ISTC & DOTS

Dr Dessy Mizarti SpP(K)

International Standards for Tuberculosis Care
• Pada prinsip baik diagnosis dan penatalaksanaan TB di berbagai belahan
dunia itu adalah sama.

• ISTC bertujuan untuk :

 Memberikan penjelasan standar penanganan TB yang dapat diterima luas
di setiap tingkat pelayanan oleh semua praktisi dan harus menggunakannya
dalam menangani pasien yang diduga atau menderita TB,
Memfasilitasi hubungan kerjasama yang efektif antar provider dalam
memberikan pelayanan bermutu tinggi kepada pasien TB meliputi semua
usia
 ISTC &
TB End TB
DOTS
Standards for Diagnosis

1 To ensure early diagnosis, providers must be aware

of individual and group risk factors for tuberculosis
and perform prompt clinical evaluations and
appropriate diagnostic testing for persons with
symptoms and findings consistent with
tuberculosis.
2 • All patients, including children, with unexplained cough
lasting two or more weeks or with unexplained findings
suggestive of tuberculosis on chest radiographs should be
evaluated for tuberculosis
3
All patients, including children, who are suspected of having
pulmonary tuberculosis and are capable of producing sputum should
have at least two sputum specimens submitted for smear microscopy
or a single sputum specimen for Xpert® MTB/RIF* testing in a
quality-assured laboratory.

Patients at risk for drug resistance, who have HIV risks, or who are
seriously ill, should have Xpert MTB/RIF performed as the initial
diagnostic test.

Blood-based serologic tests and interferon-gamma release assays

should not be used for diagnosis of active tuberculosis
4
For all patients, including children, suspected of having
extrapulmonary tuberculosis, appropriate specimens from the
suspected sites of involvement should be obtained for microbiological
and histological examination.

An Xpert MTB/RIF test is recommended as the preferred initial

microbiological test for suspected tuberculous meningitis because of
the need for a rapid diagnosis.
5

In patients suspected of having pulmonary tuberculosis whose sputum

smears are negative, Xpert MTB/RIF and/or sputum cultures should be
performed.

Among smear- and Xpert MTB/RIF negative persons with clinical

evidence strongly suggestive of tuberculosis, antituberculosis
treatment should be initiated after collection of specimens for culture
examination
6
• For all children suspected of having intrathoracic (i.e., pulmonary,
pleural, and mediastinal or hilar lymph node) tuberculosis
bacteriological confirmation should be sought through examination of
respiratory secretions (expectorated sputum, induced sputum, gastric
lavage) for smear microscopy, an Xpert MTB/RIF test, and/or culture.
 Standards for Treatment

7
To fulfill her/his public health responsibility, as well as responsibility
to the individual patient, the provider
must prescribe an appropriate treatment regimen,
monitor adherence to the regimen, and, when necessary,
address factors leading to interruption or discontinuation of
treatment.

Fulfilling these responsibilities will likely require coordination with

local public health services and/or other agencies
8 All patients who have not been treated previously and do not have other
risk factors for drug resistance should receive a WHO-approved first-line treatment
regimen using quality assured drugs.

The initial phase should consist of two months of isoniazid, rifampicin,

pyrazinamide, and ethambutol.*

The continuation phase should consist of isoniazid and rifampicin given for 4
months.

The doses of antituberculosis drugs used should conform to WHO

recommendations.

Fixed-dose combination drugs may provide a more convenient form of drug

administration.
9
A patient-centered approach to treatment should be developed for all
Patients
in order to promote adherence,
 improve quality of life, and
relieve suffering.

This approach should be based on the patient’s needs and mutual respect
between the patient and the provider.
Continue
10
Response to treatment in patients with pulmonary tuberculosis (including
those with tuberculosis diagnosed by a rapid molecular test) should be
monitored by follow up sputum smear microscopy at the time of completion of
the initial phase of treatment (two months).

If the sputum smear is positive at completion of the initial phase, sputum
microscopy should be performed again at 3 months and, if positive, rapid molecular
drug sensitivity testing (line probe assays or Xpert MTB/RIF) or culture with drug
susceptibility testing should be performed.

In patients with extrapulmonary tuberculosis and in children, the response to

treatment is best assessed clinically.
 An assessment of the likelihood of drug resistance, based on history of prior treatment,

11 exposure to a possible source case having drug-resistant organisms, and the community
prevalence of drug resistance (if known), should be undertaken for all patients.

Drug susceptibility testing should be performed at the start of therapy for all patients at a risk
of drug resistance.

Patients who remain sputum smear-positive at completion of 3 months of treatment, patients

in whom treatment has failed, and patients who have been lost to follow up or relapsed
following one or more courses of treatment should always be assessed for drug resistance.

