Tuberculosis Treatment MODULE-B

DETECT CASES OF MDR-TB a

Detect Cases of MDR-TB

B

AcknowledgementsThese training modules for Drug-resistant Tuberculosis will be used by the National TB Program, Infectious Disease Office, National Centers for Disease Prevention and Control, Philippine Department of Health and its partners in the Local Government Units in the integration of the Programmatic MDR-TB Management into the National TB Program. The documents were prepared by the core team of the Programmatic Management of Drug-Resistant TB (PMDT) Program of the Tropical Disease Foundation, Philippines with the technical assistance from the WHO:

Ma. Imelda D. Quelapio, MD, PMDT Executive Officer & Program Manager

Nona Rachel Mira, RN, MPH, Training OfficerVirgil Belen, RN, Nurse Clinical CoordinatorRuth Orillaza-Chi, MD, Medical Clinical CoordinatorAlbert Angelo L. Concepcion, RN, MHSS, Program

Coordinator Nerizza Múñez, RPh, Drugs and Supplies Management

CoordinatorGrace Egos, RMT, MSPH, Laboratory ManagerThelma E. Tupasi, MD, Program DirectorJacob H. Creswell, MPH, WHO Consultant

With contributions from:Michael Evangelista, RMT – PMDT Laboratory CoordinatorJohn Stuart Pancho, RN – Training Assistant Roberto Belchez, RN - Field CoordinatorGail de las Alas, RSW, MSSW – Social Worker Coordinator

The contributions from the following are also acknowledged: The technical inputs, editorial review and coordination provided by Dr. Michael N. Voniatis, WHO Medical Officer for Stop TB in the Philippines; the guidance provided by Ms. Karin Bergstrom of the Stop TB Department, WHO–HQ, Geneva; the technical support of the Stop TB Unit of the WHO Western Pacific Regional Office (WPRO); the collaboration and support of the technical and managerial staff of the National TB Programme, Department of Health, Philippines, in particular Dr. Rosalind G. Vianzon, National TB Program Manager and Dr. Vivian Lofranco, focal point on MDR-TB at DOH; the Center for Health Development, the National Capital Region, the NTP Coordinators of the local government units in Metro Manila, Philippines, the MDR-TB Treatment Center staff, and other partners.

The production of the module is supported by WHO Regional Office for the Western Pacific and WHO Headquarters, with funding from Eli Lilly and the United States Agency for International Development. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the World Health Organization and the donors.

National Library of the Philippines Cataloguing in Publication Data

Management of Drug-resistant Tuberculosis Training for Health Facility

Staff in the Philippines

1) Tuberculosis (Disease) – Multidrug-Resistant Tuberculosis

2) Training Modules

ISSN # 2012-2675

Recommended citation:

Tropical Disease Foundation and Department of Health, Philippines,

2008. Management of Drug-resistant Tuberculosis Training for Health

Facility Staff in the Philippines

© Tropical Disease Foundation (TDF) and Department of Health,

Philippines (DOH) 2008.

All rights reserved. Copying and/or transmitting portions or all of this

work without permission, or selling this material or portions of this

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encourage dissemination of these modules and will normally grant

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is being distributed without warranty of any kind, either expressed

or implied. The responsibility for the interpretation and use of the

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damages arising from its use.

Requests for permission to reproduce, in part or in whole, or to

translate the training modules should be addressed to either of the

agencies below:

Tropical Disease Foundation, Philippine International Center for

Tuberculosis, Amorsolo corner Urban Avenue, Makati 1229, Philippines,

Fax No. (+63 2) 810 2874; email: [email protected]

Center for Infectious and Degenerative Diseases, National Center for

Disease Prevention and Control, Department of Health, 3rd Floor, Bldg.

13, San Lazaro Compound, Sta. Cruz, Manila, Philippines, Fax: (632)

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Cover and text design: Digix Design Studio / Alexdesigns.ph

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DETECT CASES OF MDR-TB 3

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Objectives of this module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1. Identify MDR-TB suspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Exercise A: Written exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.1 Refer MDR-TB suspects to the appropriate Treatment Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Exercise B: Written exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2. Collect and record patient data for the MDR-TB suspect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.1 Fill out the MDR-TB Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.2 Fill out the PMDT Acknowledgement Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

2.3 Fill out the TB Symptomatics Masterlist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Exercise C: Written exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.4 Make a referral to the Consilium if necessary and enter the patient in the Category IV Register . . . 58

3. Discuss the “Paunawa” or Terms of Understanding with the patient . . . . . . . . . . . . . . . . . . . . . . . . 60

3.1 Provide patient education on MDR-TB and the diagnostic process . . . . . . . . . . . . . . . . . . . . . . . . . 60

3.2 Obtain patient’s signature in Panawa or Terms of Understanding . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4. Collect sputum for smear, culture and DST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

4.1 Enlist the MDR-TB suspect’s cooperation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

4.2 Fill out the Mycobacteriology Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

4.3 Collect sputum samples from the MDR-TB suspect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

4.3.1 Alternative methods of sputum collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

4.4 Pack the sputum samples and send to the laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

4.4.1 Prepare the Laboratory Receiving Form for Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Exercise D: Written exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

5. Receive and record the smear and culture results

in the TB Symptomatics Masterlist and decide on the appropriate action . . . . . . . . . . . . . . . . . . . 72

5.1 Record the smear results in the TB Symptomatics Masterlist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

5.2 Decide on the appropriate action in response to the smear results . . . . . . . . . . . . . . . . . . . . . . . . . . 76

5.3 Record the culture results in the TB Symptomatics Masterlist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

5.4 Decide on the appropriate action in response to the culture results . . . . . . . . . . . . . . . . . . . . . . . . . 78

6. Receive and record the DST results in the TB Symptomatics Masterlist,

Category IV Register and Consiliumex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

6.1 Record DST results in the TB Symptomatics Masterlist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Exercise E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

MODULE B

4 DETECT CASES OF MDR-TB

6.2 Assign a Pre-enrollment number to the patient if confirmed to have MDR-TB . . . . . . . . . . . . . . . . . 92

6.3 Record the results in the patient’s chart and in Consiliumex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

6.4 Schedule a case for presentation at the next Consilium meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Example of a Consiliumex showing Consilium decision on treatment regimen. . . . . . . . . . . . . . . . . 95

6.5 Return an updated Acknowledgement Form to the referring DOTS facility . . . . . . . . . . . . . . . . . . . . . 99

7. Inform MDR-TB suspects of laboratory test results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

7.1 Patients with drug resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

7.2 Patient with no drug resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

8. Trace household contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

8.1 Obtain a written consent from the patient in Kasunduan/”Contract” for treatment

and interview the patient’s household contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

8.2 Complete the list of the patient’s contacts on the Contact Initial Investigation Form

and conduct interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

8.3 Instruct patients’ symptomatic household contacts to receive appropriate care and follow-up . . 107

8.4 Evaluate children by physical exam, chest x-ray and TST. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Summary of important points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Self-assessment questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Answers to self-assessment questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Annex A. Proper Collection of Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Annex B. Procedures for Obtaining Sputum Specimens in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Annex C. Proper Labeling, Sealing and Transportation of Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120


Introduction

The detection of multidrug-resistant TB (MDR-TB) is more complex and time-consuming than the detection of a case of TB that is susceptible to first-line drugs. To stop transmission, early detection of MDR-TB is important. Failure to detect MDR-TB will lead to the spread of the drug-resistant strain to others, intake of incorrect treatment regimens, amplification of drug resistance and poor treatment outcomes.

Patients with pulmonary TB (PTB) excrete tubercle bacilli that can be detected by examining their sputum under a microscope, that is, by direct sputum smear microscopy (DSSM). However, drug resistance cannot be diagnosed with DSSM alone. This is because a positive smear of drug-resistant TB (DR-TB) looks the same as a positive smear of drug-susceptible TB. They are caused by the same organism, Mycobacterium tuberculosis (M. tuberculosis).

To detect if the strain of TB is resistant or not, a culture and drug susceptibility test (DST) must be done. This laboratory procedure determines if the M. tuberculosis strain does not grow in the presence of anti-TB drugs. If the strain grows, it is said to be resistant to that drug. The sputum must therefore be cultured, and a DST of the isolated M. tuberculosis from the culture must be done. MDR-TB demonstrates resistance to at least isoniazid and rifampicin, the two most powerful anti-TB drugs, with or without resistance to other anti-TB drugs. All patients with suspected MDR-TB must therefore have culture and DST in addition to smear, to confidently diagnose MDR-TB or any type of drug resistance.

Ideally, all TB symptomatics should undergo DSSM, culture and DST. However, given the limited resources available in the Philippines at the moment, this is not possible for all of the TB suspects in the country. To more efficiently diagnose those patients who have MDR-TB, a list of risk groups for MDR-TB will be described in detail in the following pages. To detect cases of resistance early, health facilities should check for MDR-TB risk factors in all TB patients or persons who present with symptoms suggestive of PTB, primarily cough. All persons presenting at a DOTS facility who are found to be at high risk should be referred to an MDR-TB Treatment Center for diagnosis.

Confirmed MDR-TB cases by DST, as well as those highly suspected of MDR-TB, still unconfirmed but needing immediate treatment must be presented to the consilium for further discussion and possible initiation of a Category IV regimen. The consilium is a multi-disciplinary case management committee composed of program staff, physicians, nurses and other relevant health care workers with expertise on MDR-TB management. This committee meets regularly to confirm the diagnosis, determine treatment regimens, assess response to treatment, and determine final outcome through a consensus using standards based on the WHO Guidelines for Programmatic Management of Drug-resistant TB.

Pulmonary MDR-TB patients are generally infectious cases since they are often chronic cases, and have more extensive lung damage. They discharge tubercle bacilli into the air by coughing, sneezing, etc. Close contacts of MDR-TB cases, e.g., in the home, can become infected with a drug-resistant strain of TB when they breathe in a significant amount of tubercle bacilli. The longer MDR-TB cases are untreated, the greater will be the likelihood that they will infect their close contacts.

Early identification of MDR-TB suspects should be a priority for every DOTS facility, in order to promptly treat the infectious cases before they spread the drug-resistant strain to others. Early treatment of these cases increases the likelihood of a favorable outcome and minimizes destruction of the lungs by the microorganism. It also limits the amplification of resistance and prevents the emergence of extensively drug-resistant TB (XDR-TB).

MODULE B


Objectives of this module

Participants will learn to: Refer to section:

Identify MDR-TB suspects 1Refer MDR-TB suspects for screening using the MDR -TB Suspects Referral Form 1Collect and record patient data from the MDR-TB suspect 2Fill out and use the MDR-TB Screening Form, the Acknowledgement Form, 2and the TB Symptomatics MasterlistMake an early referral to the Consilium 2Provide patient education using the Paunawa or Terms of Understanding 2Collect sputum samples and request the necessary tests 4Use laboratory results to identify MDR-TB cases 5, 6Inform MDR-TB suspects of the results and begin additional care as needed 7Check household contacts of MDR-TB cases 8

If you need to look up an unfamiliar word, refer to the glossary in Module A.

