall
be referred to a PhilHealth Committee for appropriate action.
b) In accordance with Section 46 of the Implementing Rules and Regulations of R.A.

7875, qualified PhilHealth members and their dependents shall be entitled to the
outpatient TB DOTS benefit package if:
· The member has paid at least three monthly premium contributions within the
immediate six months prior to enrollment at the DOTS Center for employed
and individually paying members.
· The member is covered within the date of effectivity of membership as stated
in the ID Card/Eligibility Certificate in the case of sponsored (indigents),
pensioners and overseas Filipino workers.
c) Qualified dependents of a PhilHealth member may be one of the following:

· Spouse who is not a PhilHealth member;
· Children under 21 years old, not married and unemployed;
· Parents > 60 years of age, who is not a member, and wholly dependent on the
member
The DOTS Provider shall render services to a qualified PhilHealth member
and its dependents based on the Manual of Procedures of the National
Tuberculosis Control Program 2004.
d) PhilHealth shall provide a comprehensive package that will cover follow-up

diagnostic work-up, follow-up consultations and anti-TB drugs for all members
diagnosed with TB as defined above.
4-2. Providers
a) Providers of the DOTS Benefit Package shall be out-patient DOTS centers duly
accredited by PhilHealth. Accreditation will be based on standards developed by
the Corporation in consultations with stakeholders. Quality Assurance standards
are based on the PhilHealth Benchbook. Likewise, PhilHealth shall accredit
physicians rendering DOTS services.
b) DOTS centers such as those but not limited to a hospital, HMO, LGU health
units, factory clinic, church-based clinics, school clinics are qualified to become
providers after being duly certified by the Center for Health Development (CHD)
Sentrong Sigla Assessment Team (Public Sector) or the Philippine Coalition Against
Tuberculosis or PhilCAT (Private Sector).
4-3. Certification and Accreditation

a) The CHD or PhilCAT, whichever is applicable, shall certify providers to ensure
quality of DOTS implementation.

b) Standards for accreditation of providers shall be based on the new PhilHealth
Benchbook on Performance of Improvement of Health Services and all other
necessary claims processing requirements.
4-4. Payment
a) Drugs, consultation fees and laboratory fees will be covered by a flat rate of Pesos
4,000 per case payable in two separate payments.
b) The first payment of Pesos 2,500 shall be made after completion of the intensive
phase and the final payment of Pesos 1,500 shall be made after the end of the
maintenance phase.
c) Reimbursement requirements shall be in accordance with PhilHealth claims

reimbursement guidelines.
d) PhilHealth shall not reimburse a qualified TB patient who is considered a defaulter

if he/she decides to go back to the program. This is to ensure that all DOTS
centers will take full responsibility of patient compliance and at the same time
ensure the program’s success rate.
4-5. Reimbursement Process

The reimbursement process shall have three phases: registration of qualified TB patient,
release of first payment and release of final payment (second payment).
a) For registration purposes, a photocopy of the NTP Treatment Card of a qualified

TB patient shall be submitted to PhilHealth within 60 days upon enrollment at the
DOTS Center. Other supporting documents may be required, which may include
the following:
· Proof of contribution for the self-employed
· Proof of dependency which may include marriage certificate for spouse and
birth certificate for children, as the case may be
b) For release of first payment, the DOTS Center shall submit to the PhilHealth Claims
Department the following: (1) PhilHealth Claim Form 1, (2) Photocopy of the
NTP Treatment Card and (3) TB–DOTS Package Claim Form 5 within 60 days
after the completion of intensive phase.
c) For release of final payment (second payment), the DOTS Center shall submit to
the PhilHealth Claims Department the following: (1) PhilHealth Claim Form 1, (2)
Photocopy of the NTP Treatment Card and (3) TB–DOTS Package Claim Form
5 within 60 days after the completion of maintenance phase.
d) All claims applications are covered by the rule on ICD–10 requirement of the
Corporation.
e) Claims with incomplete requirements shall be returned to the DOTS Center and
must be complied with the 60 days prescription.
f) Non-compliance shall cause denial of a claim.
4-6. National TB Registry

All DOTS Centers shall be linked to the National TB Registry. This registry shall
provide all the information and utilization of the benefit package. Likewise, the National
TB Registry shall collect and process the basic information on the patient’s treatment,
provider update and referral status.
4-7. Monitoring
The Health Finance Policy and Services Sector shall spearhead monitoring of this
program.
A committee composed of Quality Assurance Research and Policy Development Group,

Accreditation Department and Fraud Unit shall develop the monitoring tool in
collaboration with DOH and PhilCAT.

ANNEXES
ANNEXES 79
ANNEX 1: FLOW OF NTP ACTIVITIES
Identification of TB symptomatics
COMMUNITY Symptoms of TB
• Cough for 2 weeks or more
• Sputum expectoration
• Fever
• Significant weight loss
• Hemoptysis
• Chest and/or back pains
Collection and examination of 3 sputum

TREATMENT UNIT specimens for diagnosis
Case Finding Sputum specimens (3 Specimens) with

Request Form for Sputum Examination
MICROSCOPY CENTER
Results of the sputum smear examination (Sputum

Smear Examination for Diagnosis)
Diagnosis
Initiation of Treatment
Collection and examination of 1 sputum specimen

Case Holding with DOTS
for follow up based on specified schedule
Sputum specimen (1 specimen per once) with Request

Form for Sputum Examination
MICROSCOPY CENTER
Results(Sputum Smear Examination for Follow-up)
Treatment Completion
Report Treatment Outcome/Request Supplies

Monitoring and Supervision
ANNEXES 81
ANNEX 2: FLOWCHART FOR THE
DIAGNOSIS OF PULMONARY TUBERCULOSIS
TB Symptomatic
(cough for 2 weeks or more)
Three (3)
sputum collection
2 or 3 Only one (1) All

smear positive smear positive (*1) smear negative
Refer to Physician
Classify as smear Collect another 3 (Observe and give
positive TB sputum specimen symptomatic treatment
for 2-3 weeks)
If at least one (1) If all smear

smear positive negative If symptoms persist,
collect another three
(3) sputum specimens
and refer to Physician
(refer to flow chart in
Classify as smear- Request Annex 3)
positive TB for CXR
If consistent with If not consistent with

active TB active TB
Classify as smear- Observe/Further

positive TB Exam, if necessary
ANNEX 3: FLOWCHART FOR THE DIAGNOSIS OF
SMEAR-NEGATIVE PULMONARY TUBERCULOSIS
This flow chart is a sample for making decision of the physician. Arrangement may be
required in accordance with the patient condition as well as the available resources on
TB control.
all 3 smear
NEGATIVE
Refer to Physician
(sympt. Tx for 2-3 weeks)
If symptoms persist,
collect another three
(3) sputum specimens
2 or 3 smear POSITIVE only one (1) smear

all 3 smear NEGATIVE
positive
Classify as Refer to Annex 2 (*1) Request for CXR

Smear-Positive TB
No abnormal findings on
Abnormal findings on CXR
CXR
Observe/further
TB Diagnostic Committee
examination
Not consistent with active

Consistent with active TB TB
Classify as Smear- Observe/further

Negative TB examination
ANNEXES 83
ANNEX 4: APPROACH TO TB ASYMPTOMATIC
Patient asymptomatic
CXR available
(with lesions suggestive of TB
Previous CXR available
YES NO
Previous treatment for PTB Induce sputum
completed and verified production
YES NO Sputum (+) Sputum (-)

AFB AFB)
May repeat
Lesion Lesion worse/ Lesion Lesion
Treat with CXR (after 6
stable new stable worse/new
Reg 1 months) or
treat with
Reg 3
Advise patient. Further Further

May be Sputum
investigation investigation
cleared for induction
required required
employment.
Sputum (+) Sputum (-)

AFB AFB)
Treat with Reg Treat with Reg

1 3
ANNEX 5: GUIDE TO CASE FINDING
SPUTUM COLLECTION UNIT TB Symptomatics with

(to be accomplished by the Midwife/Nurse/Physician) symptoms as:
1. Register the client in NTP Client List (or Target Client List).
2. Label each sputum containers (name and serial no. 1, 2, 3). > Cough for 2 weeks or more
> Fever
3. Collect 3 sputum specimens (spot, early morning, spot).
> Significant weight loss
4. Fill-out the Laboratory Request Form for Sputum Examination. > Chest and/or back pains
5. Pack and send the specimen/s to the Microscopy Center with the > Hemoptysis
Laboratory Request Form for Sputum Examination.
MICROSCOPY CENTER
(to be accomplished by the Medical Technologist/Microscopist)
1. Register the client in NTP Laboratory Register.
2. Record the date received and the Laboratory Serial No. in the
Laboratory Request Form for Sputum Examination.
3. Sputum Smear Examination: smearing, fixing, staining and reading
slides
4. Record the results in the Laboratory Request Form for Sputum
Examination and in the NTP Laboratory Register.
5. Send back accomplished Laboratory Request Form for Sputum
Examination the collection unit..
SPUTUM COLLECTION UNIT

(to be accomplished by the Midwife/Nurse/Physician)
1. Record the results in the NTP Client List/Target Client List (TCL)
2. Inform and explain the result to the patient (If doubtful, immediately
collect another 3 specimens for confirmation).
3. Refer to Nurse/Physician
DIAGNOSIS AND
INITIATION OF
TREATMENT
ANNEXES 85
ANNEX 6: GUIDE TO DIAGNOSIS AND INITIATION OF TREATMENT
CLINICAL DIAGNOSIS
(Determination of patient type and classification is done by the Physician/Nurse/Midwife)
1. Verify information gathered on case finding
• Symptoms/condition of patient
• Result of sputum examination
• Result of further examination (i.e. CXR, Culture, etc.)
• Source of infection
2. Verify sputum smear examination results
3. Review history of previous treatment
INITIATION OF TREATMENT
To be done by the 1. Physical assessment and prescription of appropriate regimen for
Physician the TB patient (according to the patient type and the classification)
To be done by the Nurse 2. Registration

(initially) • Fill-in the NTP Treatment Card
• Fill-in two NTP ID Cards, one for the treatment partner and one
for the patient
• Register in the TB Register
To be done by all health 3. Health education with emphasis on key messages such as:
workers • TB is infectious. It can affect anybody.
• TB can be cured but requires regular drug intake.
• Results of irregular drug intake.
• Side effects of anti-TB drugs.
• Importance of follow-up sputum smear examinations.
• Importance of family/treatment partner support.
To be done by the Nurse 4. Intake of first dose
• Record the date when treatment started.
• Record the due date of the 1st follow-up sputum examination in
the NTP Treatment Card and NTP ID Cards.
To be done by the Nurse 5. DOT
and treatment partners • Assign a treatment partner.
• Do DOT for both intensive and maintenance phases of
treatment.
• Conduct weekly consultation meeting at the health facility
during the whole course of treatment.
To be done by the nurse/ 6. Record keeping
midwife/treatment partner/ 1) Maintain and update the TB Register
patient 2) Maintain and update the NTP Treatment Card at the health
facility.
3) Maintain and update the NTP ID Cards.
4) Keep the NTP ID Card.
ANNEX 7: TREATMENT REGIMENS
TB Diagnostic TB Patients To Be Given Tuberculosis Treatment

Category Treatment Regimen & Duration of
Treatment
• New pulmonary smear
(+) cases 2HRZE / 4HR :
• New pulmonary smear (-) HRZE for two months
cases with extensive during the intensive phase.
Category I
parenchymal involvement
and as assessed by the HR for 4 months during the
TBDC maintenance phase.
• Extra-pulmonary TB
cases
2HRZE / 5HRE :
HRZES for the first two
• Failure cases months, then HRZE for the
• Relapse cases third month during the
Category II • RAD intensive phase.
• Other (smear +)
• Other (smear -) HRE for the next five
months during the
maintenance phase.
2HRZE* / 4HR :
• New smear(-) but with
HRZE for 2 months during
minimal pulmonary TB on
Category III the intensive phase.
radiography and as
assessed by the TBDC
HR for 4 months during the
maintenance phase.
*Ethambutol may be omitted for patients with non-cavitary, smear-negative pulmonary TB who
are known to be HIV-negative, patients who are known to be infected with fully drug susceptible
bacilli. Young children with primary TB should be given 3 drugs combination only (without ethambutol).
Source: “Operational Guide for National Tuberculosis Control Program on the Introduction and
Use of Fixed Dose Combination.” WHO 2002
ANNEXES 87
ANNEX 8A: DRUG DOSAGE AND ADJUSTMENT
DRUG Dose
Doseper
per kg
kg body
body weigh
weight and
and maximum dose
maximum dose
ISONIAZID 5 (4-6) mg/kg, and not to exceed 400mg daily
RIFAMPICIN 10 (8-12) mg/kg, and not to exceed 600mg daily
PYRAZINAMIDE 25 (20-30) mg/kg, and not to exceed 2g daily
ETHAMBUTOL 15 (15-20) mg/kg, and not to exceed 1.2g daily
STREPTOMYCIN 15 (12-18) mg/kg, and not to exceed 1g daily
ANNEX 8B: FDC COMPOSITION
FDC - A FDC - B
DRUG
4-Drug (HRZE) 2-Drug (HR)
ISONIAZID (H) 75mg 75mg
RIFAMPICIN (R) 150mg 150mg
PYRAZINAMIDE (Z) 400mg
ETHAMBUTOL (E) 275mg
DOSAGE PER TREATMENT REGIMEN

