Professional Documents
Culture Documents
Joint DOH and PhilCAT Comprehensive and Unified Policy For TB Control in The Philippines
Joint DOH and PhilCAT Comprehensive and Unified Policy For TB Control in The Philippines
Department of Health
Government of the Philippines
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.
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
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.
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.
i
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.
ii
iii
iv
Table of Contents
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
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
ANNEXES:
vii
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
viii
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
ix
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
x
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
xi
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
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
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.
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
4 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
CHAPTER II : INTRODUCTION 5
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.
6 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
CHAPTER II : INTRODUCTION 7
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.
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).
8 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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;
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).
4. NTP Strategies
To achieve its objectives, the NTP shall focus on the following strategies and activities:
10 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
12 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
b) LGUs
14 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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).
16 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
· Maintain and update the relevant NTP forms (Treatment Cards, ID Cards,
NTP Client List).
18 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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
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
22 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
24 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
· 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,
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:
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.
26 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
28 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
30 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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.
32 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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:
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.
34 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
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.
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.
5-1. 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.
36 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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:
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.
38 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
c) Monitoring Forms:
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.
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.)
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
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.
a) Policies:
1) Direct sputum examination shall be the primary diagnostic tool for case finding.
42 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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.
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.
44 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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.
46 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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
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.
48 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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.
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
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.
50 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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 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.
52 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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).
3-4. 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.
54 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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):
Employees Clients
Dependents
Sputum Examination
TB Disease
56 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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;
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.
b) EC Program Benefits:
58 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
the employee is duly reported to the System.
- 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:
- 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.
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).
60 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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. 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 4 (Annexes 20-
A to 20-C, pages 129 to 130) and Functional Independence
Measure (FIM) classification of permanent total disability (Annex
21, page131).
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:
· 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
62 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
· 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.
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.
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
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.
· 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.
64 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
- 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:
- 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.
- Extrapulmonary TB:
• 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.
- Pulmonary TB:
66 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ii. Extension of TB Sickness Benefit Package:
(a) Pulmonary TB
(b) Extrapulmonary TB
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
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.
· 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.
· Medical Requirements:
i. Pulmonary TB
- He/she met the criteria for PTB and has proof of at least 100 days
of documented treatment.
68 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
- 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, 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.
- He/she satisfies functional impairment classification for Permanent
Partial Disability of organ system involved and Functional
Independence Measure (FIM).
* 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
History and physical examination of attending physician,
histopathological 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.
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.
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
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.
72 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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.
2-8. 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.
3-5. 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.
74 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
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).
4-4. 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.
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.
76 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
f) Non-compliance shall cause denial of a claim.
4-7. Monitoring
The Health Finance Policy and Services Sector shall spearhead monitoring of this
program.
ANNEXES 79
80 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
MICROSCOPY CENTER
Initiation of Treatment
MICROSCOPY CENTER
Treatment Completion
ANNEXES 81
ANNEX 2: FLOWCHART FOR THE
DIAGNOSIS OF PULMONARY TUBERCULOSIS
TB Symptomatic
(cough for 2 weeks or more)
Three (3)
sputum collection
Refer to Physician
Classify as smear Collect another 3 (Observe and give
positive TB sputum specimen symptomatic treatment
for 2-3 weeks)
82 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
No abnormal findings on
Abnormal findings on CXR
CXR
Observe/further
TB Diagnostic Committee
examination
ANNEXES 83
ANNEX 4: APPROACH TO TB ASYMPTOMATIC
Patient asymptomatic
CXR available
(with lesions suggestive of TB
YES NO
Previous treatment for PTB Induce sputum
completed and verified production
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
84 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 5: GUIDE TO CASE FINDING
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..