For patients in whom drug resistance is considered to be likely an Xpert MTB/RIF test should
be the initial diagnostic test. If rifampicin resistance is detected, culture and testing for
susceptibility to isoniazid, fluoroquinolones, and second-line injectable drugs should be
performed promptly.

Patient counseling and education, as well as treatment with an empirical second-line regimen,
should begin immediately to minimize the potential for transmission. Infection control
measures appropriate to the setting should be applied.
12  Patients with or highly likely to have tuberculosis caused by drug-resistant
(especially MDR/XDR) organisms should be treated with specialized regimens containing
quality-assured second-line antituberculosis drugs.

 The doses of antituberculosis drugs should conform to WHO recommendations. The

regimen chosen may be standardized or based on presumed or confirmed drug
susceptibility patterns.

 At least five drugs, pyrazinamide and four drugs to which the organisms are known or
presumed to be susceptible, including an injectable agent, should be used in a 6–8 month
 Intensive phase, and at least 3 drugs to which the organisms are known or presumed to be
susceptible, should be used in the continuation phase.
 Treatment should be given for at least 18–24 months beyond culture conversion.

 Patient-centered measures, including observation of treatment, are required to ensure

adherence.
 Consultation with a specialist experienced in treatment of patients with MDR/XDR
tuberculosis should be obtained.
13
An accessible, systematically maintained record of all medications
given,bacteriologic response, outcomes, and adverse reactions should be
maintained for all patients.
 Standards for Addressing HIV Infection and
other Co-morbid Conditions
14
HIV testing and counseling should be conducted for all patients with, or suspected
of having, tuberculosis unless there is a confirmed negative test within the
previous two months.

Because of the close relationship of tuberculosis and HIV infection, integrated

approaches to prevention, diagnosis, and treatment of both tuberculosis and HIV
infection are recommended in areas with high HIV prevalence.

HIV testing is of special importance as part of routine management of all patients

in areas with a high prevalence of HIV infection in the general population, in
patients with symptoms and/or signs of HIV-related conditions, and in patients
having a history suggestive of high risk of HIV exposure.
15 In persons with HIV infection and tuberculosis who have profound
immunosuppression (CD4 counts less than 50 cells/mm3), ART should be
initiated within 2 weeks of beginning treatment for tuberculosis unless
tuberculous meningitis is present.

For all other patients with HIV and tuberculosis, regardless of CD4 counts,
antiretroviral therapy should be initiated within 8 weeks of beginning
treatment for tuberculosis.

Patients with tuberculosis and HIV infection should also receive

cotrimoxazole as prophylaxis for other infections.
16 • Persons with HIV infection who, after careful evaluation, do not have
active tuberculosis should be treated for presumed latent tuberculosis
infection with isoniazid for at least 6 months.
Latent TB infection (LTBI): a state of persistent immune response to
stimulation by M. Tuberculosis antigens with no evidence of clinically
manifest active TB
a) 1/3 world’s population is estimated to be infected with M.Tb
The vast majority of infected people have no sign and symptoms of TB
but are at risk for active TB disease
b) 5-10% of those infected will develop active disease, usually within the
first 5 years after initial infection → depend on several factors
(immunological status)
17 All providers should conduct a thorough assessment for co-morbid conditions and other
factors that could affect tuberculosis treatment response or outcome and identify
additional services that would support an optimal outcome for each patient.

These services should be incorporated into an individualized plan of care that includes
assessment of and referrals for treatment of other illnesses.

Particular attention should be paid to diseases or conditions known to affect treatment

outcome, for example, diabetes mellitus, drug and alcohol abuse, undernutrition, and
tobacco smoking.

Referrals to other psychosocial support services or to such services as antenatal or well-

baby care should also be provided
 Standards for Public Health and Prevention

18 All providers should ensure that persons in close contact with patients
who have infectious tuberculosis are evaluated and managed in line with
international recommendations.

The highest priority Persons with symptoms suggestive of tuberculosis

contacts for evaluation
Children aged <5 years

Contacts with known or suspected immunocompromised

states, particularly HIV infection
Contacts of patients with MDR/XDR tuberculosis
 Children <5 years of age and persons of any age with HIV infection who are
19 close contacts of a person with infectious tuberculosis, and who, after careful
evaluation, do not have active tuberculosis, should be treated for presumed
latent tuberculosis infection with isoniazid for at least six months.

More likely to develop disseminated and

serious forms of tuberculosis such as
meningitis

Should be treated with isoniazid, 10

mg/kg/day (up to a maximum of 300 mg),
for 6 months

Tuberculin skin test and interferon-gamma release assays may be used to

identify those at increased risk for developing active tuberculosis and who are
therefore candidates for treatment of latent infection once active tuberculosis is
excluded.
 Each health care facility caring for patients who have, or are suspected
20 of having, infectious tuberculosis should develop and implement an
appropriate tuberculosis infection control plan to minimize possible
transmission of M. tuberculosis to patients and health care workers.