The number of tablets of FDCs per patient will depend on the body weight. Hence,
all patients must be weighted
ed in kilogram before treatment is started.
ANNEX 8C: FDC DOSAGING
CATEGORY
REGIMENI:I: 22 HRZE
HRZE/ /4HR
4HR
No. of tablets per day No. of tablets per day
Intensive Phase Maintenance Phase
Body Weight (kg)
(2 months) (4 months)
FDC - A (HRZE) FDC - B (HR)
30 - 37 2 2
38 - 54 3 3
55 - 70 4 4
>> 71 5 5
CATEGORY
REGIMEN II:
II: 22 HRZES
HRZES //HRZE
HRZE/ /4HRE
4HRE
INTENSIVE PHASE MAINTENANCE PHASE

Body Weight
First two months Third month
(kg)
FDC - A FDC - A FDC - B E
STREPTOMYCIN
(HRZE) (HRZE) (HR) 400 mg
30 - 37 2 0.75 g 2 2 1
38 - 54 3 0.75 g 3 3 2
55 - 70 4 0.75 g 4 4 3
>
> 71 5 0.75 g 5 5 3
CATEGORY
REGIMEN III:
III: 22 HRZE
HRZE/ /4HR
4HR
No. of tablets per day No. of tablets per day

Intensive Phase Maintenance Phase
Body Weight (kg)
(2 months) (4 months)
FDC - A (HRZE) FDC - B (HR)
30 - 37 2 2
38 - 54 3 3
55 - 70 4 4
>
> 71 5 5
ANNEXES 89
ANNEX 9: FDC DRUG SAMPLES
FDC A Blister Pack
FDC B Blister Pack
Pyrazinamide Blister Pack
Ethambutol Blister Pack
ANNEX 10A: SCHEDULE OF SPUTUM SMEAR
FOLLOW-UP EXAMINATION
CATEGORY I
REGIMEN I
Schedule of Sputum Treatment Regimen

Regimen for Category I (2hrze/4hr)
I (2HRZE/4HR)
Smear Follow-up with One Month Extension
Examination Regular Treatment
(HRZE)
Towards the end of the

YES
2nd month (if positive)
Towards the end of the (if
negative) YES
3rd month

YES
4th month

YES
5th month

YES (* 1)
6th month

YES (* 1)
7th month
* 1 Check the follow-up sputum smear examination at the end of the treatment (during the last week of
treatment) for the patient who has smear positive in the last follow-up smear examination and shows smear
negative in the repeated smear examination.
ANNEXES 91
ANNEX 10B: SCHEDULE OF SPUTUM SMEAR
FOLLOW-UP EXAMINATION
REGIMENFOR
TREATMENT REGIMENS II andCATEGORY
REGIMEN IIIII AND CATEGORY III
Treatment
Regimen Regimen for Category II
II (2HRZES/1HRZE/5HRE)
Schedule of Sputum (2HRZES/1HRZE/5HRE) Category III
Regimen
Treatment III
Regimen
Smear Follow-up with One Month
Regular Treatment (2HRZE/4HR)
(2HRZE/4HR)
Examination Extension (HRZE)
YES
2nd month
YES (If positive)
3rd month
(If negative) YES
4th month
YES
5th month
YES
6th month
7th month
YES (* 2)
8th month
YES (* 2)
9th month
* 2 Check the follow-up sputum smear examination at the end of the treatment (during the last week of
treatment) for the patient who has smear positive in the last follow-up smear examination and shows
smear negative in the repeated smear examination.
ANNEX 11: SUMMARY OF TREATMENT REGIMEN MODIFICATION
BASED ON THE SPUTUM FOLLOW-UP
Examination Results
TreatmentRegimen
Regimen- for
1 Category I
1st mo. 2nd mo. 3rd mo. 4th mo. 5th mo. 6th mo. 7th mo.
HRZE HR
*
If negative,
If positive
If positive H R ZE HR
*
With Extension
TreatmentRegimen
Regimen-for
2 Category II
1st mo. 2nd mo. 3rd mo. 4th mo. 5th mo. 6th mo. 7th mo. 8th mo. 9th mo.
HRZES HRZE HRE
*
If negative,
If positive
If positive, HRZE HRE
*
With Extension
Treatment Regimen
Regimen -for
3 Category III
1st mo. 2nd mo. 3rd mo. 4th mo. 5th mo. 6th mo.
HR ZE HR
* Check the follow-up sputum smear examination at the end of the treatment for the patient who has smear positive in the last follow-up
smear examination and shows smear negative in the repeated smear examination.
ANNEXES 93
ANNEX 12: GUIDE IN MANAGING SCC DRUGS SIDE EFFECTS
Side effects Drug(s) responsible What to do?
MINOR SIDE EFFECTS - Patient should be encouraged to continue taking medicines.
1. Gastro-intestinal intolerance Rifampicin Give medication at bedtime.

2. Mild skin reactions Any kind of drugs Give anti-histamines.
3. Orange/red colored unine Rifampicin Reassure the patient.
Apply warm compress. Rotate sites
4. Pain at the injection site Streptomycin
of injection.
Give Pyridoxine (Vitamin B6):
5. Burning sensation in the feet
Isoniazid 100 - 200mg daily for treatment
due to peripheral neuropathy
10mg daily for prevention.
Give aspirin or NSAID.
6. Arthralgia due to
Pyrazinamide If symptoms persist, consider gout
hyperuricemia
and give allopurinol. *
7. Flu-like symptoms (fever,
muscle pains, inflammation of Rifampicin Give antipyretics.
the respiratory tract)
MAJOR SIDE EFFECTS: Discontinue taking medicines and refer to the Physician immediately.
1. Severe skin rash due to Any kind of drugs (especially Discontinue anti-TB drugs and refer
hypersensitivity Streptomycin) to the Physician.
Discontinue anti-TB drugs and refer
Any kind of drugs (especially
to the Physician.
2. Jaundice due to hepatitis Isoniazid, Rifampicin and
If symptoms subside, resume
Pyrazinamide)
treatment and monitor clinically.
3. Impairment of visual acuity
Discontinue Ethambutol and refer
and color vision due to optic Ethambutol
to an ophthalmologist.
neuritis
4. Hearing impairment, ringing
of the ear and dizziness due to Discontinue Streptomycin and refer
Streptomycin
the damage of the eighth to the Physician.
cranial nerve
5. Oliguria or albuminuria due Streptomycin Discontinue anti-TB drugs and refer
to renal disorder Rifampicin to the Physician.
Isoniazid Discontinue all TB drugs d and
6. Psychosis and convulsion
refer to the Physician.
7. Thrombocytopenia, anemia, Discontinue anti-TB drugs and refer
Rifampicin
shock to the Physician.
ANNEX 13A: TREATMENT REGIMEN MODIFICATIONS BASED ON THE
RESULTS OF SPUTUM FOLLOW-UP EXAMINATIONS (without extension)
Follow-up Examinations
TREATMENT REGIMEN FOR CATEGORY I
• Do sputum smear examinations for follow-up towards the end of the 2nd month of treatment.
• If the sputum examination result is NEGATIVE, start Maintenance Phase (HR) and follow Annex 13A.
• If the sputum examination result is POSITIVE, extend intensive Phase (HRZE) for another one month
and follow Annex 13B.
Treatment Modification Based on the Results of the Sputum Follow-up Examinations for Regimen - I
Without Extension
Towards the end of Towards the end of the
In the beginning of the 6th month
the 4th month 6th month (* 1)
If smear negative, continue If smear negative, complete the maintenance phase until the end of
the maintenance phase the treatment course and declare as "Cure".
(HR).
If smear positive, repeat smear If smear negative in the If smear negative, declare as
examination immediately for repeated smear examination, "Cure."
confirmation and consult with continue the maintenance phase
If smear positive, declare as
Provincial/City/CHD TB (HR) and do the smear
"Treatment Failure," then re-
Coordinators through examination towards the end of
register as "Failure" and start
MHO/CHO/PPMD/PPMDPhysician.
Physician the 6th month of treatment.
Regimen-II.
If smear positive again in the
repeated smear examination,
declare as "Treatment Failure,"
then re-register as "Failure" and
start Regimen II.
If smear positive, continue If smear negative, continue the maintenance phase (HR) and do If smear negative, declare as
the maintenance phase the smear examination towards the end of the 6th month of "Cure."
(HR). treatment.
If smear positive, declare as
"Treatment Failure," then re-
register as "Failure" and start
Regimen- II.
If smear positive, declare as "Treatment Failure," then re-register
as "Failure" and start Regimen II.
* 1 Check the follow-up sputum smear examination towards the end of the 6th month of the treatment only for the patient who has
smear positive in the beginning of the 6th month and shows smear negative in the repeated smear examination; and for the patient
who has smear positive towards the end of the 4th month turns out to be negative in the beginning of the 6th month.
ANNEXES 95
ANNEX 13B: TREATMENT REGIMEN MODIFICATIONS
BASED ON SPUTUM FOLLOW-UP EXAMINATIONS (with Extension)
Follow-up Examinations for Treatment Regimen Category I with Extension
Follow-up Examinations for Regimen-1 with Extension

Towards the Towards the Towards the end
end of the end of the 5th In the beginning of the 7th month of the 7th month (*
3rd mo. mo. 2)
If smear negative, If smear negative, If smear negative, complete the maintenance phase until the
start the continue the end of the treatment course and declare as "Cure".
maintenance maintenance phase
If smear positive, repeat If smear negative in the If smear negative, declare
phase (HR). (HR).
smear examination repeated examination, as "Cure."
immediately for confirmation continue the maintenance
If smear positive, declare
and consult with Phase (HR) and do the
as "Treatment Failure,"
Provincial/City/CHD TB smear examination towards
then re-register as
Coordinators through the end of the 7th month of
"Failure" and start
MHO/CHO/PPMD
MHO/CHO/ PPMDPhysician. treatment.
Regimen-II.
Physician.
If smear positive in the
repeated examination,
declare as "Treatment
Failure," then re-register as
"Failure" and start Regimen
II.
If smear positive, If smear negative, continue the maintenance phase (HR) If smear negative, declare
continue the and do the smear examination towards the end of the 7th as "Cure."
maintenance phase month of treatment.
(HR) anyway.
then re-register as
"Failure" and start
Regimen-II.
If still smear positive, declare as "Treatment Failure," then
re-register as "Failure" and start Regimen-II.
If smear positive, If smear negative, If smear negative, complete the maintenance phase until the
start the continue the end of the treatment course and declare as "Cure."
maintenance maintenance phase
If smear positive, repeat If smear negative in the If smear negative, declare
phase (HR) (HR).
smear examination repeated examination, as "Cure."
anyway.
immediately for confirmation continue the maintenance
and consult phase (HR) and do the
Provincial/City/CHD TB smear examination towards
then re-register as
Coordinators through the end of the 7th month of
"Failure" and start
MHO/CHO/
MHO/CHO/PPMDPPMDPhysician. treatment.
Regimen-II.
Physician.
If smear positive in the
repeated examination,
Failure," then re-register as
"Failure" and start Regimen-
II.
If still smear positive,
declare as
"Treatment Failure,"
then re-register as
"Failure" and start
Regimen-II.
* 2 Check the follow-up sputum smear examination towards the end of the 7th month of treatment only for the patient who has smear
positive in the beginning of the 7th month and shows smear negative in the repeated smear examination; and for the patient who has
smear positive towards the end of the 5th month and turns out to be negative in the beginning of the 7th month.
ANNEX 13C: TREATMENT REGIMEN MODIFICATIONS
BASED ON SPUTUM RESULTS
Follow-up Examinations for Treatment Regimen Category II without Extension
TREATMENT REGIMEN FOR CATEGORY II
• Do sputum smear examination for follow-up towards the end of the 3rd mo. of treatment.
• If sputum examination result is NEGATIVE, START Maintenance Phase (HRE) and follow Annex 13C.
• If sputum examination result is Positive, extend Intensive Phase (HRZE) for another one (1) month
and follow Annex 13D.
Follow-up Examinations for Regimen-II without Extension

Towards the end of Towards the end of the
In the beginning of the 8th mo.
the 5th mo. 8th mo. (* 3)
If smear negative, continue If smear negative, complete the maintenance phase until the end of
the maintenance phase the treatment course and declare as "Cure."
(HRE). If smear positive, repeat smear If smear negative in the repeated If smear negative, declare as
examination immediately for smear examination, continue the "Cure."
confirmation and consult with maintenance phase (HRE) and
Provincial/City/CHD TB do the smear examination If smear positive, declare as
Coordinators through MHO towards the end of the 8th "Treatment Failure."
Physician.
/CHO/PPMD Physician. month.
If smear positive again in the
repeated smear examination
complete the maintenance phase
(HRE) until the end of the
treatment course and declare as
"Treatment Failure."
If smear positive, continue If smear negative, continue the maintenance phase (HRE) and do If smear negative, declare as
the maintenance phase the sputum smear examination towards the end of the 8th month. "Cure."
(HRE) anyway. If smear positive, declare as
If smear positive, complete the maintenance phase (HRE) until the
end of the treatment course and declare as "Treatment Failure."
smear positive towards the end of the 5th month and turns out to be negative in the beginning of the 8th month.
ANNEXES 97
ANNEX 13D: TREATMENT REGIMEN MODIFICATIONS
BASED ON SPUTUM RESULTS
Follow-up Examinations for Treatment Regimen Category II with Extension
Follow-up Examinations for Regimen-II with Extension