MODULE B


1. Identify MDR-TB suspects

MDR-TB suspects are TB symptomatics with an identified risk to develop MDR-TB. To detect these patients, high-risk groups for MDR-TB based on findings from the DOTS-Plus pilot project and the nationwide drug resistance survey (DRS) have been identified as shown in Box 1. In general, previous anti-TB treatment is a risk factor for resistance and therefore, all previously treated patients should be referred to the MDR-TB Treatment Center for screening and diagnosis.

By asking a few basic questions to TB suspects and by correctly monitoring current TB patients, DOTS facilities will be able to detect a large number of patients with high risk for MDR-TB in a timely manner.

The symptoms of pulmonary TB are the same as for MDR-TB, in particular, cough for two weeks or more. Other symptoms of TB include fever, chest and/or back pain, hemoptysis (coughing up of blood), weight loss and others such as night sweats, fatigue, body malaise, and shortness of breath. Being a contact of an MDR-TB case puts both new and retreatment patients at high risk for MDR-TB. Experience at the Tropical Disease Foundation (TDF) showed that among 1,737 MDR-TB contacts, 251 (14%) had radiographic evidence of TB. From these, 181 who submitted sputum and had available results, 42 (23%) turned out culture-positive, with MDR noted in 24 (57.1%), drug resistance other than MDR-TB in 7 (16.7%) and pan-susceptibility in 11 (26.2%).

For retreatment cases, some patient types have higher MDR-TB prevalence than others. In the Philippines, information regarding this is still being gathered, and all retreatment cases are considered at risk of being MDR-TB. Among patients receiving DOTS Category II treatment, MDR-TB is suspected if there is non sputum smear-conversion on the third month of treatment. A limited study from the TDF DOTS-Plus pilot project showed that of 22 Category II non-converters among 226 enrolled patients, MDR-TB was noted in 73% (16). On the other hand, of 36 Category I non-converters on month 2 among 181 enrolled cases, MDR-TB was noted in only 6%.

Additionally, if a patient presents to a DOTS facility with TB and reports that he has already received two or more courses of anti-TB treatment that were self-administered upon prescription of a doctor, that patient should be suspected of having MDR-TB and be referred to an MDR-TB Treatment Center. A treatment course is defined as at least a month of intake of anti-TB drug(s) excluding prophylactic treatment.

While HIV is not by itself a risk factor for MDR-TB, since TB/HIV coinfected patients usually have negative sputum smear results, HIV-positive individuals who have TB symptoms should be investigated for resistance using culture and DST. Furthermore, HIV co-infection with MDR-TB is a severe disease with a very high mortality rate and should be diagnosed promptly for immediate treatment.

Without proper detection and treatment of persons who are at high risk for DR-TB, there is a great danger that DR-TB will continue to spread in the community.

MODULE B


The following table describes the high-risk groups for MDR-TB.

BOX 1: High-risk groups for MDR-TB

A. Retreatment cases

Failure1.

Category I failure: – a patient who remains (or becomes) sputum smear-positive on the 5th month or later of DOTS Category I treatment Category II failure (chronic TB case): – a patient who remains (or becomes) smear-positive on the 5th month or later of DOTS Category II treatment or who remains sputum-positive at the end of a retreatment regimen

Relapse of category I or II:2. a patient who has been declared cured or treatment completed, and is diagnosed with bacteriologically (smear or culture) positive TB

Return after default:3. a patient who returns to treatment with positive bacteriology (smear or culture) following interruption of treatment for two months or more

“Other”4. type of patient: a patient with one month or more of anti-TB drug intake under the DOTS strategy that cannot be classified into any type of retreatment, or a patient with one month or more of non-DOTS treatment.

Non-DOTS patient whether sputum-positive or sputum-negative a) “Other-positive”: a sputum-positive patient with one month or more of DOTS treatment who b) cannot be typed as Treatment failure, Relapse, or Return after default. For example, a patient who is smear-negative initially then turned out to be positive at sputum follow-up during DOTS treatment .“Other negative:” a sputum-negative patient with one month or more of DOTS treatment who c) cannot be typed as Treatment failure, Relapse, or Return after default. For example, a patient who returns to TB treatment with negative bacteriology (smear or culture) following interruption of treatment for two months or more

*A treatment course is defined as at least a month of intake of anti-TB drug(s) excluding primary and prophylactic treatment.

Non-converter of Category II:5. a patient who remains smear-positive at the end of the third month of DOTS Category II treatment

B. New or retreatment cases

Symptomatic contact of a confirmed or suspected drug-resistant patient:6. A “contact” refers to a household contact who is a person who normally sleeps in the same dwelling unit as the drug-resistant index case for at least three months and has a common arrangement for preparation and consumption of food. This patient has a higher risk of contracting the drug-resistant strain of the index case.

HIV-positive patient7. who has pulmonary or extra-pulmonary TB symptoms or has chest x-ray findings suggestive of TB: HIV infection by itself is not a risk factor specifically for MDR-TB, but for TB, in general. Since HIV-infected patients with MDR-TB have high mortality, early diagnosis through culture and DST are recommended.

MODULE B


Now do Exercise A – Written Exercise

When you have reached this point in the module, you are now ready to do Exercise A. Follow the instructions for Exercise A. Do this excercise by yourself.

Then discuss your answers with a facilitator.

Exercise A: Written exercise

Identify MDR-TB Suspects

In this exercise you will identify those patients that should be considered high-risk for having MDR-TB. Read each of the cases below. For each case, put a check on “Yes” for those who should be considered MDR-TB suspects and determine to which high-risk group they belong. Put a check on “No” for those who are not considered MDR-TB suspects.

Case 1A 34 year old female patient, who took only 4 months of Category I treatment last year, has returned to the DOTS facility. The patient was sputum smear (-) on the 2nd and 4th months of follow-up but thereafter stopped treatment since she was already feeling better. Now the patient complains of a persistent cough for the last 4 weeks with back pain, hemoptysis and weight loss. Sputum examination result was smear-positive.

MDR-TB suspect? Yes No High-risk group

Case 2A female patient who has received 3 different courses of TB medications over a period of many years with a private doctor has come to your facility for consultation. The patient said she took all of the medicines and completed treatment each time but now has a cough and fears it may again be TB. She also has weight loss, hemoptysis, occasional fever, chest pain and night sweats. She has come to the DOTS facility because she no longer has money to pay for treatment.


Case 3A 55 year old male has been complaining of cough for three weeks, night sweats and fatigue. When interviewed, he says that he has not been sick for a long time but his wife told him he must come in to be checked because their 25 year old son who lived in the same house with them died of MDR-TB last year. The patient has no history of TB and has a normal chest x-ray.


MODULE B


Case 4A 17 year-old female student has come to your DOTS facility for cough of more than two weeks and fever of five days. She has never been diagnosed or treated for TB in the past. She denies exposure to anybody with TB in the home or in school. You examine her and she has rales on both lower lung fields.


Case 5A female patient, 18 years old, who is being treated for HIV in one of the treatment hubs in Metro Manila develops fever, and weight loss. The DOTS facility recognized her to be the sister of a non-converting Category II patient who has been going to this health center for TB treatment.


Case 6A Category II (relapse) male patient just finished the third month of treatment and is still smear-positive. He still has cough and back pain and has been losing weight. The patient has had no adverse events and complies with the treatment schedule.


When you have finished this exercise,please discuss your answers with a facilitator.

MODULE B


1.1 Refer MDR-TB suspects to the appropriate Treatment Center

Once a patient has been identified to be an MDR-TB suspect in a DOTS facility, he should be referred to the appropriate MDR-TB Treatment Center using the MDR-TB Suspects Referral Form. This form is available in DOTS facilities.

To complete the MDR-TB Suspects Referral Form, the referring DOTS facility fills in the date, the suspect’s name and the demographic information. Write the name of your DOTS facility and the Treatment Center to which the patient is being referred. Write the reasons for referring, e.g., factors that make the patient at risk for MDR-TB. Write the details being asked for on the TB history and treatment.

If the patient being referred has been on DOTS treatment, a photocopy of the DOTS Treatment Card should be sent along with the MDR-TB Suspects Referral Form. If not, a referral note should be sent along which details the TB history including the history of use of anti-TB drugs. Instruct the patient to present the MDR-TB Suspects Referral Form and the copy of the DOTS Treatment Card or referral note when he or she visits the Treatment Center for assessment.

Depending on the location of the local government unit or city/municipality where the DR-TB suspect resides or is identified, the referring DOTS facility will send the patient to the designated Treatment Center guided by the zoning map (Figure 1). This illustrates the location of the different Treatment Centers currently limited to Metro Manila. Table 1 shows the details of the zoning map and is just a guide which may be modified to suit the patient’s convenience, in case his residence is nearer another Treatment Center than the one suggested in the map. If the patient was identified as an MDR-TB suspect at an MDR-TB Treatment Center itself, the MDR-TB Suspects Referral Form need not be accomplished. An example of the form is shown on page 14. See Reference Booklet for instructions on how to fill it out.

FIGURE 1. Zoning map for referral of MDR-TB suspects

Treatment Center in MM- South (to be set-up)

PTSI Tayuman DOTS Center, City of Manila

TDF-MMC DOTS Clinic, Makati City

KASAKA-QI MDR-TB Housing Facility , Quezon City

LCP- PHDU DOTS Center, Quezon City

DJNRMH DOTS Center, (formerly TALA Hospital) Caloocan City

1

2

3

4

5

6

1

2

3

4

5

6

DJNRMH: Dr. Jose N. Rodriquez Memorial HospitalKASAKA-QI: Kabalikat sa Kalusugan – Quezon InstituteLCP-PHDU: Lung Center of the Philippine – Public Health Domiciliary UnitPTSI: Philippine Tuberculosis Society, Inc. TDF-MMC: Tropical Disease Foundation – Makati Medical Center

DOTS facilities, whether public or private, from all over Metro Manila may refer their MDR-TB suspects to any of the Treatment Centers shown above. The Treatment Center which is most proximal to the patient’s residence or address would be most convenient to the patient and should be selected.

MODULE B


A flow chart for the referral of MDR-TB suspects is illustrated in Figure 2, page 14.

TABLE 1. Zoning of local government units and MDR-TB Treatment Centers

ZONE LGU MDR-TB Treatment Centers

1

Caloocan: North Bayan

Dr. Jose N. Rodriguez Memorial Hospital (DJNRMH) DOTS Center KASAKA-QI MDR-TB Housing Facility PTSI Tayuman DOTS Center

Malabon KASAKA-QI MDR-TB Housing Facility PTSI Tayuman DOTS Center Navotas

Valenzuela LCP-PHDU DOTS Center PTSI Tayuman DOTS Center

2

Marikina LCP-PHDU DOTS Center

Pasig

TDF-MMC DOTS ClinicPateros

Taguig

QCLCP –PHDU DOTS CenterKASAKA-QI MDR-TB Housing FacilityDJNRMH Treatment Center

3

Manila Tondo Sta. Mesa Sampaloc Others

PTSI Tayuman DOTS Center KASAKA-QI MDR-TB Housing Facility TDF-MMC DOTS Clinic

MakatiTDF-MMC DOTS Clinic

Mandaluyong

San Juan KASAKA-QI MDR TB Housing Facility

4

Las Pinas

TDF-MMC DOTS Clinic Treatment Center in MM-South

Muntinlupa

Paranaque

Pasay

FIGURE 2. Flow chart for the referral of MDR-TB suspects

MODULE B


Programmatic Management of Drug - Resistant TB(PMDT)

MDR-TB Suspects Referral Form

Date of Referral (mm/dd/yy)

Name Last First Name Middle name

Age Sex

Address Brgy. ( House # and name of street)

City/Province Region Tel. No.