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)
86 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 7: TREATMENT REGIMENS
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
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
88 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
CATEGORY
REGIMEN III:
III: 22 HRZE
HRZE/ /4HR
4HR
30 - 37 2 2
38 - 54 3 3
55 - 70 4 4
>
> 71 5 5
ANNEXES 89
ANNEX 9: FDC DRUG SAMPLES
90 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 10A: SCHEDULE OF SPUTUM SMEAR
FOLLOW-UP EXAMINATION
CATEGORY I
REGIMEN I
* 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)
Towards the end of the
YES
2nd month
Towards the end of the
YES (If positive)
3rd month
Towards the end of the
(If negative) YES
4th month
Towards the end of the
YES
5th month
Towards the end of the
YES
6th month
Towards the end of the
7th month
Towards the end of the
YES (* 2)
8th month
Towards the end of the
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.
92 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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.
*
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
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.
94 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
* 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.
96 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 13C: TREATMENT REGIMEN MODIFICATIONS
BASED ON SPUTUM RESULTS
Follow-up Examinations for Treatment Regimen Category II without Extension
• 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.
* 3 Check the follow-up sputum smear examination towards the end of the 8th month of treatment only for the patient who has smear
positive in the beginning of the 8th 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 8th month.
ANNEXES 97
ANNEX 13D: TREATMENT REGIMEN MODIFICATIONS
BASED ON SPUTUM RESULTS
Follow-up Examinations for Treatment Regimen Category II with Extension
* 4 Check the follow-up sputum smear examination towards the end of the 9th month of treatment only for the patient who has smear
positive in the beginning of the 9th month and shows smear negative in the repeated smear examination; and for the patient who has
smear positive at the end of the 6th month and turns out to be negative in the beginning of the 9th month.
98 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 14A: TREATMENT REGIMEN MODIFICATIONS FOR NEW
SMEAR-POSITIVE CASES WHO INTERRUPTED TREATMENTS
ANNEXES 99
ANNEX 14B: TREATMENT REGIMEN MODIFICATION FOR
RELAPSE & FAILURE CASES WHO INTERRUPTED TREATMENT
More than 2 Less than 2 No, use the same treatment Continue Regimen for
No Continue Regimen-II
Category II
months weeks card.
* 2 This is the exceptional case to define as "Defaulter" for a patient who interrupted treatment of less than 8 weeks.
100 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 15: GUIDE TO CASE HOLDING
ANNEXES 101
ANNEX 16: GUIDE TO ENSURE TREATMENT
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
102 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 17: PERSONS RESPONSIBLE FOR
THE RECORDING FORMS
Treatment partner
NTP Identification Card Nurse (kept by the treatment partner and
the patient)
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
104 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
TB Case No.:__________________
(Be sure to enter the patient’s TB Case No. for follow-up of patient’s Chemotherapy)
Specimen 1 2* 3*
Visual Appearance**
Reading
Laboratory Diagnosis
* Specimen #2 & 3 = not applicable if sputum follow-up
** Muco-purrulent, bloodstained, saliva, etc.
The completed form (with results) should be sent to the treatment unit to record the results in the
laboratory register.
106 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 18B: NTP LABORATORY REQUEST FORM
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.
(4) Write the exact age of the patient in years.
(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
ANNEX 18B: NTP LABORATORY REQUEST FORM
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.
108 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
(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.
(4) Write the exact age of the patient in years.
(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.
110 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
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
112 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
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)
_____________________________,
_____________________________
MHO/RHP TREATMENT PARTNER/S (5):
(SIGNATURE OVER PRINTED NAME)
114 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 18E: NTP IDENTIFICATION CARD (BACK)
Remarks:
Remarks:
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.