Towards the end Towards the end Towards the end
In the beginning of the 9th mo.
of the 4th mo. of the 6th mo. of the 9th mo. (* 4)
If smear positive or If smear negative, If smear negative, complete the maintenance phase
smear negative, start continue the until the end of the treatment course and declare as
the maintenance phase maintenance phase "Cure."
(HRE) anyway. (HRE). If smear positive, repeat If smear negative in the If smear negative, declare
smear examination repeated smear as "Cure."
immediately for examination, continue the
confirmation and consult maintenance phase
with Provincial/City/CHD (HRE) and do the smear If smear positive, declare
TB Coordinators through examination towards the as "Treatment Failure."
MHO/CHO/PPMD
MHO/CHO/ PPMD end of the 9th month of
Physician.
Physician. treatment.
If smear positive again in
the repeated smear
examination, complete the
maintenance phase
(HRE) until the end and
Failure."
If smear positive, If smear negative, continue the maintenance phase If smear negative, declare
continue the (HRE) and do the smear examination towards the as "Cure."
maintenance phase end of the 9th month of treatment. If smear positive,
(HRE) anyway. complete the maintenance
phase (HRE) until the end
of the treatment course
and declare as
If still smear positive, complete the maintenance
phase (HRE) until the end of the treatment course and
declare as "Treatment Failure."
smear positive at the end of the 6th month and turns out to be negative in the beginning of the 9th month.
ANNEX 14A: TREATMENT REGIMEN MODIFICATIONS FOR NEW
SMEAR-POSITIVE CASES WHO INTERRUPTED TREATMENTS
Who Interrupted Treatment

Length of Length of Do a Result of Treatment
Register again?
treatment interruption smear? smear modification
Less than Less than 2 No, use the same treatment Continue Regimen for
No Continue Regimen-I
Category I
one month weeks card.
No, open a new treatment Start again on Regimen

Positive card and use same case Start again on Regimen- I
2 weeks or for Category I
Yes number.
more
No, use the same treatment Continue Regimen for
Negative Continue Regimen-I
card. Category I
One to two Less than 2 No, use the same treatment Continue Regimen for
No Continue Regimen - I
months weeks card. Category I
Complete the remaining
No, use the same treatment Intensive Phase, add one
Positive
card. extra month of Intensive
2 to 8 weeks Yes Phase.
Negative Continue Regimen - I
card. Category I
Close the previous
More than 8
StartStart on Regimen
- II for
registration as "Defaulter",
Positive on Regimen
weeks but then re-register as "RAD", Category II
Yes open a new treatment card.
within the 6
month regimen No, use the same treatment Continue Regimen for
card. Category I
More than 2 Less than 2 No, use the same Continue Regimen for
No Continue Regimen - I
months weeks treatment card. Category I
Close the previous
registration as "Defaulter" Start on Regimen for
Positive (*1), then re-register as Start on Regimen - II
"RAD", open a new
Category II
2 to 8 weeks Yes
treatment card.
card. Category I
Close the previous
More than 8 registration as "Defaulter", Start on Regimen for
Positive Start on Regimen- II
weeks but then re-register as "RAD", Category II
Yes open a new treatment card.
within the 6
month regimen Negative
No, use the same Continue Regimen for
Continue Regimen - I
treatment card. Category I
ANNEXES 99
ANNEX 14B: TREATMENT REGIMEN MODIFICATION FOR
RELAPSE & FAILURE CASES WHO INTERRUPTED TREATMENT
Who Interrupted Treatment

Length of Length of Do a Result of Treatment
Register again?
treatment interruption smear? smear modification
Less than Less than 2 No, use the same treatment Continue Regimen for
No Continue Regimen-II
Category II
one month weeks card.
No, open a new treatment Start again on Regimen

Positive card and use same case Start again on Regimen-
for Category II II
2 weeks or number.
Yes
more Continue Regimen for
No, use the same treatment
Negative Continue Regimen-II
card. Category II
One to two Less than 2 No, use the same treatment Continue Regimen for
No Continue Regimen - II
Category II
months weeks card.
Complete the remaining

No, use the same treatment Intensive Phase, add one
Positive
card. extra month of Intensive
2 to 8 weeks Yes Phase.
Negative Continue Regimen - II
card. Category II
Close the previous
registration as "Defaulter", Start on Regimen for
More than 8 Positive Start on Regimen-II
then re-register as "RAD", Category II
weeks but open a new treatment card.
Yes
within the 6 Close the previous
month regimen registration as "Defaulter", Continue Regimen for
Negative ContinueCategory
Regimen-II
II
then re-register as "RAD",
open a new treatment card.
More than 2 Less than 2 No, use the same treatment Continue Regimen for
No Continue Regimen-II
Category II
months weeks card.
Close the previous

registration as "Defaulter" Start on Regimen for
Positive (*2), then re-register as Start on Regimen-II
Category II
2 to 8 weeks Yes "RAD", open a new
treatment card.
Negative Continue Regimen-II
card. Category II
Close the previous
registration as "Defaulter", Start on Regimen for
Positive Start on Regimen-II
Category II
then re-register as "RAD",
More than 8
open a new treatment card.
weeks but
Yes Close the previous
within the 6
registration as "Defaulter", Continue Regimen for
month regimen Negative then re-register as "RAD", ContinueCategory
Regimen-II
II
open using a new
treatment card.
* 2 This is the exceptional case to define as "Defaulter" for a patient who interrupted treatment of less than 8 weeks.
ANNEX 15: GUIDE TO CASE HOLDING
AT THE TREATMENT UNIT

To be accomplished by 1. Conduct health education to patient and his/her family on the following key
the health workers messages:
• Importance of regular drug intake
• Results of irregular drug intake
• Side effects of anti-TB drugs
• Necessity of follow-up sputum smear examinations
• Importance of family and treatment partner support
2. Conduct regular consultation meeting with patient and treatment
partner during the course of treatment.
To be accomplished by 3. Monitor and record treatment regularly.
the Nurse/Midwife and • TB Register (Nurse)
treatment partner • NTP Treatment Card (Midwife)
• NTP ID Card (Treatment Partner and TB patient)
To be accomplished by 4. Do follow-up sputum smear examinations on time.
the Nurse/Midwife • Label container with the name of the patient and serial No.1, 2, 3.
• Collect 1 sputum specimen (preferably early morning specimen).
• Fill up the NTP Laboratory Request Form for Sputum Examination
• Pack the specimens securely and send together with the properly
accomplished Laboratory Request Form for Sputum Examination to
microscopy center.
AT THE MICROSCOPY CENTER

(To be accomplished by the Medical Technologist or Microscopist)
1. Register in the NTP Laboratory Register (date received and serial number)
2. Smearing, fixing, staining, and microscopic examination.
3. Record the results in the Laboratory Request Form for Sputum Examination and in the NTP
Laboratory Register
4. Send the Laboratory Request Form for Sputum Examination to the treatment unit.
AT THE TREATMENT UNIT

To be accomplished by Record the sputum-smear examination results and due date of next sputum
the Nurse/Midwife smear follow-up examination in the NTP Treatment Card. Any follow-up
examination with smear positive results must be referred to the physician.
To be accomplished by Record the results in the NTP TB Register.
the Nurse
To be accomplished by Inform the treatment partner of the sputum-smear examination results so that
Nurse/Midwife she can update the NTP ID Card.
To be accomplished by Upon Treatment Completion
the Physician, Nurse 1. Evaluate and record the treatment outcome in the NTP TB Register and
and Midwife NTP Treatment Card.
2. Prepare the Quarterly Report on Treatment Outcome and submit it.
ANNEXES 101
ANNEX 16: GUIDE TO ENSURE TREATMENT
Recorded Information should be checked to ensure individual treatment.
NTP TREATMENT CARD

(to be accomplished by the Nurse or Midwife)
Record of Individual Patients
• TB Case Number
• Classification, Type and Regimen
• Sputum examination results on diagnosis, for follow-up
• Drug collection
• Defaulter action
• Treatment outcome
Laboratory Register
The nurse should check the following
(to be accomplished by the Medical
information weekly. These are:
technologist/microscopist)
Record of laboratory examination
• Is the diagnosis correct?
results
• Is the treatment regimen appropriate?
• 3 sputum collection
• Are all smear-positive cases registered
• Sputum-smear examination results
and treated properly with DOT?
on diagnosis/for follow-up
• Are drugs collected on time?
• Are follow-up exams done on time?
• Are treatments regular and effective?
• Are actions taken to retrieve defaulters?
NTP TB Register
(to be accomplished by the Nurse)
Record of Treatment Activity in the Treatment Unit
• TB Case Number
• Classification, Type and Regimen
• Sputum examination results on diagnosis and for follow-up
• Defaulter action
• Treatment outcome
ANNEX 17: PERSONS RESPONSIBLE FOR
THE RECORDING FORMS
Responsible for Initial Records

Responsible for RECORDS
Recording
Recording Maintenance and Updating
NTP Client List/Target Client

Midwife/Nurse
Midwife/Nurse Midwife/Nurse
Midwife/Nurse
List
NTP Laboratory Request

Form for Sputum Midwife/Nurse
Examination
Medical Technologist and Medical Technologist and

NTP Laboratory Register
Microscopist Microscopist
NTP Treatment Card Nurse Midwife/Nurse
Treatment partner
NTP Identification Card Nurse (kept by the treatment partner and
the patient)
NTP TB Register Nurse Nurse
NTP Referral/Transfer Form Physician/Nurse
ANNEXES 103
ANNEX 18: RECORDING & REPORTING FORMS
RECORDING FORMS
TB SYMPTOMATICS MASTERLIST
NTP LABORATORY REQUEST FORM FOR SPUTUM EXAMINATION
NTP LABORATORY REGISTER
NTP TREATMENT CARD
NTP IDENTIFICATION CARD
TB REGISTER
NTP REFERRAL/TRANSFER FORM
TB DIAGNOSTIC COMMITTEE (TBDC) REFERRAL FORM
TTB DIAGNOSTIC COMMITTEE MASTERLIST
NTP MONITORING CHECKLIST
REPORTING FORMS AND COUNTING SHEETS
QUARTERLY REPORT ON NTP LABORATORY ACTIVITIES

COUNTING SHEET FOR LABORATORY ACTIVITIES REPORT
QUARTERLY REPORT ON NEW CASES AND RELAPSES OF TUBERCULOSIS AND ON
DRUG INVENTORY AND REQUIREMENT
COUNTING SHEET FOR CASE FINDING BY TYPES/DRUG INVENTORY
QUARTERLY REPORT ON THE TREATMENT OUTCOME OF PULMONARY TB CASES
REGISTERED 13 – 15 MONTHS EARLIER
COUNTING SHEET FOR QUARTERLY REPORT ON THE TREATMENT OUTCOME OF
PULMONARY TB CASES
QUARTERLY TB DIAGNOSTIC COMMITTEE ACCOMPLISHMENT REPORT
ANNEX 18A: NTP CLIENT LIST / TARGET CLIENT LIST (TCL)
The following are the instructions on how to record information in the NTP Client List.
(1) Write the family serial number based on the family consultation record or annual serial number for TB
symptomatics in the clinic.
(2) Write the date (mo/dd/yr) when the TB symptomatics were discovered.
(3) Write the patient’s full name, with the family name written first in capital letters followed by the first
name.
(4) Write the patient’s full address including landmarks/telephone or celfone number (if possible) so that
the patient can be traced in case he/she does not return to get his/her examination results.
(5) Write the exact age of the patient in years.
(6) Indicate the sex of the patient, write M for male and F for female.
(7) Write the date when each sputum specimen is collected and its corresponding results written below.
(8) Write the date and results of sputum collection in TB Sx with doubtful smear results on the first
examination.
(9) Write the date (mo/dd/yr) when the patient was referred for an X-ray examination.
(10) Write the date when the X-ray finding was received by the health worker and its results written below.
(11) Write the TB Case Number for patients who have been diagnosed with TB and registered.
(12) Write any significant information pertaining to symptomology, referral or diagnostic findings, such as
patient with massive hemoptysis, referred to hospital, etc.
Note: Target Client List (TCL) may be used as TB Symptomatic Masterlist in Public Health facilities.
ANNEXES 105
ANNEX 18B: NTP LABORATORY REQUEST FORM
FOR SPUTUM EXAMINATION
TO BE FILLED OUT BY NURSE OR MIDWIFE
Name of Collection Unit: ____________________ Date of Submission: _________________

Name of Patient:___________________________ Age: ______ Sex: M F
Address (in full): ______________________________________________________________
Disease Classification: Pulmonary Extra-pulmonary
Site: _________________________
Reason for Examination Diagnosis Follow-up Others
TB Case No.:__________________
Specimen Date of Collection

1
2
3
Signature of Specimen Collector:__________________________ Remarks: ______________

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
(Be sure to enter the patient’s TB Case No. for follow-up of patient’s Chemotherapy)
TO BE FILLED UP BY MICROSCOPY UNIT/LABORATORY PERSONNEL
Date Received: ____________________