Referring Health Center or DOTS facility:

Name of HC/PPMD/ DOTS facility: Tel. No.

Address of Facility: Fax No.

City Region Referring MD

Referred to (Please check)

MMC/TDF Clinic Dr. Jose N. Rodriguez Memorial Hospital (TALA)

KASAKA QI PTSI Tayuman

Lung Center of the Philippines (LCP) Others, pls. specify _________________________

Reason/s for referring MDR-TB suspect

Category I failure Non-converter of category II

Category II failure Symptomatic contact of confirmed or

Relapse Category I suspected drug-resistant index case

Relapse Category II HIV-positive with TB symptoms

Return After Default (RAD)

Other:

Non-DOTS patient that does not fit above

Other (+)

Other (-)

TB History and treatment

Date start of tx. Where By whom Anti-TB drugs taken and duration Outcome

1997 Rosal Health Center 2 HRZE 4 HR Unknown

2003 Sampaguita Health Cen-ter 2HRZES 4HRZE Failed

September 14, 2004

Sampaguita Health Cen-ter 3 HRZES 3 HRZE Failed

To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.

4 / 25/ 05

Balagtas Jose Amorsolo

50 y/o Male

Sampaguita H.C.#3436 Balut Tondo

Manila NCR Dr. A. Madrid

(02) 244-6999(02) 244-6999

2425 Buendia St. Balut, Tondo

Manila NCR (02) 244-6847

Be guided by the zoning map on Figure 1 and Table 1 when identifying the appropriate Treatment Center

The reason for referral is clearly checked based on TB history and previous treatment.

Example of an MDR-TB Suspects Referral Form

MODULE B


MDR-TB suspects

Retreatment casesFailure:

Category I�Category II�

RelapseCategory I�Category II�

Return after default “Other”Non-converter of Category II

New or retreatment casesSymptomatic contact of MDR-TB patientsHIV (+) patient

Refer to MDR-TB Treatment Center (TC)

Suspect assessed by TC physician

Confirmed MDR-TB suspect

Submit 2 sputum specimens for smear, culture and DST

Suspect is not seriously ill Suspect is seriously ill

Await laboratory results Refer to Consilium

Release of results: DSSM: 4-5 days after the last specimen collectionCulture: 3-3.5 months after specimen collectionDST: 4-5 months after specimen collection

Inform referring facility of results

FORMS USED


MDR-TB Screening Form Acknowledgement Form“Paunawa” or Terms of Understanding TB Symptomatics Masterlist

Mycobacteriology Request FormLaboratory Receiving Form (Specimens)

Non-MDR-TB suspect: Refer back to referring physician/DOTS facility

Smear and culture resultDST resultLaboratory Releasing Form (Results)

Consiliumex

Acknowledgement Form

MODULE B


Now do Exercise A – Written Exercise

When you have reached this point in the module, you are ready to do Exercise B. Turn to the next page and follow the instructions for Exercise B.

Do this exercise by yourself. Then discuss your answers with a facilitator.

Exercise B: Written exercise

Filling out the MDR-TB Suspects Referral Form

The purpose of this exercise is to practice completing an MDR-TB Suspects Referral Form. Use the blank MDR-TB Suspects Referral Form provided for each of the cases below. This form is important so that identified MDR-TB suspects are correctly referred to Treatment Centers for the proper tests. The cases for this exercise are the cases you encountered in Exercise A. Assume that you are the referring physician and write your name on the space provided in the Form.

Case 1

34 year old female patient, Sonia Santos Sariwa, with present address at # 23 Santol St., Barangay San Antonio, Cavite City. Tel. No. (046) 431-4086. Date of birth: August 18, 1973

She finished 4 months of Category I treatment in your DOTS facility, Santol Health Center in the patient’s own barangay. She started in June of 2002 and was sputum smear (-) on the 2nd month. After 2 months of HR, she was again smear (-) on the 4th month of follow-up. The patient felt better and decided to abandon treatment despite your strong advice.

Today is November 29, 2007 and the patient has returned complaining of a persistent cough for the last 4 weeks with back pain, hemoptysis and weight loss. Sputum was smear-positive.

The contact telefax number of your health center is (046) 431-25253.






Age Sex

















Other:


Other (+)

Other (-)




MODULE B


Case 2

Rolanda Ramirez Reloz, 49 years old, has received 3 different courses of TB medications over a period of many years with Dr. A. Reyes as her private doctor.

The patient’s treatment history started in:August 2003: Myrin P Forte x 3 months and Myrin x 3 months 2nd treatment: August 2005: Myrin P Forte x 6 months 3rd treatment: December 2006: 3 months of Econokit- MDR and 4 months of Econopack

She said she took all the medicines and claimed to have finished treatment each time but now has a cough and fears it may again be TB. She also has weight loss, hemoptysis, occasional fever, chest pain and night sweats. She has come to your DOTS facility today, December 3, 2007, because she no longer has money to pay for treatment. Chest x-ray done a week ago showed a cavitary lesion on the right upper lobe, infiltrates on the left lower lobe and minimal pleural effusion, right.

Mrs. Reloz is presently residing at 44526 Jhonny St., Brgy. Pio del Pilar, Makati City. Tel: 989014301. Date of birth is September 2, 1958. Your facility is Pio del Pilar Health Center, Brgy Pio del Pilar, Makati City. Telephone no. 8889045






Age Sex

















Other:


Other (+)

Other (-)




MODULE B


Case 3

Santiago Suma Santos, a 55 year old male with present address at 2062-1 Anak Bayan, Paco, Manila. Tel. 530-55555, has been complaining of cough for three weeks, night sweats and fatigue. When interviewed, he says that he has come upon his wife’s advice considering that their 25 year old son died of MDR-TB last year. He has had no history of TB but now has minimal infiltrates on the left upper lobe on the film done December 1, 2007.

Date of birth: April 2, 1952Your DOTS facility is J. Fabella Health Center, San Andres, Manila. Telefax. no. 530-444444. Today is December 5, 2007.






Age Sex

















Other:


Other (+)

Other (-)




MODULE B


Case 5

A female patient, Susana Sandok Sarmiento, 18 years old, who is being treated for HIV in one of the treatment hubs in Metro Manila develops fever, and weight loss. Your staff at the Quirino Health Center recognized her to be the sister of a non-converting Category II patient who has been going to this health center for TB treatment. Chest x-ray of Susana done on October 8, 2007 showed a normal result.

Today is December 6, 2007. Date of birth: June 18, 1989

Present address is at 1598 Interior 86 P. Quirino Avenue, Pandacan, Manila with telephone number 589-63636.Your Health Center is located in Quirino Ave., Pandacan, Manila with telephone no. 599-0001.






Age Sex

















Other:


Other (+)

Other (-)




MODULE B


Case 6

Patient Rodolfo Remo Robles, 30 years old, was declared cured from Category I treatment which started on June 1, 2006 in Poblacion Health Center. However, he went into relapse for which the 2nd treatment was started on September 3, 2007. Treatment with Category II is ongoing at your DOTS facility, Poblacion Health Center in the same street and barangay where the patient resides.

Today, December 7, 2007, the patient is on his 3rd month of treatment and the follow-up smear result came out positive. He still has cough and back pain and has been losing weight. The patient has had no adverse events and complies with the treatment schedule.

Present address is at 276281 Poblacion Sn Vicente St., Bayanan, Muntinlupa City. Tel 5305555.Date of birth: March 28, 1977Tel no. of your health center is 8098420.






Age Sex

















Other:


Other (+)

Other (-)




MODULE B



MODULE B


2. Collect and record patient data for the MDR-TB suspect

The Treatment Center will receive the MDR-TB suspect referred by the DOTS facility and if you work at the Treatment Center, you will proceed to obtain and record information about the suspect and his condition and medical history. This background information will be recorded on the MDR-TB Screening Form. Later, this patient will be registered in the TB Symptomatics Masterlist.

2.1 Fill out the MDR-TB Screening Form The MDR-TB Screening Form is an individual form for each MDR-TB suspect that holds a large amount of background information about the patient. It is necessary that the Treatment Center staff fills out the form completely and accurately to provide the most precise information for each patient’s record. The Treatment Center physician is responsible for monitoring the completeness and accuracy of the MDR-TB Screening Form.

The MDR-TB Screening Form is a record of the following:

MDR-TB suspects’ demographics and contact informationI. MDR- TB suspects’ present medical complaint and symptomsII. MDR-TB suspects’ past medical history especially previous TB treatment and exposure; co-morbid conditions III. such as HIV, diabetes mellitus, kidney or liver disease, etc.Social historyIV. Doctor’s physical examination findings and laboratory proceduresV. Assessment or initial diagnosis and the specific type of suspect and risk factors for drug-resistanceVI. Plan for diagnosis and/or treatmentVII.

The Screening code is the unique identification number assigned to every TB symptomatic who undergoes the process of screening at the Treatment Center (See table below). This number is given once the patient is entered in the TB Symptomatics Masterlist for PMDT. See Reference Booklet for instructions on how to fill out the TB Symptomatics Masterlist.

TABLE 2 :Screening code (TC-YY-MM-NNNN)

Code Description

TC

Treatment Center: TDF-MMC DOTS Clinic01– KASAKA-QI MDR-TB Housing Facility02– LCP-PHDU DOTS Center03– Dr. Jose N. Rodriguez Memorial Hospital (DJNRMH)- DOTS Center04– Philippine Tuberculosis Society Inc. (PTSI) Tayuman DOTS Center05–

YY Current year the patient was screened, e.g., 08 for 2008MM Current month the patient was screened, e.g., 01 for JanuaryNNNN Accrual number that begins with 0001 at the start of every month

The example on page 28 shows that the patient, Jose Balagtas, with Screening Code 02-05-04-0081 was screened in KASAKA-QI MDR-TB Housing Facility in April 2005 and was the 81st TB or MDR-TB suspect to be screened since the start of the month in that Treatment Center. Permanent address is the address where the patient has stayed on a long-term basis, e.g., in the province, while the current address is the residence where he can be contacted while undergoing diagnosis for TB or MDR-TB, e.g., relocation address in Metro Manila.

Elaborate on the patient’s symptoms including duration, and other details, e.g., quantification of weight loss, or blood during hemoptysis, etc. Write the patient’s past TB treatment: what drugs were taken, where treated, whether DOTS or non-DOTS, and the outcome of such treatments; exposure to active TB or MDR-TB; comorbid illnesses, allergy, etc. Write the smoking, alcohol and drug use, and sexual history.

MODULE B


Write the physical examination findings, and laboratory procedures that were done prior to the screening, the radiographic findings including an illustration of where the radiographic lesions are found in the lungs. Finally, write down your assessment of the patient, whether TB or non-TB, and if new or retreatment. If the patient is a retreatment case, specify what category, whether failure of category I or II, return after default, relapse of category I, II or IV, or “other”. Specify also if there are risk factors other than a history of treatment, e.g., being a contact of an MDR-TB case, non-conversion of Category II treatment, TB symptomatic HIV-positive, or whether he has had 2 or more treatment courses.Write the management plans, e.g., what sputum examinations to make and how many specimens for each.

