NTP 101: Realizing the Importance of the National TB Program

Healthcare – Session 2 Lecture 5.5

WHAT IS NTP? I. CASE FINDING
• It stands for National Tuberculosis Program
• It is the Government's commitment to address • is the identification and diagnosis of TB cases
the TB problem in the country. among individuals with suspected signs and
• The NTP is being implemented nationwide in all symptoms of TB
government health centers, government
o It is the basic step in TB control.
hospitals and selected private institution.
• Its objectives are to detect active TB cases (at • Objective – early identify & diagnose TB cases
least 70%) and cure them (at least 85%).
• Achieving and sustaining targets will eventually • Types:
result to the decline of the TB problem in the
Philippines. o Passive case finding – finding TB cases
among TB symptomatic who consults TB
VISION, MISSION AND GOAL OF NTP DOTS facility
VISION
o Active case finding – purposive
• A country where TB is no longer a public health
action/effort to find TB cases who do not
problem
consult TB DOTS facility
MISSION • TB symptomatic case – any person with cough
• Ensure that TB-DOTS Services are available,
accessible and affordable to the communities in
collaboration with the LGUs and other partners
GOAL
• To reduce mortality and morbidity from TB by
half by the year 2015

NTP Targets (70/85)

for 2 or more weeks with or without the

5 ELEMENTS OF DOTS STRATEGY following symptoms
• Sustained political commitment o Fever
• Access to quality-assured TB sputum microscopy
• Standardized short-course treatment for all TB o Chest and/back pains not referable to
cases any musculoskeletal disorders
• under proper case management conditions
o Hemoptysis or recurrent blood-streaked
(DOT),
sputum
• technically sound and socially supportive
treatment o Significant weight loss
• services
• Uninterrupted supply of quality-assured drugs o Other symptoms
• Recording and reporting system that enables the ▪ Sweating, fatigue, body malaise,
• assessment of each patient’s treatment outcome shortness of breath
and
• that of the program’s performance

MAJOR COMPONENTS OF NTP

I. Case Finding
II. Case Holding

JOANA ELISHA LANDICHO

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 NTP 101: Realizing the Importance of the National TB Program
Healthcare – Session 2
NTP 101 CHALLENGE:
“TRUTH or LIE”
Direct sputum smear microscopy is the basic test
needed in diagnosing pulmonary TB.
TRUTH or LIE?
FACTS
• Direct Sputum Smear Microscopy (DSSM)
o Principal diagnostic method/tool in NTP case
finding because:
✓ It provides a definitive diagnosis of active TB
✓ The procedure is simple
✓ It is economical
✓ A microscopy center could be put up even in
remote areas
o Only trained MedTech or microscopists shall
perform DSSM. However, in far flung areas,
BHWs or other community health volunteers
may be allowed to do smearing and fixing
specimens, as long as they have been trained
and are supervised by their respective NTP
MedTech/microscopist
TB suspects should be referred to any laboratory for
direct sputum smear microscopy.
TRUTH or LIE?
FACTS
• All TB symptomatic identified shall be asked to
undergo DSSM for diagnosis before start of
treatment, regardless of whether or not they
have available x-ray results or whether or not
they are suspected of having Extrapulmonary TB
▪ The only contraindication for sputum
collection is hemoptysis; in which case,
DSSM will be requested after control of
hemoptysis
Direct sputum smear microscopy requires three early
morning specimens.
TRUTH or LIE?
FACTS
• For Diagnosis: 3 sputum specimens
taken/collected w/in 2 days
▪ 1st specimen – “spot specimen” –
collected at the time of consultation in
TB DOTS facility
▪ 2nd specimen – very first sputum
produced early in the morning
immediately after waking up – collected
by patient in the house
Lecture 5.5
▪ 3rd specimen – “2nd spot specimen” –
collected in TB DOTS facility when the
patient comes back to submit the 2nd
specimen
• 1st and 3rd sputum specimen collections are
supervised by the TB DOTS facility staff to ensure
quality sputum specimen collection
• If patient fails to complete the 3-specimen
collection within one week, another set of 3
should be collected
For Diagnosis: 3 sputum specimens taken/collected
w/in 2 days
▪ Sputum cup for sputum specimen collection
provided by TB DOTS facility
▪ “QUALITY sputum specimen” – phlegm,
mucoid
▪ Instruction how to collect/produce quality
sputum
1. Rinse mouth with water
2. Breathe deeply thru the nose, hold
breath, then exhale slowly thru the
mouth (Done twice)
3. Breathe deeply thru the nose, hold
breath, then cough strongly at the height
of deep inspiration and spit the
sputum/phlegm in the container
▪ Label body of sputum cup indicating patient’s
complete name and order of specimen (1st, 2nd,
or 3rd)
▪ Observe precautions against infection during
the demonstration. Stay behind the patient.
Collect specimen outside the facility.
DSSM positive cases should be referred to a physician
primarily for close contacts investigation in their
household.
TRUTH or LIE?
FACTS
• DSSM Smear (+) cases
o DSSM results serve as bases for:
✓ categorizing TB symptomatic according to
standard case definition
✓ Proper treatment regimen
✓ Monitoring progress of patients with sputum
smear (+) TB while on anti-TB treatment
✓ Confirming cure at the end of anti – TB treatment
JOANA ELISHA LANDICHO
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 NTP 101: Realizing the Importance of the National TB Program
Healthcare – Session 2 Lecture 5.5
o Smear (+) cases are the basis for tracing TB Refer cases for chest X-ray, if negative for DSSM
illness among children and other family
members