Laboratory Serial No._______________________
Specimen 1 2* 3*
Visual Appearance**
Reading
Laboratory Diagnosis
* Specimen #2 & 3 = not applicable if sputum follow-up
** Muco-purrulent, bloodstained, saliva, etc.
Date of Examination:____________________ Examined by (Signature):________________
The completed form (with results) should be sent to the treatment unit to record the results in the
laboratory register.
FOR SPUTUM EXAMINATION (UPPER PORTION)
The following are the instructions on how to record information in the upper portion of the Laboratory
Request Form for Sputum Examination. (To be accomplished by the midwife/nurse).
(1) Write the name of the health facility (BHS/RHU/PPMD Unit) where sputum specimen was collected.
(2) Write the date (mo/dd/yr) when the sputum specimens were sent to the laboratory/microscopy unit.
(3) Write the patient’s full name with his/her family name first followed by his/her first name.
(5) Indicate the sex of the patient, write M for male and F for female.
(6) Write the patient’s full address including landmarks/telephone or celfone number (if possible) so the
patient can be traced in case he/she does not return to get his examination results.
(7) Check the Pulmonary box if the patient is a pulmonary TB suspect. Check the Extra-pulmonary box for
TB of organs other than the Lung, i.e. pleura (TB pleurisy), bones, genito-urinary tract etc., and the site
(name of the organ or body part is written).
(8) Check the diagnosis box for sputum specimens collected for diagnosis (three specimen). The follow-up
box is checked for sputum specimen collected to follow-up sputum smear status of patients under
treatment (one specimen). Check the box on Others for reasons other than the two.
(9) Write the TB Case Number from treatment card/TB registry of patients for follow-up.
(10) Write the date of collection of each sputum specimen and should correspond to the number labeled on
the sputum container; for diagnosis (three specimen), for follow-up (one specimen).
(11) Place the signature of the sputum collector or head of the referring treatment unit.
ANNEXES 107
FOR SPUTUM EXAMINATION (LOWER PORTION)
The completed form (with results) should be sent to the treatment unit to record the
results on the Tuberculosis Treatment Card.
The following are the instructions on how to record information in the lower portion of the
Laboratory Request Form for Sputum Examination (to be accomplished by the Medical Tech-
nologist or Microscopist).
(1) Write the date when the sputum specimen was received with this form at the laboratory or
microscopy center.
(2) Indicate the laboratory serial number designated for each specific sputum microscopy
examination in the laboratory or microscopy center.
(3) Write the observed visual appearance of each specimen submitted.
(4) Write the readings of each specimen examined for sputum microscopy. This is either negative
or positive. If negative, indicate “O.” if positive, indicate the positivity grading as follows:
“+n” = 1– 9 AFB / 100 visual fields
“1+” = 10 – 99 AFB / 100 visual fields
“2+” = 1– 10 AFB / OIF in at least 50 visual fields
“3+” = More than 10 AFB / OIF in at least 20 visual fields
(5) Record the overall evaluation of the specimens submitted for sputum microscopy. A POSITIVE
result should have at least two specimens positive. A NEGATIVE result should have at least
three specimens negative. A DOUBTFUL result has only one specimen positive.
(6) Write the date when the specimens were examined.
(7) The Medical Technologist or Microscopist who actually examined the sputum specimen
must sign in the space provided in the form.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
ANNEXES
Sab.
L Date of Name Age Sex Name of Name Address
Name / Examined Date of Examination Remarks Signature
Serial No. Registration Collection /Type
o f of PhilCAT Certification No. for /Result of MT
/Treatment Referring Dx Ff-up 1st 2nd
Unit Physician (TB
Case
No.)
ANNEX 18C: NTP LABORATORY REGISTER (FORM)
109
ANNEX 18C: NTP LABORATORY REGISTER
(RECORDING INSTRUCTIONS)
The following are the instructions on how to record information in the Laboratory Register
(to be accomplished by the Medical Technologist or Microscopist).
(1) Write the laboratory serial number assigned for every examination made, whether for diagnosis
or for follow-up.
(2) Write the date when the 1st sputum specimen was received by the microscopy center.
(3) Write the patient’s full name with his family name first in capital letters followed by the first
name.
(5) Indicate patient’s sex with the letter M for male and the letter F for female.
(6) Write the name of the health facility where sputum for diagnosis was collected or name of
treatment unit for patients on follow-up.
(7) Indicate the name and the PhilCAT certification number of the referring physician.
(8) Write the patient’s full address should include landmarks or telephone number/celfone number
(if available).
(9) Check Dx when sputum examination was requested for diagnosis. The TB case number is
indicated in the column on follow-up examination.
(10) Write the date and the results of each sputum specimen examined in the corresponding
columns provided.
(11) Write in the remarks column, significant information pertaining to the examination, i.e., Positive,
Negative, Doubtful. For visual appearance of the specimens, use the abbreviation M for muco-
purulent, S for salivary or QNS for inadequate specimen.
(12) Signature of medical technologist or microscopist who actually examined the sputum
specimens.
ANNEX 18D: NTP TREATMENT CARD
1
4 5
3
2
6 7 8
9 10
13
11
12
14
15 18
16
17 19
a b c d
20
21
22 23
(Back page of NTP Treatment Card)
DRUG INTAKE (INTENSIVE PHASE) 24
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
DRUG INTAKE (MAINTENANCE PHASE) 25

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Remarks:
REMARKS:
26
ANNEXES 111
ANNEX 18D: NTP TREATMENT CARD (CONTINUATION)
1
4 5
3
2
6 7 8 9 10
13
11
12
14
15 18
16
19
The following are the instructions on how to record information in the treatment card.
(1) Write the TB Case Number assigned to a TB case from the TB register.
(2) PhilHealth ID Card Number
(3) Write the date when this NTP Treatment Card was opened.
(4) Write the name of the region and province where the treatment facility is located.
(5) Write the name of the health facility/treatment unit where the patient is receiving TB
treatment.
(6) Write the patient’s full name with his family name written first in capital letters followed by
the first name.
(7) Write the patient’s occupation and place of work.
(8) Write the exact age of the patient.
(9) To indicate patient’s sex, encircle the letter M for male and the letter F for female.
(10) Number of Household contact.
(11) Write the patient’s full address including landmarks/telephone number (if available) to
easily trace him/her.
(12) Write the name/relationships/address of a person who can assist the patient for a regular
treatment during the entire treatment course. Indicate the number of persons living with
the patient.
(13) Mark/check the appropriate box whether patient has BCG scar or not.
(14) Indicate the exact history of patient’s previous TB treatment should be carefully recorded.
If the patient has previous TB treatment history, mark Yes and mark whether it is less than
a month or more than a month and specify the drug administered to the him/her; record
the year and the place the patient received TB medicines.
(15) Check/mark the appropriate box indicating the classification of the patient (Pulmonary or
Extra-pulmonary TB). Mark/check the space that indicates the type of patient based on
the previous TB treatment history and results of sputum examination before treatment
(New, Relapse, Transferred In, Return After Default, Failure, Other).
(16) Name of referring health worker and type of referral.
(17) Record sputum examination results and weight in kilograms of patient.
(a-e) Month 0 pertains to the sputum examination result before treatment. Fill up the date
examined and the result of the sputum examination before treatment in the columns
designated. The Due Date when follow-up sputum examination is scheduled, the Date
ANNEX 18D: NTP TREATMENT CARD (CONTINUATION)
e 17
a b c d
20
21
22 23
Examined when the sputum examination is actually made and the Result of the follow-up
sputum examination should be filled up carefully in the columns of Month 2 to Month >7
according to the schedule of following-up sputum examination.
(18) Write the patient’s treatment regimen by the category, I, II or III.
(19) Write the date when the first dose is actually taken by the patient.
(20) Mark one of the Treatment Outcome Cured Treatment Completed, Died, Treatment Failure, Defaulter,
Transfer Out. The date is when the patient stopped taking medicines.
(21) Write any pertinent information concerning the diagnosis and treatment process of the patient.
(22) Write the name of treatment partner assigned to the patient.
(23) Write the designation of the treatment partner, PHN RHM, or BHW.
(Back page of NTP Treatment Card)
DRUG INTAKE (INTENSIVE PHASE) 24
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
DRUG INTAKE (MAINTENANCE PHASE) 25

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Remarks: 26
(24-25) Mark the date the treatment partner collects the medicines for the following one week at BHS and
draw line between marks. If the midwife at the BHS as treatment utilizes this TB Treatment Card as a
TB Identification Card, each box should be marked, to indicate the day and month, when the patient
took his/her anti-TB drugs in front of the midwife (treatment partner).
(26) Record pertinent information that occur during the treatment course, i.e. adverse reactions and reasons
for failure to follow-up/ tracing action.
ANNEXES 113
ANNEX 18E: NTP IDENTIFICATION CARD (FRONT)
CERTIFICATION NTP
IDENTIFICATION CARD
NTP
This certifies that the patient, IDENTIFICATION CARD
Case No. (1)
_____________________________,
bearer of this NTP ID Card, has

been CURED (completed the MGA PAALALA
1. Ang TB ay nakakahawa pero
required treatment, daily nagagamot.
supervised by the health 2. Ang mga gamot ay kailangan araw-
personnel/BHW of araw na inumin upang tuluyang
gumaling.
_____________________________ 3. Kailangang magpasuri ng plema sa
RHU/ Health Center and, with itinakdang araw ng health worker
Negative smear follow-up result at upang malaman kung gumagaling na.
4. Kapag magaling ka na higit kang
the end of the treatment). makakatulong sa iyong pamilya at
kabarangay.
Issued this __________ day of
_______________, 20___. HEALTH UNIT (2):
____________________
NAME OF PATIENT (3):
_______________
ADDRESS (in full) (4):
_____________________________
MHO/RHP TREATMENT PARTNER/S (5):
(SIGNATURE OVER PRINTED NAME)
(1) The case number designated to a TB case

from the TB Register after initiation of
treatment/registration is completed.
(2) The name of the health facility/treatment
unit where the patient is receiving TB
treatment.
(3) The full name of the patient (family name
written first followed by the given name).
(4) The exact address of the patient. Indicate the
landmarks and telephone number (if any) to
easily trace for necessary action.
(5) The name of the treatment partner (a
responsible person supervising the patient’s daily
drug intake).
ANNEX 18E: NTP IDENTIFICATION CARD (BACK)
DISEASE CLASSIFICATION (6)

TYPE OF PATIENT (8)
(6)
[ ] Pulmonary [ ] New [ ] Treatment Failure
[ ] Extra-Pulmonary [ ] Relapse [ ] Return after default
Site: ________________________ [ ] Transfer In [ ] Others
REGIMEN (7) _____________ SPUTUM EXAMINATION RESULT (9)

Before >7
Treatment started: 2 mos 3 mos 4 mos 5 mos 6 mos
Tx mos
Date
Mo. _____ Day: _____ Yr.: _______ Result

Weight (kg)
DRUG INTAKE (INTENSIVE PHASE) (10)

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
DRUG INTAKE (MAINTENANCE PHASE)

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Remarks:
Remarks:
(6) Disease Classification: Tick one.

(7) Indicate the prescribed treatment regimen. Indicate the exact date when treatment started.
(8) Type of Patient. Tick one.
(9) All sputum examinations done to the patient. Before Tx, indicate examination results before
treatment. In the succeeding months, indicate the follow up examination results and weight in
kilograms.
(10) DRUG INTAKE WITH DOT. Indicate the month and tick or sign the corresponding day when
treatment was started. Tick each box, indicating the day and the month, when the patient took
his/her anti-TB drugs in front of the treatment partner. Indicate a missed day with a blank.
ANNEXES 115
ANNEX 18F: TB REGISTER
Year: _____________________
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
Date of TB Case Name Age Sex Address Health Name /Type of Referring
Referring Physician
Health Worker CLASS TYPE OF PATIENT REGIMEN
Registrati- No. Facility OF TB
on DIAG. Return
Name TypeofofReferral
Referral (P/EP) New Relapse Trans. in after Failure Other
default
The following are the descriptions of the items to be recorded in the form.
(1) The exact date when the patient was registered in the TB Register.
(2) The case number assigned to a TB case after registration.
(3) Name of patient (surname first)
(4) Age of the patient in years.
(5) Indicate the patient’s sex with the letter M for male and the letter F for female.
(6) The exact address of the patient including phone number, if available and the nearest
landmark to easily locate the patient.
(7) The health facility or treatment unit where the patient is receiving treatment for TB.
(8) Name and PhilCAT Certification No. of Referring Physician / Health Worker, and
type of referral (Public, PPMD, PDI, Walk-in)
(9) “P” for Pulmonary TB, “EP” for Extra-pulmonary TB.
(10) Check or mark the TYPE of patient under the appropriate column provided.
(11) Indicate the prescribed SCC treatment regimen as Category: I, II, III.
ANNEX 18F: TB REGISTER (CONTINUATION)
Name of Health Facility

(12) (13) (14) (15) (16)
DATE STARTED TX. SPUTUM EXAMINATION RESULTS/WEIGHT RECORD TREATMENT OUTCOME Tr. Part. Remarks
(upper space: date of exam; middle space: results; lower space: weight) (CXR
result, etc.)
Treat. Treat.
Before TX. 2nd mon. 3rd mon. 4th mon. 5th mon. 6th mon. > 7th mon. Cure Died Default Transf. Out
Compl. Failure
The following are instructions on how to record information on the form.