A filled out MDR-TB Screening Form is shown on the following pages. See Reference Booklet for instructions on how to fill this out.


Mark with check ( ) if symptom is present, PE is done and disease is present, otherwise, mark with (X). Please ensure the completeness of all information.

Screened at: MMC/TDF KASAKA LCP Others, specify

Screening code: (TC-YY-MM-NNNN) Date: (mm/dd/yy)

I. Demographics

Name: Surname Given Name Middle Name

Sex: Male Date of birth: Age: Place of birth: Female (mm/dd/yy)

Nationality: Religion: Civil status: Single Married Widowed Living together Divorced/ legally separated

Permanent address:

zip code Tel. no.: area code+ tel #

City address:


E-mail address: Family monthly income: Occupation: Employer: Office address: Tel. no.: area code+ tel #

Spouse: Address/ Contact #: Father: Mother: Parent’s address: Tel. no.: area code+ tel #

Person to notify in case of emergency: Relationship: Address: Tel. No.: area code+ tel #

Referred by: HC Govt Inst PPMD FBO NGO Pvt MD/Institution Specify name, Address of referring facility: Number of household contacts: Less than or equal 10 yrs old: More than 10 yrs old: Chief Complaint/s:

II. Review of Symptom/s Duration in month/s Comments

Cough Fever Back/ chest pain Hemoptysis Weight loss Night sweats Other symptoms: Dyspnea at rest Dyspnea on exertion Pedal edema


MDR - TB SCREENING FORM

Balagtas Jose Amorsolo

2425 Buendia St., Balut, Tondo, Manila

Same as above

None None N/A None N/A

Joy Balagtas (02) 244-6847Eduardo Balagtas (Deceased) Lorna Balagtas (Deceased)

Marites Balagtas Daughter2425 Buendia St., Balut, Tondo, Manila

#3436 Balut, Tondo, ManilaSapaguita Health Center

5 2 3Persistent coughing with fresh blood

> 6 months With expectoration of yellowish sputum3 weeks Remittent, usually in the afternoon> 6 months Right upper back pain4 Months Last episodes 4/23/05 2 TBSP 6 months Approximately 10 kg 3 weeks

> 1 month> 6 months

1772 (02) 244-6847

01/20/ 55 50 y/0 Manila

Filipino Roman Catholic

02-05-04-0081 04 /28 / 05

Screening code: TC: 02= KASAKAYY: 05= 2005MM: 04= April0081: 81st patient to be screened in KASAKA in April 2005

Permanent address is the patient’s long-term address

City address is the address in Metro Manila where the patient is staying to access diagnosis and possible treatment.

Example of an MDR-TB Screening Form


III. Past Medical History:

History of previous TB treatment: (from first to last)

Start date( mm/dd/yyyy )

Regimen and duration( mos.)

Treatment facility DOTS(Y/N)

Outcome(1=cured, 2=tx completed,

3=failed, 4=defaulted, 5=unknown)

1. 2. 3. 4. 5. 6. 7.

Exposure to active TB: No If Yes MDR Non MDR

Co- morbidities Duration Comments: (drugs taken, status, etc.)

Diabetes Mellitus Cancer HIVinfection/AIDS Kidney disease Lung disease Epilepsy Psychiatric condition Others

year (s) year (s) year (s) year (s) year (s) year (s) year (s) year (s)

Status

Allergy: Drugs: Type of reaction:

1. 2.

Concomitant drugs / Duration:

Previous surgery: None Pneumonectomy/ Lobectomy Others, specify

Date of surgery: / / Complications:

IV. Social History:

Tobacco/ Cigarettes Alcohol Drug Abuse Current Current Current Past Past Past Never Never Never Sticks/day x yrs Type /bottles /day x yrs Type (shabu, marijuana, etc) Women: LMP / / G P (mm/dd/yy)

Contraceptive use (for women only): No yes, specify

Sexual History:

Programmatic Management of Drug - Resistant TB (PMDT)MDR - TB SCREENING FORM | page 2 of 4

None NA

NANA

20 sticks/day x 31yrs Beer 2/day x 35yrs

2003 2HRZES 4HRZE Sampaguita Health Center Y 32003 2HRZES 4HRZE Rosal Health Center Y 5

9/14/04 2HRZES 3HRZE Sampaguita Health Center Y 3

2 Glibenclamide 5mg TID

Had two partners other than wife / commercial sex workers

Check for other drugs used by the patient to help identify co-morbidities.

Validate the information in the MDR-TB Suspects Referral Form by doing actual interview of the patient’s TB treatment history.

MODULE B



V. Physical examination and laboratory procedures:

Height: cm Weight: Kg. Vital Signs: Temp: Celsius PR/ HR: / min RR at rest: /min BP: mmHg O2 sat by Pulse oximeter: %

System examination:

0 = Not done1 = Normal2 = Abnormal Describe abnormalities

General Health:

Skin:

BCG scar:

Oropharynx:

Cardiovascular:

Thorax & Lungs:

Use of accessory muscles:

Abdomen:

Genito-Urinary:

Extremities:

Neurological:

Lymph Nodes:

Endocrine:

Laboratory procedures:

Smear, Culture and DST results from other laboratory Date

/ /

/ /

/ /

Other laboratory results:

Liver function tests

Renal function tests

CBC

FBS, etc.

167 49. 2 37.4 90 28

120/80

2 Ambulatory, cachectic 2 Poor skin turgor

AFB 2+ 02 15 05

None

2 (+) wheezing, bilateral lung elds, decreased breath sounds on R lung eld 2 (+) SCM, intercostal retractions

Present 1 1

Always ask for results of smear, culture & DST done prior to consultation, if available.

1 1 1 1 1 1

MODULE B



Chest X-ray: Date: / /

0 - Normal 7 - Fibrosis

1 - Cavitary 8 - Fibrothorax

2 - Infiltrate 9 - Bullae

3 - Nodule 10 - Pleural effusion

4 - Miliary TB 11 - Pneumothorax

5 - Intrathoracic lymphadenopathy

12 - Bronchiectasis

13 - Atelectasis

6 - Endobronchial spread

14 - Consolidation

15 - Mass

VI. Assessment:

TB suspect New

Retreatment

If retreatment, check any of the following types. If new or retreatment, check any of the following risk

factors.

Drug-resistant TB suspect (Categories) Category I Failure Category II Failure Return after Default (RAD) Category I Relapse Category II Relapse Category IV Relapse Other

Non-DOTS

Other (+)

Other (-)

None Symptomatic contact of confirmed/ suspected MDRTB patient Non-converter of Category II Symptomatic HIV-positive 2 or more non-DOTS treatment course

Disease other than TB, specify

VII. Plan:

For smear x For TB culture x For Drug susceptibility testing Start TB treatment, specify regimen: Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment

Others

Attending MD: Date:

Right Lung Left Lung

04 17 2005

1

2

22

Dr. Dan Rivera 4 / 28 / 05

8

2

Based on the patient’s TB treatment history, select the appropriate category.

Based on the patient’s background, symptoms, HIV status, Category II conversion, and number of treatment courses, select the appropriate risk factors for drug resistance.

The plan for diagnosis and treatment indicates the sputum tests to be performed and how many samples are needed in order to confirm the assessment.

The Treatment Center physician ensures the completeness of data on the MDR-TB Screening Form.

MODULE B


2.2 Fill out the Acknowledgement Form

After the patient has been interviewed and examined by the Treatment Center physician with all data recorded on the MDR-TB Screening Form, he will fill out the Acknowledgement Form in duplicate copies. Tick the box for “initial diagnosis”. This form is used to inform the referring DOTS facility or doctor that the MDR-TB suspect has been received and examined by the Treatment Center. The Treatment Center physician addresses the form to the referring physician or DOTS facility, writes down the pertinent data including relevant history, past treatment, patient type and physical examination findings. He also writes down the initial diagnosis, and management plans such as laboratory procedures to confirm the diagnosis, or any symptomatic treatment being given. See the Reference Booklet for instructions on how to fill out the Acknowledgment Form.

There are some patients for whom the treatment of TB needs to be stopped while waiting for the DST results. This depends on the suspect’s history of TB treatment or the outcome he had from these treatments. There are also patients who will be referred back to the referring DOTS facility for continuation of DOTS treatment while waiting for DST results. The Treatment Center physician will be the one to advise the patient on what to do with his current treatment and will write this advice down on the Acknowledgement Form. All previously treated patients, symptomatic contacts of drug-resistant cases, whether new or retreatment, are suspects for drug resistance; hence, these patients are candidates for sputum culture and DST in addition to smear. HIV patients with TB symptoms should also have culture and DST because of the high mortality in TB/HIV co-infection.

DOTS facilities are advised to refer all their previously treated symptomatic patients, whether smear-positive or smear-negative, Category II non-converters, symptomatic contacts of confirmed or suspected drug-resistant cases, and HIV cases with TB symptoms to MDR-TB Treatment Centers. The following table will guide the Treatment Center when giving advice to patients. This decision table may undergo some changes as more evidence on this matter is gathered from the experience in the Philippines.

TABLE 3: Decision table for patients awaiting DST results

Type of suspect Action to take

Relapse –Return after default –Category I failure –“Other” with only one previous treatment –

Start Category II regimen while awaiting DST. If smear non-converter on Category II (on month 3), stop treatment and refer back to the MDR-TB Treat-ment Center and await DST.

Category II failure –Previously treated patients with two or more treatment –courses in the past

Stop treatment and await DST.

Symptomatic contact of a confirmed or suspected drug- –resistant case

Action will depend on consilium decision guided by smear result, previous history and clinical status

HIV positive with TB symptoms –

Start Category I regimen, if newStart Category II or Category IV, if previously treated, depending on joint decision of consilium and HIV doctor.

MDR-TB suspects who are noted to be critically ill at the time of screening or are clinically deteriorating are immediately referred to the Consilium for case discussion and possible expedited treatment using the appropriate regimen. This is discussed in more detail in section 2.4 in this module.

After completing the Acknowledgement Form, give one copy to the patient to be given back to his referring physician or facility and attach the other copy to the MDR-TB Screening Form which remains at the Treatment Center. There are occasions when the patient is unable to give this back to the referring physician. Hence, a copy of the accomplished Acknowledgement Form may need to be sent directly by telefax, if the contact number is known. An example of a PMDT Acknowledgement Form is shown on the next page.

Later when DST results have been received by the Treatment Center, another Acknowledgement Form is completed and sent to the referring physician or facility this time with the box for “final diagnosis” ticked and updated information on the patient given.

MODULE B


Date: Initial Diagnosis Final Diagnosis

To:

Thank you for referring your patient , for further TB diagnosis/management.

Pertinent findings/ Laboratory examinations:

Plans/Recommendations:

Clinic Physician:

Contact numbers:

Treatment Center:



4/28/05

Dr. A. Madrid Sampaguita Health CenterTondo, Manila

Jose A. Balagtas

Received anti –TB treatment since 1997Failure of category II treatment on two occasions. (+) wheezing, bilateral lung elds, decreased breath sounds on R lung eld

To consider Multidrug-resistant TB

For AFS/TBC and DSTAwait DST result prior to initiation of treatment

Dr. Dan Rivera742-1534/ 781-3761 to 65 loc. 146KASAKA QI Treatment Center

Duplicate copy of PMDT Acknowledgement Form must always be made.

The patient must give the duplicate copy to the referring MD.