116 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 18F: TB REGISTER (CONTINUATION)
ANNEXES 117
ANNEX 18G1: PPMD REFERRAL FORM / NTP (Sample PPMD Form)
118 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 18G2: PPMD FOLLOW-UP FORM / NTP (Sample PPMD Form)
ANNEXES 119
ANNEX 18H: QUARTERLY REPORT ON NTP LABORATORY / ACTIVITIES
Prepared by:
Type of Facility: - Public-initiated
Public PPMD - Private-initiated
Designation
CASE FINDING
Laboratory Activities Public
Walk-in PPMD
Referral
TREATMENT FOLLOW-UP
120 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 18I: COUNTING SHEET FOR LABORATORY ACTIVITIES REPORT
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
Prepared by:
Type of Facility: - Public-initiated
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
III (x 6) (x 12)
Childhood TB
Available on hand
Re-order for Reg. I,
II and III
122 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 18K: COUNTING SHEET FOR CASE FINDING BY TYPE /
DRUG INVENTORY
* 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:
1. NEW CASES
1.1. Smear-positive
1.2. Smear-negative
2. RE=TREATMENT
2.1. Relapse
2.2 Failure
New Smear-Positive
New Smear-Negative
Relapse
Failure
TOTAL NUMBER
EVALUATED
124 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 19: PROGRAM INDICATORS
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)
126 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 20A: IMPAIRMENT CLASSIFICATION FOR RESPIRATORY
DISEASE INJURIES (Modified from American Thoracic Society Criteria)
ANNEXES 127
ANNEX 20B: ATS FUNCTIONAL CLASSIFICATION (of Dyspnea)
128 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT
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)
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
130 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
ANNEXES 131
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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.
HELPER
132 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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
HELPER
ANNEXES 133
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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)
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 (setting out bathing equipment, and initial preparation such as
preparing the water or washing materials).
134 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
NO HELPER
HELPER
ANNEXES 135
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
Indicates dressing from the waist down as well as donning and removing
prosthesis or orthosis when applicable.
NO HELPER
HELPER
136 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
6. TOILETING
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.
HELPER
ANNEXES 137
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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.
138 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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
5 Supervision or Requires supervision (e.g. standing by, cuing, or coaxing) or set-
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
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
C. MOBILITY
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
HELPER
Comment: When assessing bed to chair transfer, the subject begins and ends in the supine position.
140 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
2. TRANSFERS - TOILET
NO HELPER
HELPER
ANNEXES 141
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
NO HELPER
HELPER
142 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
D. LOCOMOTION
1. WALK/WHEELCHAIR
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
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
2. STAIRS
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.
HELPER
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.
144 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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.
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
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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
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.
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).
146 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
F. SPECIAL COGNITION
1. SOCIAL INTERACTION
NO HELPER
HELPER
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
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
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.
HELPER
4 Minimal Direction Subject solves routine problems 75% to 90% 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.
148 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)
3. MEMORY
NO HELPER
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.
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 _________________________________________
________________________ _________________________________________
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
150 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 22B: TB BENEFIT FORM (DOLE Guidelines - Back)
Signature M.D.
License No.
SSS/GSIS/PHIC Accre. No.
PTR No.
Pulmonary TB
Met Criteria for PTB? 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.
SSS/GSIS/PHIC Accre. No.
PTR No.
ANNEXES 151
ANNEX 23A: TB DIAGNOSTIC COMMITTEE
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.
152 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 23A: TB DIAGNOSTIC COMMITTEE (Continuation)
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:
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.
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
ANNEX 23A: TB DIAGNOSTIC COMMITTEE (Continuation)
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.
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 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.
154 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 23A: TB DIAGNOSTIC COMMITTEE (Continuation)
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.
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.
ANNEXES 155
ANNEX 23B: TB DIAGNOSTIC COMMITTEE (TBDC) Referral Form
156 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 23B: TB DIAGNOSTIC COMMITTEE (TBDC) Referral Form
ANNEXES 157
ANNEX 23C: QUARTERLY TBDC ACCOMPLISHMENT REPORT FORM
Province/City: CHD:
TBDC DIAGNOSIS
158 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
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
160 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 24: NTP MONITORING CHECKLIST (Page 2)
ANNEXES 161
ANNEX 24: NTP MONITORING CHECKLIST (Page 3)
162 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)
ANNEX 24: NTP MONITORING CHECKLIST (Page 4)
ANNEXES 163
164 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)