(12) Write the date when the patient first started treatment.
(13) Indicate all sputum examinations done to the patient. Indicate the date of examination done
in the upper row and the examination results in the middle row and weight in kilograms in the
lower row.
(14) Check the appropriate treatment outcome and indicate the exact date (mm/dd/yr) when the
patient stopped or completed treatment or his last day of drug intake.
(15) Treatment Partner: PHN/RHM/BHW/FM/Others.
(16) Remarks – Result of CXR and any information about the patient’s status or any action taken
on his behalf.
ANNEXES 117
ANNEX 18G1: PPMD REFERRAL FORM / NTP (Sample PPMD Form)
TO BE FILLED-UP BY DOTS REFERRING PHYSICIAN
TO BE FILLED-UP BY RHU/HC/PPMD UNIT STAFF
ANNEX 18G2: PPMD FOLLOW-UP FORM / NTP (Sample PPMD Form)
TO BE FILLED-UP BY RHU/HC/PPMD UNIT STAFF
TO BE FILLED-UP BY MEDICAL TECHNOLOGIST OR MICROSCOPIST
ANNEXES 119
ANNEX 18H: QUARTERLY REPORT ON NTP LABORATORY / ACTIVITIES
QUARTERLY REPORT ON NTP LABORATORY ACTIVITES

Name of Province/City: TB Symptomatics/Patients examined
during the ____ Quarter of _____
Name of Health Facility: Date Reported:
Prepared by:
Type of Facility: - Public-initiated
Public PPMD - Private-initiated
Designation
CASE FINDING
Laboratory Activities Public
Walk-in PPMD
Referral
1. No. of TB Symptomatics examined:
2. No. of TB Symptomatics with 3 sputum specimens:
3. No. of TB Symptomatics diagnosed as smear-positive with 2 or

more positive results:
(including the number of doubtful cases in the 1st collection with at least one
positive result in the 2nd collection set)
4. No. of TB Symptomatics with Doubtful result:
TREATMENT FOLLOW-UP
5. No. of Follow-up examination done:

Number of smear positive
ANNEX 18I: COUNTING SHEET FOR LABORATORY ACTIVITIES REPORT
ANNEX 12: GUIDE IN MANAGING SCC DRUGS SIDE EFFECTS
No. of TB Symptomatics
Start Lab. Total No. of TB Symptomatics No. of TB Symptomatics No. of TB Symptomatics No. of Follow-up
Page with 3 sputum
No. Persons Examined with 2 or more positive with doubtful result examination done
specimens
10
ANNEXES 121
ANNEX 18J: QUARTERLY REPORT ON CASE FINDING & DRUGS INVENTORY
Quarterly Report on New Cases and Relapses of Tubercolosis and on

Quarterly Report on Case Finding and Drug Inventory Requirement
Drug Inventory and Requirement
Name of Province/City: TB Patients registered during
the ____ Quarter of _____
Name of Health Facility: Date Reported:
Prepared by:
Public PPMD - Private-initiated Designation
CASE
CASEHOLDING REPORT:
FINDING REPORT:
Health Facility Total
Type of Patient Age Group Public
Walk-in Referral
PPMD
Walk-in
Public Referral
PPMD
M F M F
A. Pulmonary
A. Pulomonary Tubercolosis
Tuberculosis 0 - 14
1. Smear-positive cases
1.1. New 15 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 & above
SUB-TOTAL
1.1. Relapses
2. New Smear-negative
cases
B. New Extra-pulmonary TB
TOTAL
DRUG INVENTORY AND REQUIREMENT REPORT:

FDC A FDC B INHsrp RFPsrp
Est. No. of PZA tab Ethambutol SM
Regimen (HRZE) (HR) (100mg /tsp (100mg /tsp
Cases (BP) (BP) (vial)
(BP) (BP) 120ml) 60ml)
I (x 6) (x 12)
II (x 9) (x 15) (x 10) (x 56)
III (x 6) (x 12)
Childhood TB
Total for Reg. I, II,

and III
Total + Buffer (Total
multiplied by 2)
Available on hand
Re-order for Reg. I,
II and III
ANNEX 18K: COUNTING SHEET FOR CASE FINDING BY TYPE /
DRUG INVENTORY
New Smear Positive

Failure,
New Progre-
Start TB Total New Primary Transfer In,
Page 0-14 15-24 25-34 35-44 45-54 55-64 65-+ Total Rel. Smear ssive Cat. -I Cat. -II Cat. -III
Case No. Persons EP PTB Others
Neg. PTB
(*)
M F M F M F M F M F M F M F M F
* This column is not for reporting but only for counting validation
ANNEXES 123
ANNEX 18L: NTP QUARTERLY REPORT ON THE TREATMENT
OUTCOME OF PULMONARY TB CASES
5 EARLIER
REGISTERED 13 - 16
Name of Province/City: Patients registered during the Date Reported:
Name of Health Facility: ________ Quarter of _________ Prepared by:

Public PPMD - Private-initiated Designation:
Name of Province/City: Patients registered during the Date Reported:

Name of Health Facility Prepared by:
__________ Quarter of __________
Designation:
TOTAL NUMBER OF
REPORTED PULMONARY TB
TYPE (1) (2) (3) (4) (5) (6) (1 - 6)
CURE TREATMENT DIED TREATMENT DEFAULTER TRANSFER TOTAL NO.
CASES* COMPLETED FAILURE OUT EVALUATED
(Copy the total number you reported in the
Case-Finding Report during the same
quarter)
1. NEW CASES
1.1. Smear-positive
1.2. Smear-negative
2. RE=TREATMENT
2.1. Relapse
2.2 Failure
TOTAL NUMBER EVALUATED

* Of those, ________ (number) were excluded from evaluation of chemotherapy for the following reasons: Trans-in, Other and Extra-pulmonary.
ANNEX 18M: COUNTING SHEET FOR QUARTERLY REPORT ON THE

TREATMENT OUTCOME OF PULMONARY TB CASES
__________ Quarter of __________

TREATMENT TREATMENT TRANSFER
TYPE CURED COMPLETED
DIED FAILURE
DEFAULTER
OUT
TOTAL
New Smear-Positive
New Smear-Negative
Relapse
Failure
TOTAL NUMBER
EVALUATED
ANNEX 19: PROGRAM INDICATORS
INDICATORS CALCULATION DATA SOURCE

CASE FINDING
1. Three- sputum Number of TB symptomatics who submitted 3 Quarterly Report on
Collection Rate (%) sputum specimens
# of TB symptomatics w/ 3 sputum specimens Laboratory Activities;
X 100
Total # of TB symptomatics examined x 100 Laboratory Register
Total number of TB symptomatics examined
2. Positivity Rate (%) Total number of sputum smear-positive cases Quarterly Report on
discoveredTotal # of sputum smear (+) cases X 100 Laboratory Activities;
Total # of TB symptomatics examined x 100 Laboratory Register
Total number of TB symptomatics examined
3. Case Detection Number of New smear-positive cases detected Quarterly Report on TB
Rate (CDR) of # of new smear (+) cases detected x 100 Register Case finding
X 100
new smear- Number# ofof estimated
estimated new new
smearsmear-positive
(+) TB cases TB
positive cases cases
(The denominator is a WHO estimation for each
country based on available data including case
notifications, mortality and studies on disease
prevalence and risk of infection, and adjusted for
countries with high incidence. These estimations
are reported every year by WHO in the annual
“Global Tuberculosis Control” report.)
4. Proportion of pulmonary
Case Notification Rate Number of New smear-positive cases notified Quarterly Report on
smear
of new positive cases
smear-positive x 100,000 Casefinding TB
# of pulmonary smear (+) cases registered
out of per
cases pulmonary Total number
total100,000 of population in the specified
Total # of pulmonary cases registered
area
X 100 Register
cases (%)
population
TB DIAGNOSTIC COMMITTEE
5. Proportion of new Number of new smear-negative, CXR positive TB TBDC Register
smear-negative, CXR cases diagnosed as active TB
# of new smear (-), CXR (+) active TB x 100
positive TB cases X 100
Total Total # ofofsmear
number (-), CXR (+) TBDCCXR
smear-negative, cases positive TB
diagnosed as active
TB for treatment cases evaluated by TBDC
OLD
6. Proportion of new Number of new smear-negative, CXR positive TB (TBDC Register)
smear-negative, CXR # of newinitiated
cases smear (-), to
CXR (+) TB cases for re-treatment
treatment (NTP TB Register)
X 100
positive TB cases for Total # of smear (-), CXR (+) TBDC cases x 100
re-treatment Total number of smear-negative, CXR positive TB
cases evaluated by TBDC
8. Proportion of # Number of Pulmonary smear-positive cases Quarterly Report on
pulmonary smear (New and Relapse) registered Cases Initiated to
positive cases out of x 100 Treatment (TB register)
all pulmonary cases Total number of pulmonary (New smear-positive,
(%) New smear-negative and Relapse) cases
registered
ANNEXES 125
ANNEX 19: PROGRAM INDICATORS (CONTINUATION)
INDICATORS CALCULATION DATA SOURCE

CASE HOLDING
7. Sputum conversion Number of New sputum smear-positive cases TB register
rate at the end of 2 # of
which are new smear
smear (+) casesatwho
negative theareend of 2
smear (-) after 2 mos treatment
months of treatment months of treatment X 100
for new smear positive Total # of new sputum smear (+) x 100
cases of
Total number registered during samesmear-positive
New sputum period
cases (%)
cases registered during some period of time
8. Treatment outcomes • Cure rate: Quarterly Report on the
for New smear- Number# of cases
of cases who
who werewere
cured cured Treatment Outcome of
X 100 x 100 Pulmonary TB cases ;
positive cases, New Total # of cases registered
smear-negative cases, Total number of cases registered TB register
Relapse cases and • Completion rate:
Failure cases (%). Number of cases who completed treatment
# of cases who completed treatment
X 100 x 100
Total # of cases registered
(Reminder: There is no Total number of cases registered
cure rate applied to • Death rate:
smear negative cases.) Number of cases who died during the
# of cases who died during treatment
treatment X 100
x 100
Total number of cases registered
• Treatment Failure rate:
Number of smear positive cases who still
# of cases of smear (+) cases that remain
smear positive at five months or more of
smear (+) after 5 or more months of treatment
treatment X 100
x 100
• Defaulter rate:
Number of cases who were defaulted
# of cases who defaulted
X 100x 100
• Transfer-out rate:
Number of cases who transferred to another
# of cases who transferred to another
Health facility with a proper referral/transfer
Health facility with proper referral/transfer slip
slip X 100
x 100
ANNEX 20A: IMPAIRMENT CLASSIFICATION FOR RESPIRATORY
DISEASE INJURIES (Modified from American Thoracic Society Criteria)
Class I Class 2 Class 3 Class 4

CRITERIA
20% OB 30% OB 50% OB 100% OB
I. History and
P.E. Findings
Functional Grade 1 Grade 2 Grade 3 Grade 4
Classification
(DYSPNEA)
and and and and
Pertinent Slight Moderate Marked
Signs and Constitutional Constitutional Constitutional
Symptoms symptoms symptoms symptoms with
cardio-pulmonary
embarrassment
In Injuries Slight Slight limitation Moderate Marked
Constitutional of Chest restriction of restriction of
symptoms, also expansion and/or chest expansion, chest expansion
Pain, discomfort chest deformity deformities of and/or
on exertion; chest deformities of
slight limitation chest, e.g.,
of chest marked
expansion/excur- adhesions of
sion, and/or diaphragm or
chest deformity pericardium
If present
Anemia (Hgb) 81 to 100 g/l 70 to 80 g/l <70 g/l
Weight loss 10% of IBW* 15% of IBW* >15% of IBW*
Respiratory Mildly impaired Moderately Severely
impairment by impaired impaired
spirometry
Modified Tanhauser's formula for IBW for Filipinos = (height in cm - 100) x 10%
ANNEXES 127
ANNEX 20B: ATS FUNCTIONAL CLASSIFICATION (of Dyspnea)
DESCRIPTION GRADE DEGREE

Not troubled by shortness of breath when hurrying on the 0 None
level or walking up a slight hill
Walks more slowly than people of same age on the level 1 Mild
because of shortness of breath
Has to stop for breath when walking at own pace on the level 2 Moderate
Stops for breath when walking about 100 yards or after a few 3 Severe
minutes on the level
Too breathless to leave house, or breathless on dressing or 4 Very severe
undressing
ANNEX 20C: ATS RATINGS OF RESPIRATORY IMPAIRMENT

BY SPIROMETRY
PULMONARY FUNCTION FUNCTIONAL

RATING
PARAMETERS IMPLICATION
NORMAL FVC >_ 80% predicted, and No functional limitations
FEV1 > 80% of predicted
MILDLY FVC 60-79% of predicted or FEV1 Usually not correlated with
IMPAIRED 60-79%
FEV1
of predicted
60-79% of predicted diminished ability to perform
most jobs
MODERATELY FVC 51-59% of predicted, or Progressively lower level of lung
IMPAIRED FEV1 41-59% of predicted function correlated with
diminishing ability to meet the
physical demands of many jobs
SEVERELY FVC < 50% of predicted, or Unable to meet the physical
IMPAIRED FEV1 < 40% of predicted demands of most jobs including
travel to work
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT
SSS GUIDE to FUNCTIONAL ASSESSMENT
I. Procedures for Scoring the Functional Independence Measure (FIM)
II. Table: Relationship of Raw FIM Score to Impairment of the Whole-Person
III. Description of the Levels of Function and their Scores
A. SELF CARE
1. Eating
2. Grooming
3. Bathing
4. Dressing – Upper Body
5. Dressing – Lower Body
6. Toileting
B. SPHINCTER CONTROL
1. Bladder Management
2. Bowel Management
C. MOBILITY
1. Transfers – Bed, Chair, Wheelchair
2. Transfers – Toilet
3. Transfers – Tub Shower
D. LOCOMOTION
1. Walk/Wheelchair
2. Stairs
E. COMMUNICATION
1. Comprehension
2. Expression
F. SPECIAL COGNITION
1. Social Interaction
2. Problem Solving
3. Memory
ANNEXES 129
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
Procedure for Scoring

the Functional Independence Measure (FIM) *
Each of the 18 items comprising the FIM has a maximum score of 7, and the
lowest score on each item is 1. The highest total score is 126 and the lowest total
score is 18. The clinicians in the field have been adamant in their conviction that a
seven-level scale is necessary for showing claimant function change with sufficient
sensitivity. The original four-level scale was superseded in 1987 and the seven-
level scale is recommended for all items.
Comment:
The social cognition items: social interaction, problem solving, and memory
are estimates of function in three important areas of a person’s daily activity. Un-
like the other areas of function assessed with the FIM, which have been in clinical
use for years, consensus is not yet clear among behaviorists and rehabilitation
clinicians about how to quantify these activities at the level of disability. The social
cognition items in the FIM have very acceptable reliability. They have been refined
as a result of comments made by users during the trial and implementation phases
and will continue to be refined as more clinical and research experience is gained
by the field.
Step 1. Record the number which best describes the subject’s level of func-
tion for every FIM item on the coding sheet.
If the subject would be put at risk for injury if tested, then enter 1.
Leave no FIM item blank.
When two helpers are required in order for the patient to perform the
behaviors described in an item, enter level 1. Set-up is uniformly
scored a level 5 for all items.
Step 2. Convert the raw FIM score to the equivalent whole-person impair-
ment estimate (% OB). Refer to ‘Table – Relationship of Raw FIM
Score to Impairment of the Whole – Person’ on the following page.
* UNIFORM DATA SET FOR MEDICAL REHABILITATION. The Uniform Data System for Medical
Rehabilitation was developed with support from the US Department of Education, National
Institute on Disability and Rehabilitation Research (NIDRR ), grant number G008435062, and
was conducted by the State University of New York at Buffalo, School of Medicine, Department
of Rehabilitation Medicine, 1990
Relationship of Raw FIM Score to Impairment of the Whole–person