Example of the Acknowledgement Form

MODULE B


2.3 Fill out the TB Symptomatics Masterlist

Proceed to register the patient in the TB Symptomatics Masterlist.

The TB Symptomatics Masterlist is a record of ALL TB suspects, including TB and MDR-TB suspects seen at the MDR-TB Treatment Center. It is particularly useful for monitoring case detection activities and the results of all sputum examinations requested for screening from the laboratory. See Module G: Monitoring MDR-TB Case Detection and Treatment for a discussion about how to use this register for monitoring MDR-TB case detection.

Whenever you identify a TB or an MDR-TB suspect, list this patient in the TB Symptomatics Masterlist. An example of an accomplished Masterlist is shown on the next pages.

Be sure to complete the screening code, date of screening as well as the complete name and address, date of birth and sex of the patient. The complete address will enable the staff at the Treatment Center to locate the patient once the results of the tests confirm TB or MDR-TB and the patient does not return.


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TS C

ente

r05

- PT

SI T

ayum

an D

OTS

Cen

ter

06 -

___

____

_07

- _

____

___

(6)

Se

x:

1- M

ale

2- F

emal

e

(9)

So

urc

e o

f re

ferr

al

1- G

ovt.

DO

TS fa

cilit

y2-

Gov

t. N

on-D

OTS

Fac

ility

3- P

rivat

e D

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Fac

ility

4- P

rivat

e N

on-D

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Fac

ility

5- F

aith

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ed u

nit/

NG

O D

OTS

Fac

ility

6- F

aith

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ed u

nit/

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on-D

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Fa

cilit

y7-

Wal

k - i

n

(12

) R

eg

istr

ati

on

gro

up

1 - N

ew2

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er C

at I

failu

re3

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er C

at II

failu

re4

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er C

at IV

failu

re5

- Aft

er d

efau

lt6

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I re

laps

e7

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II re

laps

e

8

- Cat

IV re

laps

e

9 - T

rans

fer-

in10

- O

ther

pat

ient

w/

10.

1 N

on-D

OTS

10.

2 O

ther

(+)

10.

3 O

ther

(-)

(8)

Fu

nd

ing

:

0- G

en fu

nd2-

Rou

nd 2

5- R

ound

599

- Oth

ers;

spe

cify

__

____

____

__

This

ref

ers

to t

he f

acili

ty o

r M

D w

ho

refe

rred

the

pat

ient

to

the

Trea

tmen

t C

ente

r no

t ne

cess

arily

the

one

who

ga

ve th

e la

st T

B tr

eatm

ent.

Page

1 of

the T

B Sy

mpt

omat

ics M

aste

rlist

Detect Cases of MDR-TB 35


Risk factors

Symptoms

CXR

res

ult

sSc

reen

ing

(DSS

M/ c

ult

ure

res

ult

s) (1

6)D

ST r

esu

lts

(17

)R

egis

trat

ion

dat

e

(mm

/dd/

yy)

(18)

Pre

-en

rollm

ent

No.

(19)

(YY-

NN

NN

)

Dat

e do

ne

Dat

e sp

utu

m c

olle

cted

(mm

/dd/

yy)

HR

ZE

SK

mO

fxCf

xLf

xO

ther

Oth

erEn

roll

ed?

If Y

ES, i

ndi

cate

tre

atm

ent

star

t da

te. I

f NO,

indi

cate

rea

son

.(1

3)(1

4)(1

5)D

ate

DST

rele

ased

Con

siliu

m

date

21,

2, 3

,4,

5, 6

1,2,

8 3

+

/ MTB

4+

/ MTB

//

RR

SR

RS

SS

SN

DN

D10

/10/

0510

/18/

0505

-009

904

/ 17

/ 05

04

/25/

0504

/26/

05 /

/ /

/ 11

/24/

2007

11,

3,4

1,2

2+ /

MTB

0 /

MTB

//

RR

SS

SS

SS

SN

DN

D9/

14/0

59/

20/0

505

-009

6

03/

21

/05

04/2

8/05

04

/ 29

/ 05

/

/

/

/

Lost

bef

ore

enro

llmen

t

41,

3,4,

51,

15 1

+ /M

TB 3

+ /M

TB/

/R

RR

RR

RR

RS

ND

ND

10/5

/05

10/1

1/05

05-0

098

01

/22

/05

04/2

8/05

05

/ 2/0

5

/

/

/

/

11/8

/200

5

41

1,2,

3 0

/MTB

0 /M

TB/

/

RR

SR

SS

SS

SN

DN

D9/

23/0

59/

27/0

505

-009

7

04/0

2/05

04/2

9/05

05

/ 02

/ 05

/

/

/

/

10/4

/200

5

41,

2, 3

, 4,

5, 6

1,2

4+ /M

TB3+

/ M

TB/

/9/

6/05

05-0

079

04

/27

/05

05/0

2/05

05/0

3/05

/

/

/

/

8/10

/200

5

01,

32

1+ /M

TB1+

/ M

TB/

/S

SS

SS

SS

SS

ND

ND

8/31

/05

9/6/

0509

/07/

05

04

/25

/05

05/0

2/05

05/0

3/05

/

/

/

/

Refe

rred

to L

HC

11,

2, 3

, 4,

5, 6

1,2

0 / M

TB1+

/ M

TB/

//

//

/05

-008

0

05/0

5/05

05/1

0/05

05/1

1/05

/

/

/

/

8/30

/200

5

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

Prog

ram

mat

ic M

anag

emen

t of

Dru

g - R

esis

tant

TB

(PM

DT)

TB

SY

MP

TO

MA

TIC

S M

AS

TE

RL

IST

| pa

ge 2

of 2

(13)

Ris

k fa

ctor

s(1

4) S

ympt

oms:

(15)

CXR

res

ult

s(1

7) D

ST r

esu

lts

Sum

mar

y0

- N

one

1 - H

ouse

hold

con

tact

of M

DR

2 - N

on-c

onve

rter

cat

II

3 - H

IV-p

ositi

ve

4- ≥

2 n

on-D

OTS

trea

tmen

t cou

rses

0- N

one

1- C

ough

2- F

ever

3- C

hest

/bac

k pa

in

4- H

emop

tysi

s

5- W

eigh

t los

s

6- N

ight

swea

ts

0 - N

orm

al

1 - C

avita

ry

2 - I

nfiltr

ate

3 - N

odul

e

4 - M

iliar

y TB

5 - I

ntra

thor

acic

lym

phad

enop

athy

6 - E

ndob

ronc

hial

spre

ad

7 - F

ibro

sis

8 - F

ibro

thor

ax

9 -

Bulla

e

10 -

Pleu

ral e

ffus

ion

11 -

Pneu

mot

hora

x

12 -

Bron

chie

ctas

is

13 -

Atel

ecta

sis

14 -

Cons

olid

atio

n

15 -

Mas

s

16 -

othe

rs, s

peci

fy

__

__

__

__

__

__

__

S =

susc

eptib

le

R =

resi

stan

t

ND

= n

ot d

one

H -

Ison

iazi

d

R -

Rifa

mpi

cin

Z - P

yraz

inam

ide

E - E

tham

buto

l

S - S

trep

tom

ycin

Km

- Ka

nam

ycin

Ofx

- O

floxa

cin

Cfx

- Cifl

oxac

in

Lfx

- Lev

oflox

acin

1. N

umbe

r of D

R-TB

susp

ects

2. S

uspe

cts w

ith 2

sput

um sp

ecim

ens t

este

d

3. S

uspe

cts w

ith a

t lea

st 1

cul

ture

resu

lts

4. S

uspe

cts w

ith a

t lea

st 1

cul

ture

pos

itive

resu

lt

5. S

uspe

cts w

ith D

ST re

sults

6. S

uspe

cts w

ith H

R re

sist

ance

7. N

umbe

r of s

uspe

cts w

ith p

re-e

nrol

lmen

t num

ber

8. N

umbe

r of p

atie

nts w

ith tr

eatm

ent s

tart

dat

e

A p

ansu

scep

tible

cas

e is

refe

rred

to th

e lo

cal h

ealth

cen

ter f

or D

OTS

.

Mak

e su

re M

DR

–TB

confi

rmed

pa

tient

s ar

e im

med

iate

ly p

rese

nted

to

the

cons

ilium

for r

egim

en d

esig

n an

d st

art o

f tre

atm

ent.

Pend

ing

A P

re-e

nrol

lmen

t No.

is a

ssig

ned

to a

ll TB

sym

ptom

atic

s w

ho a

re e

ither

a) p

rove

n M

DR-

TB b

y D

ST, o

r b) d

ecid

ed

by th

e co

nsili

um to

sta

rt tr

eatm

ent e

ven

with

out D

ST

confi

rmat

ion

due

to h

igh

clin

ical

sus

pici

on.

Both

gro

ups

are

all f

or s

tart

of t

reat

men

t.

Page

2 of

the T

B Sy

mpt

omat

ics M

aste

rlist

MODULE B


For Treatment Site Staff

When you have reached this point in the module, your facilitator will show you a sample of the TB Symptomatics Masterlist. After a short discussion, continue reading on page 58.

For Treatment Center Staff Exercise C – Written Exercise

When you have reached this point in the module, you are ready to do Exercise C. See instructions below for Exercise C. Do this exercise by yourself.

Exercise C: Written exercise

Recording in the TB Symptomatics Masterlist

In this exercise each of you will be given a TB Symptomatics Masterlist. Use the patient data provided in the MDR-TB Screening Forms in the following pages, enter each TB suspect and complete the TB Symptomatics Masterlist. Work individually on this exercise. Ask your facilitator for help if you do not understand what to do.

List each of the 5 MDR-TB suspects presented below in the TB Symptomatics Masterlist and fill out Columns 1-15.Assign each, in sequence, a Screening code. Assume that the last code in the Masterlist was TC-YY-MM-096.Funding source is Round 5 GFATM.Assume that the patients went to the Treatment Center on the day that you as the referring MD made the MDR-TB Suspects Referral Form.





I. Demographics




Permanent address:


City address:










11/29/2007

Sariwa Sonia Santos

August 18, 1973 34 Cavite

Filipino Catholic

23 Santol St., Barangay San Antonio, Cavite City 4100 (046) 431-40086

Santol Health Center Barangay San Antonio, Cavite City

3 0 3persistent cough with hemoptysis

1 productive, minimal amt., whitish in color

1 approximately 5 kg

1

1 on both upper lung area, greater in right dark red in color, 4 episodes for the last 2 wks

none 10 000 Php none none

noneEufronio Sariwa (deceased) Sofriana Sariwa

23 Santol St., Barangay San Antonio, Cavite City (046) 431-40086

Sofriana Sariwa mother23 Santol St., Barangay San Antonio, Cavite City (046) 431-40086

Case 1:









1. 2. 3. 4. 5. 6. 7.





Status


1. 2.




IV. Social History:



Sexual History:


June 2002 2 HRZE / 2 HR Santol Health Center Y 4

No known food or drug allergies

11 29 2007 0 0

pillssexually active





System examination:


General Health:

Skin:

BCG scar:

Oropharynx:

Cardiovascular:

Thorax & Lungs:


Abdomen:

Genito-Urinary:

Extremities:

Neurological:

Lymph Nodes:

Endocrine:



/ /

/ /

/ /




CBC

FBS, etc.