Infection control for tuberculosis consists of managerial activities at

the facility level and a hierarchy of three categories of control
measures

Disposable Particulate
Administrative Controls Respirators (special masks
Environmental Controls designed to protect the
most important
wearer)
Administrative Controls

• Careful screening
• Early identification of patients with, or suspected of having, tuberculosis and
• Separating them from other patients, especially from patients who are highly susceptible to
tuberculosis.
• Organizing patient flow through sections of facilities for example, rapid identification of
• coughing patients, systematic use of surgical masks for coughing patients, and directing
• these patients away from crowded waiting areas (fast-tracking)

Environmental Controls
• Effective ventilation should be given a high priority
• Properly placed and shielded upper room ultraviolet germicidal irradiation fixtures
21 All providers must report both new and re-treatment tuberculosis cases
and their treatment outcomes to local public health authorities, in
conformance with applicable legal requirements and policies.

System is useful not only to monitor progress and treatment outcomes of individual
patients, but also to evaluate the overall performance of the tuberculosis control
programs at the local, national, and global levels, and to indicate programmatic
weaknesses

An additional important function of a recording and reporting system is

to identify serious adverse events resulting from antituberculosis drugs
 “DOTS” TB
(Directly observed treatment short course )
Prinsip
Menjamin seluruh dosis obat yang telah direncanakan dimakan
oleh penderita.
Idealnya :
Setiap dosis obat dimakan oleh penderita di depan petugas
5 ELEMEN STRATEGI DOTS

Komitmen politis
Jaminan 1
Ketersediaan OAT Diagnosa dengan
Yg bermutu mikroskop
4 2

5 3
Directly Observed
Treatment Short-course
Monitoring dan Pengobatan
evaluasi jangka pendek dgn
pengawasan langsung
 Tujuan Program
Menurunkan kesakitan dan kematian  menyediakan akses
Memutuskan rantai penularan  penemuan & pengobatan
Mencegah terjadinya kebal obat.

Target:
Penemuan TB (BTA +) baru, 70% dari perkiraan pasien ,
Penyembuhan sedikitnya 85% dari TB baru yg diobati.
Sedangkan Millenium Development Goals (MDGs) menargetkan pada tahun 2015 angka insidensi
dan kematian akibat TB dapat diturunkan sebesar 50% dibanding tahun 1990.

Masyarakat mandiri dalam hidup sehat

di mana TB tidak lagi menjadi masalah kesehatan masyarakat.
Form Pencatatan TB
 TB 01  kartu kontrol pengobatan
 TB 02  kartu kunjungan
 TB 03  pencataan rekapan pasien yangdiobati
 TB 04  pencatatan Laboratorium
 TB 05  formulir pemeriksaan Sputum
 TB 06  form pencatatan suspek
 TB 07  laporan triwulan penemuan kasus baru dan kambuh
 TB 08  laporan hasil pengobatan
 TB 09  form rujukan pasien pindah berobat
 TB 10  laporan hasil pengobatan pasien pindahan
 TB 11  laporan tiwulan pemeriksaan sputum
Urutan Pencatatan di Unit Pelayanan Kesehatan

 TB -- 06.
 TB -- 05.
 TB -- 04.
 TB – 01. 02
 TB -- 03
 Proses pencatatan-pelaporan UPK-
Kab./Kota-Propinsi.
• TB-07, TB-11, TB-08.
Urutan Pencatatan Pasien TB di UPK
Poliklinik/
1 Suspek
bangsal
TB. 10
TB. 06
UPK lain
Diagnosis
2
4 4b TB. 09
TB. 05 Pasien TB
3 TB. 01 TB. 02 Pelaporan tingkat kabupaten dan
propinsi
Labor
TB. 04 5 TB. 03 6
TB. 07
Dahak SP
TB. 08

TB. 11
Pelaporan pencapaian program TB
pertriwulan ke Dinas Kesehatan DINAS KESEHATAN KOTA
 PROGRAM TB NASIONAL TB 06

DAFTAR TERSANGKA PENDERITA ( SUSPEK) YANG DIPERIKSA DAHAK SPS

Bulan JANUARI Tahun 2020
Poli Paru RS Dr. M Djamil

NO UMUR HASIL PEMERIKSAAN

No IDENTITAS NAMA TERSANGKA ALAMAT LENGKAP No
SEDIAAN PENDERITA L P A B C Reg
DAHAK Lab
Tanggal Hasil Tanggal Hasil Tanggal Hasil

1 2 3 4 5 6 7 8 9 10 11 12 13

Catatan : A = Slide dahak sewaktu pertama, B= Slide dahak pagi, C = Slide dahak Sewaktu kedua
TB-06
 TB-06 hanya untuk mencatat suspek dan hasil pemeriksaan lab.
 BTA Positif. Dari TB 06 atau BTA neg dgn RO positif dibuatkan pencatatan TB-01

 Dua macam TBC yang tidak melalui pencatatan TB-06 adalah TBC ekstra paru dan TBC anak. –
langsung TB 01. TBC ekstra-paru dan TBC anak pencatatanya tanpa menggunakan TB-05 dan TB-06
oleh karena tidak memerlukan pemeriksaan mikroskopis.