(OB)
FIM OB FIM OB FIM OB FIM OB

Score Impairment Score Impairment Score Impairment Score Impairment
(%) (%) (%) (%)
126 0 98 26 70 52 42 78
125 1 97 27 69 53 41 79
124 2 96 28 68 54 40 80
123 3 95 29 67 55 39 81
122 4 94 30 66 56 38 81
121 5 93 31 65 56 37 82
120 6 92 31 64 57 36 83
119 6 91 32 63 58 35 84
118 7 90 33 62 59 34 85
117 8 89 34 61 60 33 86
116 9 88 35 60 61 32 87
115 10 87 36 59 62 31 88
114 11 86 37 58 63 30 89
113 12 85 38 57 64 29 90
112 13 84 39 56 65 28 91
111 14 83 40 55 66 27 92
110 15 82 41 54 67 26 93
109 16 81 42 53 68 25 94
108 17 80 43 52 69 24 94
107 18 79 44 51 69 23 95
106 19 78 44 50 70 22 96
105 19 77 45 49 71 21 97
104 20 76 46 48 72 20 98
103 21 75 47 47 73 19 99
102 22 74 48 46 74 18 100
101 23 73 49 45 75
100 24 72 50 44 76
99 25 71 51 43 77
ANNEXES 131
Description of the Levels of Function and Their Scores
A. SELF-CARE
1. EATING
Includes use of suitable utensils to bring food to the mouth, chewing and
swallowing, once the meal is appropriately prepared.
NO HELPER
7 Complete Eats from a dish, while managing all consistencies of food, and
Independence drinks from a cup or glass with the meal presented in the customary
manner on a table or tray. The subject uses a spoon of fork to
bring food to the mouth: food is chewed and swallowed.
6 Modified Requires an adaptive or assistive devise such as a straw, spork,

Independence rocking knife, requires more than a reasonable time to eat, or
requires modified food consistency or blenderized food, or there
are safety considerations. If the individual relies in part on other
means of alimentation, such as parenteral of gastrostomy feedings,
then he/she administers the feedings him/herself.
HELPER
5 Supervision or Requires supervision (e.g. standing by, cuing, or coaxing) or setup

Set-up (application of orthoses); or another person is required to open
containers, cut meat, butter bread or pour liquids.
4 Minimal Contact Subject performs 75% or more of feeding tasks.

Assistance
3 Moderate Assistance Performs 50% to 74% of feeding tasks
2 Maximal Allowance Performs 25% to 49% of feeding tasks

1 Total Assistance Performs <25% of feeding tasks. Or, the individual does not eat or
drink full meals by mouth but must rely in part on other means of
alimentation, such as parenteral or gastrostomy feedings, and does
not administer the findings him/herself.
2. GROOMING
Indicates oral care, hair grooming, washing hands and face, and either
shaving or applying make-up. If there is no preference for shaving or
applying make-up, then disregard.
NO HELPER
7 Complete Cleans teeth or dentures, combs or brushes hair, washes hands

Independence and face, shaves or applies make-up, including all preparations.
6 Modified Requires specialized equipment (including prosthesis, or orthosis)

Independence or takes more than a reasonable time, or there are safety
considerations.
HELPER
5 Supervision or Requires supervision (e.g. standing by, cuing, or coaxing) or set-

Set-up up (application of orthoses, setting out grooming equipment, and
initial preparation such as applying toothpaste to brush, opening
make-up containers).
4 Minimal Contact Subject performs 75% or more of grooming tasks

Assistance
3 Moderate Assistance Performs 50% to 74% of grooming tasks
2 Maximal Assistance Performs 25% to 49% of grooming tasks
1 Total Assistance Performs <25% of grooming tasks
ANNEXES 133
3. BATHING
Indicates bathing the body from the neck down (excluding the back),
either tub, shower or sponge/bed bath. Performs safely.
NO HELPER
7 Complete Baths and dries the body.
Independence
6 Modified Requires specialized equipment (including prosthesis, or orthosis)
considerations.
HELPER
Set-up up (setting out bathing equipment, and initial preparation such as
preparing the water or washing materials).
4 Minimal Contact Subject performs 75% or more of bathing tasks

Assistance
3 Moderate Assistance Performs 50% to 74% of bathing tasks
2 Maximal Assistance Performs 25% to 49% of bathing tasks
1 Total Assistance Performs <25% of bathing tasks
4. DRESSING – UPPER BODY
Indicates dressing above the waist as well as donning and removing

prosthesis or orthosis when applicable.
NO HELPER
7 Complete Dresses and undresses including obtaining clothes from their

Independence customary places such as drawers and closets; manages zippers,
buttons, and snaps; dons and removes prosthesis or orthosis when
applicable.
6 Modified Requires special adaptive closure such as Velcro, or assistive

Independence device (including prosthesis or orthosis) or takes more than a
reasonable time.
HELPER

Set-up up (application of orthosis, setting out clothes or dressing
equipment).
Minimal Contact Subject performs 75% or more of dressing tasks
4
Assistance
3 Moderate Assistance Performs 50% to 74% of dressing tasks
2 Maximal Assistance Performs 25% to 49% of dressing tasks
1 Total Assistance Performs <25% of dressing tasks
ANNEXES 135
5. DRESSING – LOWER BODY
Indicates dressing from the waist down as well as donning and removing
prosthesis or orthosis when applicable.
NO HELPER
7 Complete Dresses and undresses including obtaining clothes from their

Independence customary places such as drawers and closets; manages
underpants, slacks, skirt, belt, stockings, and shoes; manages
zippers, buttons, and snaps; dons and removes prosthesis or
orthosis when applicable.
6 Modified Requires special adaptive closure such as Velcro, or assistive

Independence device (including prosthesis or orthosis) or takes more than a
reasonable time.
HELPER

Set-up up (application of orthosis, setting out clothes or dressing
equipment).
4 Minimal Contact
Subject performs 75% or more of dressing tasks
Assistance
3 Moderate Assistance Performs 50% to 74% of dressing tasks
2 Maximal Assistance Performs 25% to 49% of dressing tasks
1 Total Assistance Performs <25% of dressing tasks
6. TOILETING
Includes maintaining perineal hygiene and adjusting clothing before and

after toilet or bedpan use. Performs safely.
NO HELPER
7 Complete Cleanses self after voiding and bowel movement; puts on sanitary
Independence napkins/inserts tampons; adjusts clothing before and after using
toilet.
6 Modified Requires specialized equipment (including prosthesis or orthosis)

considerations.
HELPER

Set-up up (application of adaptive devices or opening packages).
4 Minimal Contact Subject performs 75% or more of toileting tasks

Assistance
3 Moderate Assistance Performs 50% to 74% of toileting tasks
2 Maximal Assistance Performs 25% to 49% of toileting tasks
1 Total Assistance Performs <25% of toileting tasks
ANNEXES 137
B. SPHINCTER CONTROL
1. BLADDER MANAGEMENT
Includes complete intentional control of urinary bladder anduse of
equipment or agents necessary for bladder control.
NO HELPER
7 Complete Controls bladder completely and intentionally and is never incontinent.
Independence
6 Modified Independence Requires a urinal, bedpan, commode, catheter, absorbent pad, diaper,
urinary collecting device or urinary diversion or uses medication for control;
if catheter is used, the individual instills or irrigates catheter without
assistance; cleans, sterilizes, and sets up the equipment for irrigation
without assistance. If the individual uses a devise, he/she assembles and
applies condom drainage or al ileal appliance without assistance of another
person; empties, puts on, removes, and cleans leg bag or empties and
cleans ileal appliance bag. No accidents.
HELPER
5 Supervision or Set-up Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (placing
or emptying ) of equipment to maintain a satisfactory voiding pattern or to
maintain an external device; or because of the lapse of time to get to
bedpan or the toilet the individual may have occasional bladder accidents,
or bedpan or urinal spills, but less often than monthly.
4 Minimal Contact Requires minimal contact assistance to maintain an external devise; the
Assistance individual performs 75% or more of bladder management tasks; or may
have occasional bladder accidents, but less often than weekly.
3 Moderate Assistance Requires moderate contact assistance to maintain an external devise; the
individual performs 50% to 74% of bladder management tasks, or may
have occasional bladder accidents, but less often daily.
2 Maximal Assistance Despite assistance the individual is wet on a frequent or almost daily basis,
necessitating wearing diapers or other absorbent pads, whether or not a
catheter or ostomy devise is in place. The individual performs 25% to 49%
of bladder management tasks.
1 Total Assistance Despite assistance the individual is wet on a frequent or almost daily
basis, necessitating wearing diapers or other absorbent pads, whether or
not a catheter or ostomy devise is in place. The individual performs <25%
of bladder management tasks.
Comment: The functional goal of bladder management is to open the bladder sphincter only when that is
needed and to keep it closed the rest of the time. This may require devices, drugs or assistance in some
individuals. This item, therefore, deals with two variables: 1) level of success in bladder management and
2) level of assistance required. Usually the two follow each other, e.g. when there are more accidents usually
more assistance is required. However, should the two levels not be exactly the same, always record the
lower level.
2. BOWEL MANAGEMENT
Includes complete intentional control of bowel movementand use of
equipment or agents necessary for bowel control.
NO HELPER
7 Complete Controls bowels completely and intentionally and is never
Independence incontinent
6 Modified Requires bedpan or commode, digital stimulation or stool softeners,
Independence suppositories, laxatives, or enemas on a regular basis, or uses
other medication for control. If the individual has a colostomy, he/
she maintains it. No accidents.
HELPER
Set-up up of equipment necessary for the individual to maintain a
satisfactory excretory pattern or to maintain an ostomy device; or
the individual may have occasional bowel accidents, but less often
than monthly.
4 Minimal Contact Requires minimal contact assistance to maintain a satisfactory
Assistance excretory pattern by using suppositories or enemas or an external
devise; the individual performs 75% or more of bowel management
tasks; or may have occasional bowel accidents, but less often
than weekly.
3 Moderate Assistance Requires moderate contact assistance to maintain a satisfactory
excretory pattern by using suppositories or enemas or an external
devise; the individual performs 50% to 74% of bowel management
tasks, or may have occasional bowel accidents, but less often
than daily.
2 Maximal Assistance Despite assistance the individual is soiled on a frequent or almost
daily basis, necessitating wearing diapers or other absorbent pads,
whether or not an ostomy devise is in place. The individual
performs 25% to 49% of bowel management tasks.
1 Total Assistance Despite assistance the individual is soiled on a frequent or almost
daily basis, necessitating wearing diapers or other absorbent pads,
whether or not an ostomy devise is in place. The individual
performs <25% of bowel management tasks
Comment: The functional goal of bowel movement is to open the anal sphincter only when that is needed
and to keep it closed the rest of the time. This may require devices, drugs or assistance in some individuals.
This item, therefore, deals with two variables: 1) level of success in bowel management and 2) level of
assistance required. Usually the two follow each other, e.g. when there are more accidents usually more
assistance is required. However, should the two levels not be exactly the same, always record the lower
level.
ANNEXES 139
C. MOBILITY
1. TRANSFERS – BED, CHAIR, WHEELCHAIR
Includes all aspects of transferring to and from bed, chair, and wheelchair,
and coming to a standing position, if walking is the typical mode of
locomotion.
NO HELPER
7 Complete … If walking. Approaches, sits down and gets up to a standing

Independence position from a regular chair; transfers from bed to chair. Performs
safely.
… If in a wheelchair. Approaches a bed or chair, locks brakes, lifts

foot rests, removes arm rest if necessary, and performs either a
standing pivot or sliding transfer and returns. Performs safely.
6 Modified Requires adaptive or assistive devise (including prosthesis or

Independence orthosis) such as a sliding board, a lift, grab bars, or special seat
or chaor or brace or crutches; takes more than a reasonable time,
or there are safety considerations.
HELPER

Set-up up (positioning sliding board, moving foot rests, etc.).
4 Minimal Contact Subjects performs 75% or more of transferring tasks

Assistance
3 Moderate Assistance Performs 50% to 74% of transferring tasks.
2 Maximal Assistance Performs 25% to 49% of transferring tasks.
1 Total Assistance Performs <25% of transferring tasks.
Comment: When assessing bed to chair transfer, the subject begins and ends in the supine position.
2. TRANSFERS - TOILET
Includes getting on and off a toilet.
NO HELPER
7 Complete … If walking. Approaches, sits down and gets up from a standard

Independence toilet. Performs safely.
… If in a wheelchair. Approaches toilet, locks brakes, lifts foot

rests, removes arm rests if necessary, and does either a standing
pivot or sliding transfer and returns. Performs safely.

Independence orthosis) such as a sliding board, a lift, grab bars, or special seat;
takes more than a reasonable time, or there are safety
considerations.
HELPER

Set-up up (positioning sliding board, moving foot rests, etc.).

Assistance
1 Total Assistance Performs less than 25% of transferring tasks.
ANNEXES 141
3. TRANSFERS - TUB OR SHOWER
Includes getting into and out of a tub or shower stall.
NO HELPER
7 Complete … If walking. Approaches, enters and leaves a tub or shower stall.