155 43 37.5 98 25

130/90

2 distressed, cachectic, generally weak

2 (+) papable cervical lymph nodes

2 (+) pallor of skin, conjunctiva, palms, & nail beds (-) BCG scar

002 (+) crackles heard on both upper lung elds, more on the right

0

0

101 (+) use of accessory muscles

DSSM 0 / 2+ / 1+ 11 25 2007

MODULE B










12 - Bronchiectasis

13 - Atelectasis


14 - Consolidation

15 - Mass

VI. Assessment:

TB suspect New

Retreatment


factors.


Non-DOTS

Other (+)

Other (-)



VII. Plan:


Others

Attending MD: Date:


2 2

Dave Verzosa, MD 11/29/2007

Category II Treatment while awaiting DST; stop treatment if non-converter on 3rd month





I. Demographics




Permanent address:


City address:










12/03/2007 (Saturday)

Reloz Rolanda Ramirez

September 02, 1958 49 Makati

Filipino Catholic

44526 Jhonny St., Pio del Pilar, Makati City



1230 989014301

1230 989014301

Pio del Pilar Health Center Barangay Pio del Pilar, Makati City

5 3 2persistent cough

2 wks productive, minimal amt., whitish in color 1 wk usually in the afternoon 1 on both lung area, greater in right upper area dark red in color, 1 episode for the last wk 1 approximately 7 kg

1

none 50 000 PhpManager Mano Mano Manufacturing Company

Rolly Reloz (deceased)Christian Ramirez Sarah Ramirez

Purok 31, Barangay Pampanga, Davao City, Davao del Sur none

Rolex Reloz Son 44526 Jhonny St., Pio del Pilar, Makati City 989014301

Case 2:









1. 2. 3. 4. 5. 6. 7.





Status


1. 2.




IV. Social History:



Sexual History:


Aug. 2003 3 Myrin P Forte / 3 Myrin Dr. A. Reyes (private MD) N 5Aug. 2005 6 Myrin P Forte Dr. A. Reyes (private MD) N 5Dec. 2006 3 Econokit / 4 Econopack Dr. A. Reyes (private MD) N 5

11 25 2007 5 5

sexually inactive_for more than a year






System examination:


General Health:

Skin:

BCG scar:

Oropharynx:

Cardiovascular:

Thorax & Lungs:


Abdomen:

Genito-Urinary:

Extremities:

Neurological:

Lymph Nodes:

Endocrine:



/ /

/ /

/ /




CBC

FBS, etc.

157 4437.5 98 24

130/90

22

002

101020

distressed, cachectic(+) pallor of skin, conjunctiva, palms, & nail beds(-) BCG scar

(+) crackles heard on both lung elds(+) use of accessory muscles

(+) palpable cervical lymph nodes

MODULE B










12 - Bronchiectasis

13 - Atelectasis


14 - Consolidation

15 - Mass

VI. Assessment:

TB suspect New

Retreatment


factors.


Non-DOTS

Other (+)

Other (-)



VII. Plan:


Others

Attending MD: Date:


22


11 26 2007

1

102

Await DST results prior to initiation of treatment if DSSM (+). If DSSM (-), refer to TBDC.

MODULE B





I. Demographics




Permanent address:


City address:










12/05/2007

Santos Santiago Suma

April 02, 1952 55 Makati

Filipino Catholic

2062-1 Anak Bayan, Paco, Manila

2062-1 Anak Bayan, Paco, Manila

Padre Burgos St., Manila 5247141

1007 53055555

1007 53055555

J. Fabella Health Center San Andres, Manila

3 0 3persistent cough

3 wks productive, minimal amt., whitish in color

1 on left upper lung area; aggravated by cough

1

none 30 000 PhpAccounting Clerk Manila City Hall

Luzviminda SantosJohn Santos Diana Santos

2062-1 Anak Bayan, Paco, Manila 53055555

Luzviminda Santos 2062-1 Anak Bayan, Paco, Manila 53055555

Case 3:

MODULE B









1. 2. 3. 4. 5. 6. 7.





Status


1. 2.




IV. Social History:



Sexual History:


No previous TB treatment


sexually inactive for a year

MODULE B





System examination:


General Health:

Skin:

BCG scar:

Oropharynx:

Cardiovascular:

Thorax & Lungs:


Abdomen:

Genito-Urinary:

Extremities:

Neurological:

Lymph Nodes:

Endocrine:



/ /

/ /

/ /




CBC

FBS, etc.

169 6037.3 84 22

130/80

11

002

101020

(+) BCG scar

(+) crackles heard on left upper lung eld

(+) palpable cervical lymph nodes

MODULE B










12 - Bronchiectasis

13 - Atelectasis


14 - Consolidation

15 - Mass

VI. Assessment:

TB suspect New

Retreatment


factors.


Non-DOTS

Other (+)

Other (-)



VII. Plan:


Others

Attending MD: Date:


22


Present to consilium

12 01 2007

2

MODULE B





I. Demographics




Permanent address:


City address:










12/06/2007

Sarmiento Susana Sandok

June 18, 1989 18 Manila

Filipino Catholic

1598 Interior 86 P. Quirino Avenue, Pandacan, Manila

1598 Interior 86 P. Quirino Avenue, Pandacan, Manila

1011 599-00001

1011 599-00001

Quirino Health Center Quirino Avenue, Pandacan, Manila

7 4 3fever and weight loss

2 wks worsens in the afternoon

1 approx. 10 kg

none 20 000 Phpnone

noneSergio Sarmiento Marie Sarmiento

1598 Interior 86 P. Quirino Avenue, Pandacan, Manila 599-00001

Marie Sarmiento mother 1598 Interior 86 P. Quirino Avenue, Pandacan, Manila 599-00001

Case 5:

MODULE B









1. 2. 3. 4. 5. 6. 7.





Status


1. 2.




IV. Social History:



Sexual History:


No previous TB treatment

1 currently being treated for HIV at a treatment hub


11 30 2007 0 0

shabu

sexually inactive for a year

MODULE B





System examination:


General Health:

Skin:

BCG scar:

Oropharynx:

Cardiovascular:

Thorax & Lungs:


Abdomen:

Genito-Urinary:

Extremities:

Neurological:

Lymph Nodes:

Endocrine:



/ /

/ /

/ /




CBC

FBS, etc.

157 4237.8 100 26

130/80

2 cachectic, in distress, generally weak2 (+) skin pallor

2 (+) palpable cervical lymph nodes

(+) BCG scar00

0

0

101

1

MODULE B










12 - Bronchiectasis

13 - Atelectasis


14 - Consolidation

15 - Mass

VI. Assessment:

TB suspect New

Retreatment


factors.


Non-DOTS

Other (+)

Other (-)



VII. Plan:


Others

Attending MD: Date:


22


Start Catergory I while awaiting culture and DST results

Continue HIV treatment.

10 08 2007

00

0

00

MODULE B





I. Demographics




Permanent address:


City address:










12/07/2007

Robles Rodolfo Remo

March 28, 1977 30 Manila

Filipino Catholic

1919 Mekeni St., Barangay Mahayahay, Apalit, Pampanga

276281 Poblacion, San Vicente St., Bayanan, Muntinlupa City

2016 none

1772 123-4567

Poblacion Health Center Sn. Vicente St., Putatan, Muntinlupa City

0 0 0persistently symptomatic

3 productive, minimal in amt., whitish color

3 both in the upper lung area

1 approx. 10 kg

none 20 000 Phplaborer

nonePablo Robles (deceased) Rita Robles (deceased)

Romeo Robles brother 1598 Exterior 86 P. Quirino Avenue, Pandacan, Manila 599-10001

Case 6:

MODULE B









1. 2. 3. 4. 5. 6. 7.





Status


1. 2.




IV. Social History:



Sexual History:


06/01/06 2 HRZE / 4 HR Poblacion Health Center Y 1 09/03/07 2 HRZES / 1 HRZE Poblacion Health Center Y ongoing


sexually inactive

MODULE B





System examination:


General Health:

Skin:

BCG scar:

Oropharynx:

Cardiovascular:

Thorax & Lungs:


Abdomen:

Genito-Urinary:

Extremities:

Neurological:

Lymph Nodes:

Endocrine:



/ /

/ /

/ /




CBC

FBS, etc.

160 45 37.4 93 23

130/80

2 cachectic, in distress2 (+) skin pallor

2 (+) crackles heard over both upper lung elds

2 (+) palpable cervical lymph nodes

DSSM 2+ 12 03 2007

(–) BCG scar00

0

0

101

MODULE B










12 - Bronchiectasis

13 - Atelectasis


14 - Consolidation

15 - Mass

VI. Assessment:

TB suspect New

Retreatment


factors.


Non-DOTS

Other (+)

Other (-)



VII. Plan:


Others

Attending MD: Date:


22


Stop current treatment and await DST.

MODULE B



2.4 Make a referral to the Consilium if necessary and enter the patient in the Category IV Register

The diagnosis of MDR-TB through laboratory tests takes a number of months. In general, patients wait for confirmation of the diagnosis of MDR before they are prepared for the start of treatment. However, there are occasions that the MDR-TB suspect may be critically ill at the time of first consultation. The physician having interviewed the patient and made a physical examination must be able to assess the patient’s general condition. Some patients may need to be started on treatment urgently before the DST results are available or they will be at risk of dying. These patients should be recognized by the physician, and these cases should be presented immediately to the Consilium.

The Consilium must approve for start of treatment all patients who require MDR-TB treatment. These are patients who have either been confirmed MDR-TB by DST, or are clinically suspected MDR-TB needing urgent treatment even prior to DST results.

DST results together with other factors in the patient’s history allow the design of treatment regimens that are tailored to the specific resistance pattern of the patient to increase the likelihood of treatment success. To present cases to the consilium, the Treatment Center physician must fill out the Consiliumex for every patient. He will then present these cases in a Consilium meeting. An example of the Consiliumex and a discussion of the necessary steps to present a case to the Consilium can be found in section 6 of this module. See the Reference Booklet for instructions on how to fill out the Consiliumex.

The following criteria must be met among MDR-TB suspects screened to qualify for urgent treatment without the benefit of DST results:

The patient must first be sputum smear-positive (at least two) and/or culture-positive (at least once) if 1. pulmonary, but not necessarily for children and for extra-pulmonary TB (EPTB).The patient must be suspected to be MDR-TB based on history and risk factors. 2. The patient must have any ONE of the criteria for Category IV treatment listed in Table 4 below.3.

TABLE 4: Criteria for initiation of Category IV treatment without DST results

Criteria Condition

Acute respiratory failure and on mechanical ventilation1.

Clinical signs and symptoms without 2. any other condition as likely cause, with the following vital signs (any one).

Hypotensiona. RR > 28/min or 02 < 90% at room airb. PR > 100/min with RR > 28/min or 02 sat <90% at room c. air

With or without significant weight loss

MODULE B


Massive hemoptysis due to TB4. >a. 600 cc/24 hours>b. 300 cc/episodeAny amount w/ signs and symptoms of hemodynamic c. compromise: hypotension, and/or anemia

Progression of chest x-ray findings 4. (new lesions)

Infiltrates a. Cavities b. Pneumothorax c. Pleural effusion, etc.d.

PLUS any one of the above clinical signs and symptoms (no. 2 above)

Significant co-morbidity such as any 5. immunosuppressed state

HIV-positivea. Cancerb. Post-organ transplantc. On any immunosuppressive agentd.