Smear negative PTB cases are routinely treated with

anti-TB drugs immediately after the DSSM result.

TRUTH or LIE?

FACTS

• DSSM Smear (-) cases

▪ TB symptomatic shall be asked to undergo

other diagnostic tests (chest x-ray and / or
culture), if necessary, only after they have
undergone DSSM for diagnosis with 3 sputum
specimens yielding negative results.

▪ If the chest x-ray result is suggestive of

Pulmonary TB, the TB DOTS facility will refer
the patient’s case and submit necessary
documents (complete case history, DSSM
results and chest x-ray film of the patient) to
the TBDC for further evaluation

Referral to TBDC would reduce over-diagnosis and over-

treatment of symptomatic smear positive cases.

TRUTH or LIE?

FACTS I. CASE FINDING SUMMARY

• TBDC
o Evaluates the results of the chest x-ray film
reading together with the complete history and
findings (Smear negative with x-ray suggestive of
Pulmonary TB cases only)
o Recommends to TB DOTS facility whether or not
the case will be started on treatment
o Composition
✓ NTP Medical Coordinator
✓ Radiologist
✓ Clinician/Internist/Pulmonologist
✓ NTP Nurse Coordinator
HOW TO CONFIRM TB CASES?
Ask the symptoms
✓ TB Symptomatic – presence of chronic cough
lasting of 2 or more than 2 weeks
✓ TB Asymptomatic– absence of cough with or
without associated other symptoms
o Common among workers and applicants with
accidental finding on Chest X-ray
Collect sputum specimen for
✓ Direct Sputum Smear Microscopy (DSSM)
✓ Sputum Culture & Drug Sensitivity Testing for
M. Tuberculosis
• Fundamental to case finding is the detection of
infectious cases through DSSM - Sputum smear
(+)
• The most common symptom of pulmonary TB is
cough of 2 or more weeks with or without other
signs/symptoms.
o The associated symptoms can be
remembered as FEWBANS for fever,
easy fatigability, weight loss, blood –
tinged phlegm/back pain, anorexia,
night sweating and shortness of breath.
• Advise all TB suspects to submit 3 QUALITY
sputum specimens for DSSM for diagnosis.
• Smear negative PTB with x-ray suggestive of
pulmonary TB should be referred to TBDC prior
to treatment.
• Household members of identified TB cases who
are also TB symptomatic should be encouraged
to undergo DSSM

JOANA ELISHA LANDICHO

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 NTP 101: Realizing the Importance of the National TB Program
Healthcare – Session 2 Lecture 5.5
MAJOR COMPONENTS OF NTP TYPES OF TB CASES

II. CASE HOLDING

All TB cases registered for anti-TB treatment comply

with at least 6 months regimen

TRUTH or LIE?

The aim of case holding is to cure TB cases after six
months of treatment.
TRUTH or LIE?
II. CASE HOLDING
Is the procedure which ensures that patients complete
their treatment
• Objective – effective and complete treatment of
TB cases, esp. pulmonary sputum smears
positive cases
• Classification of TB cases
o based on the location of lesions and
DSSM result
• Types of TB Cases
o based on history of anti-TB treatment
• Types of Treatment Outcome
o based on the result of current treatment
CLASSIFICATION OF TB CASE
FACTS
National TB Prevalence (NPS) Survey (2007)
• Only 49.5% are able to complete six months of
treatment or longer
• Default rate is 21.2% among females and 18.8%
among males
• Reasons for defaulting:
✓ Long duration of treatment (6 or more months)
✓ “Feeling of wellness” experienced by the patient
while taking the anti-TB drugs during the 2nd or
more months of treatment
✓ Patient experiences side effects
If a treatment partner is not available, it is okay for the
TB DOTS facility to start the TB patient on anti-TB
treatment.
TRUTH or LIE?
FACTS

• All patients undergoing treatment shall be

supervised (DOT).