Independence Performs safely
.… If in a wheelchair. Approaches tub or shower, locks brakes,

lifts footrests, removes armrests if necessary, and does either a
standing pivot or sliding transfer and returns. Performs safely.

Independence orthosis) such as a sliding board, a lift, grab bars, or special seat;
takes more than a reasonable time, or there are safety
considerations.
HELPER

Set-up up (positioning sliding board, moving foot rests, etc.)

Assistance
1 Total Assistance Performs < 25% of transferring tasks.
D. LOCOMOTION
1. WALK/WHEELCHAIR
Includes walking, once in a standing position, or using a wheelchair, once

in a seated position, on a level surface. Check most frequent mode of
locomotion. If both are about equal, check both W and C.
W = walking C = wheelchair
NO HELPER
7 Complete … Walks a minimum of 150 feet without assistive devise. Does
Independence not use a wheelchair. Performs safely.
6 Modified Walks a minimum of 150 feet but uses a brace (orthosis) or
Independence prosthesis on leg, special adaptive shoes, cane, crutches, or
walkarette: takes more than a reasonable time, or there are safety
considerations.
If not walking, operates manual or electric wheelchair independently
for a minimum of 150 feet; turns around; maneuvers the chair to a
table, bed, toilet; negotiates at least a 3% grade; maneuvers on
rugs and over doorsills.
5 Exception Walks only short distances (a minimum of 50 feet) with or without
(Household a devise. Could take more than reasonable time, or there are
Ambulation) safety considerations, or operates a manual or electric wheelchair
independently only short distances (a minimum of 50 feet)
HELPER
5 Supervision or If walking, requires standing by supervision, cuing, or coaxing to
Set-up go a minimum of 150 feet.
If not walking, requires standing by supervision, cuing, or coaxing
to go a minimum of 150 feet in wheelchair.
4 Minimal Contact Subject performs 75% or more of locomotion effort to go a
Assistance minimum of 150 feet.
3 Moderate Assistance Performs 50% to 74% of locomotion effort to go a minimum of 150
feet.
2 Maximal Assistance Performs 25% to 49% of locomotion effort to go a minimum of 50

feet. Requires assistance of one person only.
1 Total Assistance Performs < 25% of effort, or requires assistance of two people, or
does not walk or wheel a minimum of 50 feet.
ANNEXES 143
2. STAIRS
Goes up and down 12 to 14 stairs (one flight) indoors.
NO HELPER
7 Complete Goes up and down at least one flight of stairs without any type of
Independence handrail or support. Performs safely.
6 Modified Goes up and down at least one flight of stairs requiring side support
Independence or handrail, cane or portable supports; takes more than a
reasonable time, or there are safety considerations.
5 Exception Goes up and down 4 to 6 stairs independently, with or without a

(Household devise. Could take more than reasonable time or there are safety
Ambulation) considerations.
HELPER
5 Supervision or Requires standing by supervision, cuing, or coaxing to go up and

Set-up down one flight.
4 Minimal Contact Subject performs 75% or more of effort to go up and down one
Assistance flight.
3 Moderate Assistance Performs 50% to 74% of the effort to go up and down one flight.
2 Maximal Assistance Performs 25% to 49% of stair climbing effort to go up and down 4
to 6 stairs. Requires assistance of one person only.
1 Total Assistance Performs < 25% of the effort, or requires assistance of two people,
or does not go up and down 4 – 6 stairs, or is carried.
E. COMMUNICATION
1. COMPREHENSION
Includes understanding of either auditory or visual communication (e.g.
writing, sign language, gestures). Check and evaluate the most usual
mode of comprehension. If both are equally used, check both A and V.
A = Auditory V = Visual
NO HELPER
7 Complete Understands directions and conversation that are complex or
Independence abstract; understands either spoken or written native language.
6 Modified Understands directions and conversations that are complex or

Independence abstract in most situations or with mild difficulty. No prompting is
needed. May require a hearing or visual aid, other assistive device,
or extra time to understand the information.
HELPER
5 Standby Prompting Understands directions and conversation about basic daily needs
more than 90% of the time. Requires prompting (slowed speech
rate, use of repetition, stressing particular words or phrases,
pauses; visual or gestural cues) less than 10% of the time.
4 Minimal Prompting Understands directions and conversation about basic daily needs
75% to 90% of the time.
3 Moderate Prompting Understands directions and conversation about basic daily needs
50% to 74% of the time.
2 Maximal Prompting Understands directions and conversation about basic daily needs
25% to 49% of the time. May understand only simple questions or
statements. Requires prompting more than half the time.
1 Total Assistance Understands directions and conversation about basic daily needs
< 25% of the time, or does not understand simple questions or
statements or may not respond appropriately or consistently despite
prompting.
Comment: Comprehension of complex or abstract information includes, but is not limited to understanding:
group conversation, current events appearing in television programs or newspaper articles, or abstract
information such as religion, humor, math, or finances used in daily living. Information about basic daily
needs refers to conversation, directions, question or statements related to the subject’s need for nutrition,
fluids, elimination, hygiene, sleep (physiological needs).
ANNEXES 145
2. EXPRESSION
Includes clear vocal or non-vocal expression of language. This item
includes both intelligible speech and expression of language using
writing or a communication device. Check and evaluate the most usual
mode of expression. If both are about equally used, check both V and N.
V = Vocal N = Non-vocal
NO HELPER
7 Complete Expresses complex or abstract ideas clearly and fluently.
Independence
6 Modified Expresses complex or abstract ideas in most situations, or with

Independence mild difficulty. No prompting is needed. May require an
augmentative communication device or system.
HELPER
5 Standby Prompting Expresses basic daily needs and ideas more than 90% of the time.
Requires prompting (e.g. frequent repetition) less than 10% of the
time to be understood.
4 Minimal Prompting Expresses basic daily needs and ideas 75% to 90% of the time.
3 Moderate Prompting needs and ideas 50% to 74% of the time.
Expresses basic daily

2 Maximal Prompting Expresses basic daily needs and ideas 25% to 49% of the time.
May use only single words or gestures. Needs prompting more
than half the time.
1 Total Assistance Expresses basic daily needs and ideas < 25% of the time, or does
not express basic needs appropriately or consistently despite
prompting.
Comment: Examples of complex or abstract ideas include, but is not limited to, discussing current events,
religion, or relationships with others. Expression of basic needs and ideas refers to the subject’s ability to
communicate about necessary daily activities such as nutrition, fluids, elimination, hygiene, and sleep
(physiological needs).
F. SPECIAL COGNITION
1. SOCIAL INTERACTION
Includes skills related to getting along and participating with others in

therapeutic and social situations. It represents how one deals with one’s
own needs together with the needs of others.
NO HELPER
7 Complete Interacts appropriately with staff, other patients, and family

Independence members (e.g. controls temper, accepts criticism, is aware that
words and actions have an impact on others).
6 Modified Interacts appropriately with staff, other patients, and family

Independence members in most situations or with mild difficulty. No supervision
is required. May require more than a reasonable time to adjust in
social situations or may require medication for control.
HELPER
5 Supervision Requires supervision (e.g. monitoring; verbal control; cuing, or

coaxing) only under stressful or unfamiliar conditions, but no more
than 10% of the time. May require encouragement to initiate
participation.
4 Minimal Direction Subject interacts appropriately 75% to 90% of the time.
3 Moderate Direction Interacts appropriately 50% to 74% of the time.
2 Maximal Direction Interacts appropriately 25% to 49% of the time. May need restraint.
1 Total Assistance Interacts appropriately less than 25% of the time, or not at all. May
need restraint.
Examples of socially inappropriate behaviors: temper tantrums; loud, foul or abusive language; excessive
laughing, crying; physical attack; or very withdrawn or non-interactive.
ANNEXES 147
2. PROBLEM SOLVING
Includes skills related to solving problems of daily living. This means making
reasonable, safe, and timely decisions regarding financial, social and personal affairs
and initiating, sequencing and self-correcting tasks and activities to solve the
problems.
NO HELPER
7 Complete Consistently recognizes a problem, makes appropriate decisions,
Independence initiates and caries out a sequence of steps to solve complex
problems until the task is completed, and self-corrects if errors
are made.
6 Modified Recognizes a problem, makes appropriate decisions, initiates and

Independence carries out a sequence of steps to solve complex problems in
most situations, or with mild difficulty, or requires more than a
reasonable time to make decisions about or solve complex
problems.
HELPER
5 Supervision Requires supervision (e.g. cuing, or coaxing) to solve routine

problems only under stressful or unfamiliar conditions, no more
than 10% of the time.
4 Minimal Direction Subject solves routine problems 75% to 90% of the time.
3 Moderate Direction Solves routine problems 50% to 74% of the time.
2 Maximal Direction Solves routine problems 25% to 49% of the time. Needs direction
more than half the time to initiate, plan or complete simple daily
activities. May need restraint for safety.
1 Total Assistance Solves routine problems < 25% of the time. Needs direction nearly
all the time, or does not effectively solve problems. May require
constant 1:1 direction to complete simple daily activities. May need
a restraint for safety.
Examples of problems: Complex problem solving includes activities such as: managing a checking account,
participating in discharge plans, self-administration of medications, confronting impersonal problems, and
making employment decisions. Routine problems include successfully completing daily tasks or dealing
with unplanned events or hazards that occur during daily activities.
3. MEMORY
Includes skills related to recognizing and remembering while performing

daily activities inan institutional or community setting. It includes ability to
store and retrieve information, particularly verbal and visual. A deficit in
memory impairs learning as well asperformance of tasks.
NO HELPER
7 Complete Recognizes people frequently encountered and remembers daily

Independence routines: executes requests of others without need for repetition.
6 Modified Recognizes people frequently encountered, remembers daily

Independence routines and requests of others with mild difficulty. May use self-
initiated or environmental cues, prompts or aids.
HELPER
5 Standby Prompting Requires prompting (e.g. cuing, repetition, reminders) only under
stressful or unfamiliar conditions, but no more than 10% of the
time.
4 Minimal Prompting Subject recognizes and remembers 75% to 90% of the time.
3 Moderate Prompting Recognizes and remembers 50% to 74% of the time.
2 Maximal Prompting Recognizes and remembers 25% to 49% of the time. Needs
prompting more than half the time.
1 Total Assistance Recognizes and remembers < 25% of the time, or does not
effectively recognize and remember.
ANNEXES 149
ANNEX 22A: TB BENEFIT FORM (DOLE Guidelines - Front)
TB BENEFIT FORM
Name ________________________ Age _____ Sex _____ Date of Referral _________________________
Occupation ________________________ Home Tel. No. _________________________
Company ________________________ Work Phone No. _________________________
Company Address ________________________ Home Address _________________________________________
________________________ _________________________________________
ATTENDING PHYSICIAN'S REPORT

Symptomatic? Yes No
Chronic Cough
Afternoon Fever
Hemoptysis
Weight Loss
Chest and/or Back Pain
Prior TB Diagnosis or Treatment (attach clinical abstract, if present)
Others: _______________________________________________
P.E. Findings Suggestive of TB? Yes No
Weight:
% of Ideal Body Weight
Pulomonary signs of TB:
Extra-Pulmonary signs of TB:
Sputum AFB Smears done Three Times? Yes No

Sputum 1: Positive Negative Date:
Sputum AFB Culture Positive? Yes No
Chest X-Ray Suggestive of TB? Yes No
Histopath. Suggestive of TB or Fluid Culture Positive? Yes No
Signature M.D.
License No.
SSS/GSIS/PHIC Accre. No.
PTR No.
EMPLOYER'S CERTIFICATION (For EC Claims)

Status Employee Dependent
Employment History attached Job Description attached
Pre-Employment Chest X-Ray Normal
Abnormal; plese specify ______________________________________________
Pre-Employment P.E. Normal
Abnormal; plese specify ______________________________________________
Signature
Name
Position
Company
SSS/GSIS/PhilHealth Verification
Not qualified for benefits. Reason:
Complete requirements; approved for processing
Incomplete requirements. Please submit the following before processing could proceed:
Signature
Name
Official Designation
Date
ANNEX 22B: TB BENEFIT FORM (DOLE Guidelines - Back)
EXTENSION OF TEMPORARY TOTAL DISABILITY (TB Sickness) BENEFITS

Impairment classification of class 1 or higher? Yes No
Certification from attending physician for extra-pulmonary TB? Yes No
Signature M.D.
License No.
PTR No.
PERMANENT TOTAL DISABILITY
Pulmonary TB
Met Criteria for PTB? Yes No