EPTB that is life-threatening with or 5. without bacteriologic evidence

Intracranial lesions including abscess, meningitis, POTT’s disease, etc.

Children with any one of the ff three: 6. positive tuberculin skin test (equal or more than 10 mm) ORa) positive family contact OR b) a chest x-ray finding consistent with TBc)

PLUS three of the five of the following symptoms of TB in children:chronic cough or wheeze for a) > 2 weeksunexplained fever b) > 2 weeks weight loss/ failure to gain weight/loss of appetite c) failure to respond to 2 weeks appropriate antibiotic for lower respiratory infectiond) failure to regain previous state of health 2 weeks after a viral infection or exanthem, e.g., measles. e)

For pulmonary TB, the decision for empiric Category IV treatment must require at least sputum smear-and/or culture-positive results. However, this is not required for children and for patients with EPTB who are MDR-TB suspects.

All patients with a Consilium decision for expedited treatment must be started at once on Category IV regimen. Once started on treatment, he must be entered into the Category IV Register.

MODULE B


3. Discuss the Paunawa or Terms of Understanding with the patient

The MDR-TB suspect will most likely not understand what MDR-TB is and what the process is for diagnosis and treatment. Because of the complex nature of the diagnosis of MDR-TB, we need to explain to the patient the lengthy diagnostic steps which he will undergo and the prospect of treatment. After the patient is informed about MDR-TB and the next steps in the diagnostic workup, he will be asked to sign the Paunawa or Terms of Understanding to indicate that he has been informed of the steps in the diagnosis and possible treatment, and is agreeable to receive treatment

3.1 Provide patient education on MDR-TB and the diagnostic process

Inform the MDR-TB suspect clearly and in a sensitive way about the possibility of having MDR-TB. This may be the first time you will discuss MDR-TB with the patient and the MDR-TB suspect may be quite scared or nervous about what he has. All communication must be kind, supportive and medically correct. You should provide information on:

Steps in the diagnosis of MDR-TB; diagnostic tests to be done (DSSM, culture, DST)Possibility of stopping present TB treatment to prevent amplification of resistance Timelines for receiving test results: Patient must call for results after the expected timeline for the release of results:

DSSM: 4-5 days after specimen collectionCulture: 3-3.5 months after specimen collectionDST: 4-5 months after specimen collection

Contact numbers of the MDR-TB Treatment Center where screening was done; other contact numbers which patients can call Ways to prevent transmission of TB to household contacts

The Paunawa or Terms of Understanding should be read to the patient and explained in a way that the patient can understand. The Paunawa or Terms of Understanding form can be found in the Reference Booklet. For more information about how to speak with a patient at this stage, see Module D: Inform Patients about MDR-TB.

3.2 Obtain patient’s signature in Paunawa or Terms of Understanding

Once the MDR-TB suspect has been informed about MDR-TB and the diagnostic process, the patient’s signature must be obtained to signify that he understands and is in agreement with the diagnostic procedures and the possible long and complicated treatment for MDR-TB.

Patients may not want to sign or may be wary about doing so. You should explain to him the significance of his signature. If he signs, this means that:

he is in agreement to undergo the sputum test and that he pledges to adhere to the requirements of diagnosis.he understands that since the treatment for MDR-TB is complex, accurate diagnosis is crucial.he is aware of the prospect of MDR-TB treatment and that cure requires strict adherence to treatment.

Reassure the MDR-TB suspect that the signature is required to ensure that both the health worker and the patient are together committed to the best possible outcome and this information is meant to make him aware of the rather complicated process and prevent any misunderstanding.

MODULE B


4. Collect sputum for smear, culture and DST

Upon screening, every MDR-TB suspect should submit two sputum specimens at the Treatment Center for DSSM and culture to be done at the assigned Culture Center and for DST to be done at the DST Center. Just like the zoning for Treatment Centers in Table 1, there is also Culture Center assignment per Treatment Center and DST Center assignment per Culture Center (see Table 5). While sputum collection will be done at the Treatment Center and culture at a Culture Center, DST will be done at a DST Center.

TABLE 5: Designated Culture and DST centers for each Treatment Center

Treatment Center Culture Center DST Center

TDF-MMC DOTS Clinic TDF TB Laboratory TDF TB Laboratory

NTRL if patient is coming from Muntinlupa, Las Pinas, Paranaque and Pasay

NTRL if coming from Muntinlupa, Las Pinas, Paranaque and Pasay

KASAKA-QI MDR-TB Housing Facility PTSI Laboratory NTRL

LCP-PHDU DOTS Center LCP LaboratoryTDF TB Laboratory

DJNRMH DOTS Center LCP Laboratory

PTSI Tayuman DOTS Center PTSI Laboratory NTRL

Treatment Center – MM South (to be identified) NTRL NTRL

NTRL: National TB Reference Laboratory LCP: Lung Center of the PhilippinesTDF: Tropical Disease Foundation PTSI: Philippine Tuberculosis Society, Inc.

The diagnosis of MDR-TB is crucial and must be accurate since treatment required is very long with expensive drugs that have many side effects. Hence, even if an MDR-TB suspect has culture and DST results from other referral sites, he must submit 2 more sputum samples at the MDR-TB Treatment Center for DST confirmation by a laboratory with quality assurance from a supranational laboratory. At present, these laboratories include the Tropical Disease Foundation (TDF) TB Laboratory, and the National TB Reference Laboratory (NTRL). The Cebu Regional Reference Laboratory (CRRL) will also be undergoing DST proficiency testing as well as other laboratories in the Philippines and will become future DST Centers for PMDT.

4.1 Enlist the MDR-TB suspect’s cooperation

Explain the reason for sputum examination and enlist the MDR-TB suspect’s cooperation. Explain that sputum smear and culture are essential for detecting MDR-TB and are the first two steps needed in order to run a DST.

4.2 Fill out the Mycobacteriology Request Form

All MDR-TB suspects should have a culture and DST done in addition to smear. The Mycobacteriology Request Form is used to request for sputum laboratory tests for detecting MDR-TB. One Mycobacteriology Request Form can be used to request for all three tests of one patient. Specimens other than sputum obtained from other parts of the body with suspected TB may also be sent for smear, culture and DST using this form.

Write the Screening code in the Mycobacteriology Request Form. The Category IV Registration No. is not yet applicable at the time of screening since this number is assigned only once treatment is started. Complete the demographics. No need to write the complete address, just indicate the city/province. Tick the Culture Center to do the DSSM and culture, and the DST Center to do the DST; tick what kind of specimen is being sent, the examination being requested for and the number of specimens being sent for each procedure. For screening, it is recommended that

MODULE B


specimens are sent to the Culture Center on the day of collection; hence, write DSSM X 1 and culture X 1 for this first collection and fill out another request form for the second collection.

For the example below who was referred as a Category II failure, DSSM, TB culture and DST are ticked with the number of specimens needed for DSSM and culture. Under “Schedule”, Screening refers to the first time the patient is being seen as a TB suspect. Baseline refers to the time when a patient is about to be started on Category IV treatment or has just been started on treatment (30 days before treatment and 7 days after start of treatment). Follow-up refers to the sputum examination requested after Category IV treatment has started beyond 7 days. Post-treatment refers to the period after a final outcome of cured or completed has been declared. Fill out the date the sputum was collected not the date when the sputum was sent. Indicate whether the specimen was collected as a spot specimen collected at the Treatment Center or at the patient’s home or elsewhere.

The receiving laboratory will fill out the portion on Laboratory No., Volume and Consistency.

02-05-04-0081 4/28/05

Balagtas, Jose A. 50/M Chi-Orillaza, Ruth M.D.

Tondo, Manila

22

Screening Code: Date requested:

Category IV Registration No.: (if enrolled)

Name: Age/Sex: Requesting physician:

Address: (City/ Province)

Culture center:

TDFI LCP PTSI CTRL (Cebu) NTRL

DST center:

TDFI NTRL CTRL

Specimen:

Sputum Extrapulmonary specimen, specify:

Others

Requested procedure:

DSSM x TB culture x DST

Contact tracing patient?

Yes No

Schedule: Screening Baseline Follow-up: month of tx: Months post-treatment:

Enrolled: Yes No Category: New Retreatment

1st specimen 2nd specimen 3rd specimen

Date of collection

Type of collection

(Please encircle) Spot Home Spot Home Spot Home

To be filled in by the laboratory

Laboratory No. 02-P-058283-1 02-P-058283-2Volume 10ml 8mlConsistency Salivary Muco-purulent


MYCOBACTERIOLOGY REQUEST FORM

MODULE B


4.3 Collect sputum samples from the MDR-TB suspect

Follow the guidelines for sputum collection as would happen with any TB patient. Refer to Annex A: Proper collection of specimen for the diagnosis of TB. Two sputum samples should be collected during a two-day period.

Sample one is collected “on the spot.” Give instructions to the patient. Explain why the sputum is needed and show the MDR-TB suspect how to cough up sputum and handle the labeled container. The MDR-TB suspect goes outdoors or to a well-ventilated place or to a sputum collection booth, if available, to collect the sample. Observe and guide the MDR-TB suspect during sample collection. Instruct the patient to collect 5-10 ml of sputum. After the MDR-TB suspect gives the sample to you, give him another labeled container to take home and use the next morning, while you tightly close the lid of the first container.

For labeling, use color-coded stickers:A 0 blue label indicating that the sample is for smear, culture and DST should show the name of the Treatment Center, the patient’s name, and date of collection. This is attached to the body of the cup, and not on the lid. A 0 green label means the request is for smear and culture only.A 0 white label means the request is only for smear, e.g., in some months of the follow-up period.

PMDT

Tx center: __________________Lab No.: ___________________Name: ____________________Date collected: _____________

MMC

Jose BalagtasMay 5, 2008

Sample two is collected at home by the MDR-TB suspect upon waking up the next morning. The patient brings this second sample to you at the Treatment Center right after collection.

Remember:

Attach the label on the container (not the lid) before collecting the sputum samples.

Collect sputum in a well-ventilated area, preferably outdoors or in a sputum collection

booth.

Check whether the sample contains sufficient sputum (5-10ml), not saliva. If not, ask the

MDR-TB suspect to add more.

After collecting the sputum, be sure that the lid is closed tightly.

Wash your hands thoroughly with soap and water.

Remind the MDR-TB suspect when to return for the results and inform him that the specimen regardless of the DSSM results, will be cultured.

4.3.1 Alternative methods of sputum collection

There may be MDR-TB suspects who are unable to produce sputum for examination. Examples of these are children, patients with minimal cough, the HIV-positive patients, etc. In these cases alternative measures to collect sputum should be used. Although it is beyond the scope of this document to describe in detail each process, a general description of some alternate sputum collection methods are described on the next page. See also Annex B: Procedures for Obtaining Sputum Specimens in Children.

MODULE B


Sputum induction: is a simple procedure for obtaining a sputum sample through deep 15-minute inhalation of a salt solution or hypertonic saline (3% NaCl) with the help of a nebulizer to induce a deep cough, which allows the coughing up of lung secretions. These samples are usually diluted or watery and should be labeled as “induced” so they will not be mistaken for saliva at the laboratory.