 TB-01 yang telah dibuat selanjutnya berfungsi sebagai pengumpul pencatatan selama pengobatan
sampai akhir pengobatan.

 Hasil pemeriksaan lab, follow-up dan setelah mangkir tidak tercatat pada TB-06 tetapi langsung
kembali kepada TB- 01, oleh karena awal permintaan berasal dari TB-01.

 TB 05 adalah Format pengantar permintaan pemeriksaan mikroskopis untuk diagnosis, follow up dan
mangkir.
 Hasil pemeriksaan untuk diagnosis kembali ke TB-06, sedangkan untuk follow-up dan mangkir
kembali ke TB-01.
 TB-04 adalah tempat penyimpanan semua hasil pemeriksaan lab. baik untuk diagnosis,
follow-up atau setelah mangkir.

TB-05 waktu kembali ke-peminta (poliklinik PS maupun poliklinik PRM) membawa Nomor
Register Lab. yang ada pada TB-04 untuk dicatat pada TB-06.

53
TB-
01
Berfungsi sebagai pencatat semua peristiwa/kegiatan semasa pengobatan
penderita- dari awal pengobatan (bln 0) sampai akhir pengobatan (AP)
 TB-01 dibuat berdasarkan hasil mikroskopis pertama –SP didapat minimal
neg/pos-atau mikroskopis kedua mikroskopis awal didapat neg/pos/neg atau
neg/neg/neg).
Follow-up permintaannya dari TB-01 – mengunakan TB-05-dan hasilnya
kembali ke TB-01 dari pemeriksaan 2 spesimen SP atau PS ( salah satu
positip adalah positip).
 INDIKATOR KEBERHASILAN STRATEGI DOTS
 Kepekaan penjaringan suspek : Proporsi BTA positif di antara suspek
yang diperiksa dahaknya, (5 – 15 %)
 Kontribusi terhadap Program : TB paru BTA positif diantara seluruh pasien
TB paru, (>65%)
 Angka Konversi (Convertion Rate): Proporsi Konversi diantara yang
diobati, ( > 80%)
 Angka Kesembuhan (Cure Rate) : Proporsi sembuh diantara yang diobati.
( > 85%)
 Angka Kesalahan Laboratorium (Error Rate): Proporsi jumlah beda baca
dengan yang dibaca < 5%
 Prinsip :
Memastikan pasien TB yang dirujuk/ pindah akan
menyelesaikan pengobatannya dengan benar di tempat lain
 Alur Rujukan Penderita Tuberkulosis

Koordinator Wasor TBC

HDL Kab/Kota Kab/Kota

konfirmasi
informasi

Penderita, OAT,
TB.01(kopi), surat
rujukan (TB.09)
Rumah Sakit Puskesmas
(TB.09)
 58
12/12/2021 dr. H Aminul Azwar Fas_Nas 58
 LANGKAH-2 PENERAPAN DOTS
 Melakukan asesmen dan analisa situasi , untuk mendapatkan gambaran kesiapan
UPK dan Dinas Kesehatan setempat,
 Mendapat komitmen yang kuat dari pihak pemilik, manajemen UPK (direktur ) dan
tenaga medis (dokter umum dan spesialis) serta nonmedis,
 Menyiapkan tenaga medis dan non medis yang terlatih DOTS ,
 Membentuk Tim DOTS dengan melibatkan unit terkait.
 Menyediakan ruang untuk pojok DOTS,
 Menyediakan tempat / rak penyimpanan paket-paket OAT di ruang DOTS,
 Menyiapkan laboratorium untuk pemeriksaan mikrobiologis dahak sesuai standar
dan ruang pengambilan dahak,
 Menggunakan format pencatatan sesuai dengan program tuberkulosis nasional,
 Menyediakan biaya operasional .
JEJARING PELAYANAN • JEJARING PELAYANAN TB TERDIRI
DARI :
TB • JEJARING EKSTERNAL
• JEJARING INTERNAL

JEJARING
EKTERNAL
 JEJARING PIMPINAN Komite Medik
RS
INTERNAL
TIM DOTS
UNIT DOTS

Laboratorium

Poli Umum Radiologi

Poli Spesialis Farmasi

UGD Rekam Medis

Rawat Inap PKMRS
12/12/2021 dr. H Aminul Azwar Fas_Nas 62
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