▪ No patient shall initiate treatment unless the

patient and the TB DOTS facility have agreed upon
a case holding mechanism for treatment
compliance
• Aside from clinical findings, treatment of all TB
cases shall be based on a reliable diagnostic
technique “DSSM”
• Domiciliary treatment shall be the preferred
mode of care
• National and Local government units shall
ensure provision of drugs to all smear-positive
TB cases

JOANA ELISHA LANDICHO

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 NTP 101: Realizing the Importance of the National TB Program
Healthcare – Session 2
• Quality of anti-TB drugs must be ensured
A physician can start a registered TB case on anti-TB
drugs of his/her choice
TRUTH or LIE?
FACTS
• Treatment shall be based on recommended
category of treatment regimen
TB cases with persistent sputum smear positive results
on DSSM even after treating re-treatment cases are
considered as suspect Multi-Drug Resistant (MDR) TB
cases.
TRUTH or LIE?
FACTS
• Chronic cases who are still smear-positive after a
supervised re-treatment are considered as
suspect multi-drug resistant TB cases
• They are referred to PMDT treatment facilities
for further evaluation and management
• MDR TB – is a condition which is resistant against
at least Isoniazid and Rifampicin
• The duration of MDR treatment ranges 1 – 2
years
TB cases must comply with three follow-up DSSM
during the course of treatment.
TRUTH or LIE?
FACTS
Schedule of DSSM Follow-Up
Lecture 5.5
Anti-TB drugs can cause minor
side effects that could be corrected by symptomatic
treatment.
TRUTH or LIE?
Possible Side-Effects of Anti-TB Drugs
SUMMARY
• Case holding requires 6-8 months of treatment
through DOTS Strategy using 4-5 drugs
• TB cases can be classified as Pulmonary TB (PTB)
if located in the lungs or Extra Pulmonary TB
(EPTB) if found in other organs.
• Category of treatment is based on WHO
recommendation
• All TB cases who developed side effects should
be referred to the health service provider for
advice, reassurance or treatment.
• DSSM follow-up must be done regularly as
scheduled.
• Chemotherapy is currently the only way to stop
the transmission of TB
• Effective anti-TB drugs are available in
TB DOTS facility
• Once a TB patient is registered for
treatment in a TB DOTS facility, he/she
has a complete anti-TB drug supplies
provided from the start of treatment
• Poor treatment compliance may lead to worst
outcomes
• DOT (Directly Observed Treatment) is a strategy
to ensure treatment compliance of TB patient
• DOT works by assigning a responsible
person to observe or watch the patient
take the correct medications daily
during the whole course of treatment
JOANA ELISHA LANDICHO
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 NTP 101: Realizing the Importance of the National TB Program
Healthcare – Session 2 Lecture 5.5
✓ Current trend of global recession and mobility

CURRENT STATUS: PHILIPPINES

Module 2
Context and Rationale of  9th among the 22 high burdened countries
TB Education (HBCs) worldwide – Global TB Control Report
2009
SESSION 1: Recognizing the Magnitude of the TB
Problem  4th in Case Notification Rate (TB all forms)
amongst the WPRO countries – TB Control in the
GLOBAL BURDEN OF TUBERCULOSIS
Western Pacific Region, 2009 Report
• TB is the second the most common infectious
 8th among 27 priority countries with highest
disease in the world
number of MDR-TB cases
• the leading cause of death among women and
persons with AIDS  TB is 6th in mortality and morbidity – FHSIS
• one-third of the world population is infected Report 2007
with TB.
• 8 million people develop the disease annually  73 Filipinos die from TB everyday
• 2 million deaths occur from TB
• estimated that there will be 10 million cases
annually by 2010

GLOBAL IMPACT

• TB is a disease of poverty; affecting mostly young

adults in their most productive years
• TB annual incidence rates have peaked globally
• in 2003-2004 but they are falling very slowly in
• all WHO regions
• The total number of deaths and cases is still
rising due to:
✓ Population growth
✓ Spread of HIV
✓ Emergence of MDR-/ XDR- TB

JOANA ELISHA LANDICHO

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 NTP 101: Realizing the Importance of the National TB Program
Healthcare – Session 2 Lecture 5.5
TB Control Performance, 2007

Prevalence of Drug Resistant TB

TREATMENT CENTERS FOR MDR TB SERVICES

• MMC-TDF
• LCP
• PTSI-Tayuman
• DJNRMH
• KASAKA
• ITRMC
• Eversly Children’s Hospital
• De La Salle Treatment Center
• Sorsogon Medical Missions Hospital
• Community of German Doctors
• Davao Medical Center
• Other Regional Treatment Centers

JOANA ELISHA LANDICHO

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