Impairment classificationof class 1-3 for partial Yes No
Class 4 for total? Yes No
Proof of 100 days of documented treatment? Yes No
Extra-Pulmonary TB
Met Criteria for extra-pulmonary TB? Yes No
Satisfied functional impairment classification and functional independence measure of
Yes No
organ involved
Proof of 100 days of documented treatment Yes No
Signature M.D.
License No.
PTR No.
ANNEXES 151
ANNEX 23A: TB DIAGNOSTIC COMMITTEE
The TB Diagnostic Committee (TBDC)
BACKGROUND AND RATIONALE
The D.O.T.S. strategy was pilot-tested in the Philippines’ NTP in 1996, and was subse-
quently expanded throughout the country. However, the smear (+) cases represented only
about 35% of the pulmonary TB cases,1 and among the smear negative but X-ray positive
TB cases, about 30%-50% were thought to be inactive TB cases. Most of these cases were
referrals from the private sector.
A 1997 study conducted in the NTP D.O.T.S. pilot sites showed that among cases diag-
nosed by chest X-ray, only 25% have radiographic findings suggestive of active PTB, 36%
have “suspicious shadows” only (or with doubtful TB activity), and 39% had either, normal X-
rays or, radiographic lesions secondary to other diseases (Chaulet, P; WHO). There was a
high level of over-reading and over-diagnosis that led to the unnecessary anti-TB treatment
of many patients. These patients were subjected to the psychological burden of being la-
beled as a TB patient, and were exposed to the potential adverse effects of the anti-TB
drugs. Moreover, the situation resulted in the waste of limited resources particularly anti-TB
drugs.
These observations demonstrate the inherent problems, and the relatively low accu-
racy, of the X-ray based diagnosis of TB. To improve the quality of diagnosis among the
smear negative/X-ray positive TB suspects in DOTS areas, the NTP created TB Diagnostic
Committees (TBDC) at the provincial or city level. These committees were tasked to evalu-
ate the clinical data and X-ray films of the smear negative/X-ray positive TB suspects, and
to come up with the diagnosis and the corresponding therapeutic recommendations (by
consensus) for these patients. The TBDC was subsequently integrated into the NTP frame-
work for TB case finding.
OBJECTIVES
General Objective
The TBDC was created to improve the quality of diagnosis among smear negative
PTB cases.
Specific Objectives
1. Reduce the level of over-diagnosis and over-treatment among smear negative PTB cases,
2. Ensure that the active cases of smear negative PTB are detected, and are provided with
the appropriate anti-TB treatment.
1
Ahn, DI. Mission Report; TB Prevention and Control. World Health Organization. 1998.
ANNEX 23A: TB DIAGNOSTIC COMMITTEE (Continuation)
TBDC COMPOSITION AND ROLES OF COMMITTEE MEMBERS
The TBDC is chaired by the public sector (NTP Medical Coordinator) whose mem-
bers come from the public and private sectors representing various disciplines. The
TBDC is established at the province or city level, or as an added option, at the district
level. The composition of the TBDC is as follows:
Provincial/City TB Diagnostic Committee:
1. Provincial/City NTP Medical Coordinator

1.1 Acts as the Chairperson of the TBDC (Note: another TBDC member may be designated
as co-chairperson).
1.2 Organizes the Committee.
1.3 Convenes the Committee regularly.
1.4 Moderates the discussions of the committee.
1.5 Prepares the quarterly reports of the TBDC.
1.6 Monitors and supervises the outputs of the TBDC activities
2. Radiologist
2.1 Reviews the referred x-ray films together with the other Committee members.
2.2 Provides a description and interpretation of the X-ray findings that will serve as one of
the bases for diagnosis and treatment.
3. Clinician/Internist/Pulmonologist
3.1 Provides an analysis of the clinical data of each case for correlation with the radiographic
findings.
3.2 Recommends the appropriate intervention(s) for the referred patients.
4. Provincial/City NTP Nurse Coordinator

4.1 Consolidates the necessary documents of the referred cases prior to each meeting.
4.2 Acts as the committee Secretariat.
4.3 Monitors and supervises the outputs of the TBDC activities under the direction of the
Chairperson.
ORGANIZING THE TB DIAGNOSTIC COMMITTEE
1. The NTP Coordinators (Provincial or City level) will initiate a preliminary discussion
with the PHO/CHO regarding the prospective members of the Committee.
2. An initial meeting with the potential members will be convened by the Province/City NTP
Coordinators, in consultation with the PHO/CHO, to discuss the creation of the
Committee. The CHD NTP Coordinators may be invited to provide the technical inputs.
The participants will also be given an orientation on the NTP, and on the TBDC.
3. The solicitation of membership will be formalized by the PHO/CHO. The operating details
such as the venue, and schedule of the TBDC sessions will also be finalized.
ANNEXES 153
4. A copy of the final list of members will be provided to the Provincial / City health office
and CHD.
Note: A district level TB Diagnostic Committee may also be established as an option, to make the
TBDC services more accessible to the peripheral health units and to reduce the volume of
referrals to the Provincial TBDC. The district level TBDC reports to the Provincial/City Medical
coordinator. Monitoring of the district TBDC is the responsibility of the Provincial/City NTP
coordinators.
RECORDING/REPORTING
The TBDC shall make use of the prescribed TBDC referral, recording, and reporting forms
(see table for descriptions, and Annexes 23B, 23C, 23D, and 24). The quarterly TBDC report shall
be prepared by the NTP coordinators and submitted to the CHD together with the other NTP
quarterly reports.
FORM GENERAL DESCRIPTION RESPONSIBLE PERSON
TBDC Referral Used for referring smear negative TB

Form suspects to the TBDC. The form has
two parts:
Upper Portion contains the clinical Upper portion to be filled-up by the

information of the patient. Physician or PHN referring unit: RHU,
MHC, PPMD unit.
Lower Portion contains the TBDC Lower portion to be filled-up by the

findings/decisions and therapeutic TBDC Secretariat, and duly signed by
recommendations. the TBDC Chairperson and
Secretariat.
TBDC Masterlist This is the listing of all Smear TBDC Secretariat

negative TB suspects referred to the
TBDC.
Quarterly TBDC This is the accomplishment report of Provincial/City Medical or Nurse NTP
Report form the TBDC submitted to the CHD on a Coordinators
quarterly basis.
MONITORING AND EVALUATION
Monitoring and evaluation of the TBDC shall be done in conjunction with the regular NTP
monitoring and program review. The IDO and other TB partners can join the CHD in the monitor-
ing and evaluation of the TBDC. The TBDC Chairperson/NTP Coordinators should ensure that
the TBDC recommendations are implemented by the RHU/MHC/PPMD unit accordingly.
REFERRAL PROCEDURES (Referring Unit Level)
1. The RHU/Main HC/PPMD unit shall refer to the TBDC all smear negative / X-ray positive TB
suspects using the TBDC Referral Form. The referring unit’s physician or PHN shall fill up
completely the upper portion of the TBDC Referral Form.
2. The referring unit should follow the “Sample Flowchart for the Diagnosis of Smear Negative
PTB” (MOP, page 18. 2001) in Annex 3.
3. The referring unit shall ensure that all the available chest x-ray films (including old films) and
properly filled-up TBDC Referral Form of each referred patient are submitted to the TBDC.
TB DIAGNOSTIC COMMITTEE OPERATING PROCEDURES
1. The Secretariat will consolidate all documents (including X-ray films) pertaining to each referred
case, and register all of the referred cases on the TBDC Masterlist.
2. The Committee will review all the documents and deliberate on each referred case during
their regular sessions.
3. The Committee will come-up with a consensus regarding the diagnosis and recommendations
on patient management based on the recommended Diagnostic Flowchart (Technical
Guide). If the Committee feels the need to see the patient, then the patient will be invited to
the next Committee session.
4. The Secretariat will write the TBDC diagnosis and recommendations on the Lower Portion of
the TBDC Referral Form in accordance with the discussions during the TBDC session. Both
the Chairperson and the Secretariat should affix their signatures on the completed form.
5. The completed TBDC Referral Forms will be sent back to the referring units (RHU/Main HC/
PPMD unit) for implementation of the TBDC recommendations. For patients who are
recommended for anti-TB treatment, their TBDC Referral Forms should be attached to their
respective NTP Treatment Cards. All other completed TBDC referral forms should be filed
for future reference.
6. TBDC sessions shall be held at least two times a month.
ANNEXES 155
ANNEX 23B: TB DIAGNOSTIC COMMITTEE (TBDC) Referral Form
ANNEX 23B: TB DIAGNOSTIC COMMITTEE (TBDC) Referral Form
Important data to obtain from the referral form:
1. Patient’s age and sex, and other relevant personal data.

2. Number of sputum examinations prior to TBDC referral, and compliance to MOP guidelines.
3. Laboratory results: for verification of sputum AFB results, and dates of examinations.
4. Details of medical history:past TB, associated illnesses (pulmonary or extra-pulmonary),
HIV status, etc. Provides a description of the characteristics of smear negative TB cases in
the locality (together with no.1).
5. Relevant physical findings: aids the TBDC in the inclusion or exclusion of other diseases.
6. History of previous treatment: aid for diagnosis.
a. Anti-TB treatment
b. Symptomatic treatment
7. Number of referred cases diagnosed as
a. active TB
b. inactive TB
c. other lung disease
d. non-pulmonary disease
Provides an epidemiologic profile of lung diseases among TB symptomatics.

8. Correlation of referring unit’s diagnosis with that of the TBDC: indicates the level of knowledge
at the health unit level on respiratory health; may be used as an aid in the assessment of
training needs.
Information expected from a review of RF:

1. Demographic description of smear negative cases.
2. Associated illnesses among smear neg cases.
3. Quality of history taking at the health unit level.
4. Accuracy of TBDC diagnosis
5. Effectiveness of TBDC recommendations
a. based on a follow up of the patients.
6. Limitations of the TBDC’s ability to improve the quality of diagnosis.
7. Compliance rate of HUs to TBDC recommendations and reasons for level of compliance
Information to be gathered from stakeholders:

1. Results of theTBDC recommendations: were they implemented? What were the outcomes
in clinical terms (for the patient)? How does this affect the health unit staff in terms of service
delivery?
2. What are the perceptions of TBDC members? Do they receive any feedback regarding the
results of their recommendations?
3. About the Program managers: What is the impact of the TBDC on the program, particularly
on the quality of diagnosis? Drug use? Data and information regarding TB epidemiology in
their locality?
4. From other stakeholders: PPM?, NGOs?
ANNEXES 157
ANNEX 23C: QUARTERLY TBDC ACCOMPLISHMENT REPORT FORM
Province/City: CHD:
Date for the Quarter: Year:
Prepared by: Date Submitted:
1. Total no. of (smear neg./X-ray pos.) TB suspects referred to TBDC
1.1. Classification of referred TB suspects TB, New

TB, Retreatment
Total
TBDC DIAGNOSIS
2. Total number of active TB cases diagnosed by TBDC
2.1. Classification of active TB cases diagnosed by TBDC TB, New

TB, Retreatment
Total
3. Total number of inactive TB patients
4. Total number of patients diagnosed as "other lung disease"
5. Total number of patients evaluated by TBDC for this quarter
6. Total number of patients recommended by the TBDC for

anti-TB treatment in this quarter
ANNEX 23D: TBDC MASTERLIST FORM
TBDC MASTERLIST
TBDC Diagnosis
Patient Date of Tx. Cat.
Referring Civil Date of Act.
No. Patient's Name Type Age Sex Address TBDC Inact. Other (1,2 or
Unit Status Referral TB
(N/R) Meeting TB LD 3)
(N/R)
ANNEXES 159
ANNEX 24: NTP MONITORING CHECKLIST
ANNEX 24: NTP MONITORING CHECKLIST (Page 2)
ANNEXES 161
ANNEXES 163

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Comprehensive

and Unified Policy

Philippine Coalition Against Tuberculosis

C.U.P. 2004 participating agencies:

Board of Advisers: Dr. Myrna C. Cabotaje - NCPDC, DOH

Editors: Dr. Marilyn N. Gorra - Philippine TIPS

Technical DOH: PhilCAT:

Published by the Department of Health and the Philippine Coalition

All rights reserved. No part of this work which is copyright may be

Admittedly, in the Philippines, TB has grown to epidemic proportions despite government

Mabuhay kayong lahat!

MANUEL M. DAYRIT, MD, MSc

I. Executive Summary ....................................................................................................................... 1

II. Introduction ................................................................................................................................... 3

III. The National Tuberculosis Program (NTP) ................................................................................ 11

IV. NTP Core Policies and Procedures ...........................................................................................23

VI. Guidelines for Implementation of the NTP by Government Agencies ........................................ 47

VIII. PhilHealth’s Outpatient TB DOTS Benefit Package ...................................................................73

Annex 1: Flow of NTP Activities ....................................................................................................83

CHAPTER I : EXECUTIVE SUMMARY 1

1. Annual risk of TB infection 2.5% 2.3%

2. Prevalence of sputum smear positive cases 6.6/1,000 3.1/1,000

3. Prevalence of culture positive cases 8.6/1,000 8.1/1,000

4. Radiographic findings suggestive of TB 4.2% 4.2%

2. History of TB Control in the Philippines

1910–1929. Tuberculosis control in the Philippines was started in 1910 by a private

Mid 1990’s. The mid-1990’s witnessed an intensified national campaign to increase

3. Development of the Comprehensive and Unified Policy for TB

CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM 9

· Standardized recording and reporting system enabling assessment of every

2. Vision, Mission, Goal of the NTP

Vision A country where TB is no longer a public health problem.

Mission Ensure that TB-DOTS services are available, accessible

Goal Reduction of the prevalence of sputum smear positive TB

3. Targets of the NTP

4-1. Political commitment.

4-2. Sputum microscopy.

a) Providing functional microscopes

4-3. Standardized chemotherapy under DOT.

a) Providing policies and guidelines for the treatment of TB cases;

4-4. Drug supply.

a) Establishing a drug procurement and distribution system at all levels;

b) Regularly monitoring the availability of anti-TB drugs;

4-5. Program management.

CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM 11

4-6. Data/information system.

4-7. Case detection.

5. Roles of Collaborating Agencies

5-3. DILG / Local Government Units (LGUs)

· Implement measures to undertake TB control among members of the PNP,

· Develop a local health plan in consultation with DOH/CHD/PHO/CHO/MHO.

CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM 13

5-4. Other Government Agencies

5-5. Private Sector and NGOs

6. Functions of NTP Health Workers

6-1. DOH TB Staff

6-2. CHD NTP Core Team

CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM 15

6-3. DOH Representatives (Provincial, City, and Municipal)

6-4. Provincial and City NTP Core Team

6-6. Public Health Nurse/DOTS Nurse (Public and Private)

6-7. Midwives, Other Support Staff (i.e., Field Treatment

CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM 17