Induction can be used for patients who cannot expectorate effectively or provide a quality sample, particularly those who are asymptomatic but have evidence of TB disease such as an abnormal chest x-ray, e.g., in children, or persons with HIV/AIDS. Patients should have fasted for 3-4 hours prior to the procedure to prevent vomiting and aspiration. Induction should be carried out in a well-ventilated place and all personnel in the room should use an N95 mask to avoid infection.

Gastric aspiration is performed by inserting a tube through the patient’s nose and introducing it into the stomach. The idea is to obtain a sputum sample that has been coughed up and then swallowed. The procedure is usually performed first thing in the morning as the patient tends to swallow sputum during the night. Generally, it is performed only when a sample cannot be obtained through expectoration or induction. Most often, it is used to obtain samples from children. It is recommended that children should not have had food intake in the past 2-3 hours. For logistic reasons gastric aspiration is usually carried out in a hospital setting or in a procedure room that has the necessary materials.

Bronchial aspiration with fiberoptic bronchoscopy is done for the collection of bronchial secretions by aspiration, through the fiberoptic bronchoscope (which is an instrument used for this procedure) performed by a bronchoscopist. These samples are usually diluted or watery and should be labeled as “bronchoscopy specimens” so they will not be rejected at the laboratory. Bronchoscopy should be carried out in a procedure room with infection control measures. This is usually the last resort when sputum is very difficult to collect.

4.4 Pack the sputum samples and send to the laboratory

Once the sample is collected, it must be packed and sent to the laboratory immediately. Refer to Annex C: Proper labeling, sealing and transportation of specimens. A smooth packaging and delivery process is vital to ensure that the specimens are processed correctly and in a timely manner. Keep the samples in a refrigerator or in an icebox with refrigerants. If the specimens become too warm, the sputum can degrade and the TB bacteria may not survive, become overgrown by other bacteria in the sputum, thereby diminishing the chances of recovering the bacilli.

From the refrigerator, transfer the sputum containers into a transport box. The Treatment Center will list all the samples for dispatch to a Culture Center on a Laboratory Receiving Form for Specimens. The sputum samples will go together with the individual Mycobacteriology Request Forms for each patient and the Laboratory Receiving Form for Specimens. The latter form should be signed by the messenger or person picking up the transport box. Send the samples to the Culture Center as soon as possible. The delivery process must ensure that the specimens reach the Culture Center within 24 hours of collection. If the samples will not be picked up by the messenger on the same day, keep the samples refrigerated or in the transport box with refrigerants. Make sure the refrigerants are replaced periodically to keep the specimens cool at all times. A sample of a Laboratory Receiving Form is shown in the following pages.

4.4.1 Prepare the Laboratory Receiving Form for Specimens

The Treatment Center prepares the Laboratory Receiving Form for Specimens. Tick the box for “Treatment Center” where the specimens are coming from and write the name of your center. Then tick the box for the Culture Center where the specimens are being sent to and write the name of the Culture Center. Table 5 on page 61 of this Module shows the designated Culture Center for each Treatment Center. Fill out column 1 of the table with a consecutive number from 1-25. Should you require more sheets, use another Laboratory Receiving Form and adjust the numbers from 26 onwards. For screening patients, leave blank the columns on “Category IV Registration No.” and the “Laboratory No.” The “Category IV Registration No.” is applicable only to patients who are started on Category IV treatment, while the “Laboratory No.” is applicable only for culture isolates that are being sent from the Culture laboratory to a DST Center. Write the patient’s name, the sputum specimen # over total # required specimens and/or isolates being transported for each patient, the date of collection of the first specimen (if 2/2) and the requested

MODULE B


procedures (for screening patients: DSSM, culture and DST). At the bottom, the one preparing the form signs on the space for “Endorsed by” with the date and the one picking up the box signs on the space provided for “Received by” with the date. See the Reference Booklet for more instructions on how to fill out this form.

Later when the culture turns out positive for TB at the Culture Center, the isolate is sent to the DST Center. The Culture Center fills out the Laboratory Receiving Form, also keeps blank the Category IV Registration No. but writes the Laboratory No. assigned which is TC-C-YY-NNNN-nth specimen.

TABLE 6. Laboratory No. (TC-C-YY-NNNN-Nth specimen)

Code Description

TC Treatment Center (see Table 2)

C

Culture Center T for TDF TB Laboratory N for NTRL L for LCP Laboratory P for PTSI Laboratory

YY The year the patient was screened

NNNN The consecutive specimen accrual that begins with 0001 at the start of every year

Nth specimen Whether the specimen is the 1st or the 2nd specimen

For example, the Laboratory No. 02-P-050021-2 means that the Treatment Center origin of the specimen is the KASAKA-QI MDR-TB Housing Facility, and was sent for smear and culture to PTSI Laboratory in 2005; was the 21st specimen received by the laboratory for the year, and was the second isolate for the patient.

Before sending the transport box to the laboratory, the Treatment Center must check the following:

The number of sputum specimens listed in the – Laboratory Receiving Form for Specimens are consistent with the actual number of specimen cups in the transport box.The names of patients listed on the – Laboratory Receiving Form are consistent with the ones written on the labels on the sputum cups in the transport box. Individual – Mycobacteriology Request Forms are enclosed for each of the specimens being sent.

Once the above are done, close and seal the transport box carefully. Then, put the Laboratory Receiving Form for Specimens in an envelope together with the individual Mycobacteriology Request Forms and attach the envelope to the top cover of the transport box or hand it directly to the receiving person.

At the Culture Center, the laboratory staff receiving the transport box will check the contents of the box against the Laboratory Receiving Form for Specimens and sign the form and keep a file copy at the Culture Center. If all specimens and requests in the list are accounted for, he will affix his initials on the form and date and keep a file copy at the Culture Center. If there is a discrepancy, he will call the Treatment Center for verification, document on the Form whatever discussion or agreement was made before filing this form at the Culture Center. The same is done at the DST Center when receiving culture isolates from the Culture Center.

A delivery schedule will be arranged with the laboratory receiving the sample to make sure that the samples can be quickly transported and processed once they are received. On the following page is an example of the Laboratory Receiving Form for Specimens.


4/29/05

Francia GOnzales (PTSI) 4/29/05

Laboratory Receiving Form for specimens

From: Treatment Center (TC) To: Culture Center (CC)

Culture Center (CC) DST Center

Sputum Isolates

No.

Category IV

Registration

No.

Laboratory no.*(Applicable to ISOLATES

only c/o Culture Center

Name

No. of

specimens

/ isolates

Date

collected

(mm/dd/yy)

Remarks/

Request

1 Balagtas, Jose 2/2 4/28/05 DSSM, TBC, DST

2 Salcedo, Myrna ½ 4/28/05 DSSM, TBC

3 Tan, Vincent ½ 4/28/05 DSSM, TBC, DST

4 Santos, Sylvia 1/1 4/28/05 DSSM, TBC

5 Roces, Maria 2/2 4/28/05 DSSM, TBC, DST

6 Benito, Gerald ½ 4/28/05 TBC

7 Cortez, Juan 1/1 4/28/05 DSSM

8 Uy, Susan 1/1 4/28/05 DSSM

9 Mendoza, Tina 2/2 4/28/05 DSSM, TBC, DST

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

* Laboratory no. : TC-C-YY, NNNN - Nth specimen

Endorsed by: ___________________________ Date: _________________________

Received by: ____________________________ Date: _________________________


Laboratory Receiving Form For Specimens

KASAKA-QI

Mar Rocha (TDF messenger)

NTRL

If two specimens are being submitted together, write the date of collection of the FIRST specimen.

Not applicable for screening cases. Applicable only for enrolled cases with follow-up specimens being sent.

Not applicable to Treatment Centers. Applicable only to Culture Centers submitting isolates to DST Centers.

Make sure this list is consistent with the names on the sputum cup labels submitted to the Culture Center.

Verify this information against the Mycobacte-riology Request Form.

MODULE B


For Treatment Site Staff

Group Discussion

When you have reached this point in the module, your group will briefly discuss the designated Culture and DST Center for each Treatment Center where you will refer MDR-TB suspects. Use the table on page 61. After the discussion, continue reading on page 72.

For Treatment Center Staff

– Written Exercise

When you have reached this point in the module, you are ready to do Exercise D. Turn to the next page and follow the instructions for Exercise D. Do this exercise by yourself. Then discuss your answers with a facilitator.

Exercise D: Written exercise

Filling out a Mycobacteriology Request Form

The purpose of this exercise is to practice completing the Mycobacteriology Request Form for patients that have been identified as MDR-TB suspects.

The following four cases (Cases 1, 2, 3, 5) were the cases you identified as suspects in the previous exercise. Use the data provided in the MDR-TB Screening Forms which have been previously given to you. Completing the Mycobacteriology Request Form is important to ensure that the proper examinations are requested and DR-TB is appropriately detected.

Work on this exercise individually.

For each of the following patients, fill out the Mycobacteriology Request Form.1.

Please refer to page 61 for the designated Culture and DST center for the different Treatment Centers.2.

Assumptions: All first specimens were collected spot at the Treatment Center while the second specimen was collected at the patient’s home.All first samples of the patients were collected on the day of screening and the second samples on the following day except for Case #2 who first came on a Saturday and came back for his second sample on the following Monday. The date the MDR-TB Suspect’s Referral Form from the DOTS facility was filled out is the date of screening at the Treatment Center.

MODULE B


Case 1

Patient Information: Patient is Sonia Santos Sariwa.Today is November 29, 2007.





Culture center:


DST center:

TDFI NTRL CTRL

Specimen:


Others




Yes No




Date of collection

Type of collection



Laboratory No.

Volume

Consistency



MODULE B






Culture center:


DST center:

TDFI NTRL CTRL

Specimen:


Others




Yes No




Date of collection

Type of collection



Laboratory No.

Volume

Consistency



Case 2

Patient is Rolanda Ramirez Reloz.Today is December 3, 2007(Monday)

MODULE B


Case 3

Patient is Santiago Suma Santos.Today is December 5, 2007.





Culture center:


DST center:

TDFI NTRL CTRL

Specimen:


Others




Yes No




Date of collection

Type of collection



Laboratory No.

Volume

Consistency



MODULE B


Case 5

Patient is Susana Sandok SarmientoToday is December 6, 2007.


Then read until the next stop sign.





Culture center:


DST center:

TDFI NTRL CTRL

Specimen:


Others




Yes No




Date of collection

Type of collection



Laboratory No.

Volume

Consistency



MODULE B


5. Receive and record the smear and culture results in the TB Symptomatics Masterlist and decide on the appropriate action

The staff at the Culture Center will record the results of the DSSM and the culture in the PMDT Laboratory Register.

The Culture Center will then individually print out the results of the smear on the appropriate Result Form for DSSM and Culture as soon as available for each patient and send these back to the Treatment Center together with a Laboratory Releasing Form for Results. The latter provides a summary list of all the sputum results, whether smear or culture, being sent back to the Treatment Center. This is done similarly by the DST Center as soon as DST results are available.

DSSM results are released as they are available and should not wait for culture results. The Culture Center staff will tick “From” and write the Culture Center’s name. He then ticks “To” and writes the Treatment Center to which the results are being released. On each row he writes the Laboratory No. (TC-C-YYNNNN-nth) and the name of the patient, the test that is being released and the date the sputum was collected. The Culture Center staff who prepared the list signs on the space for “Endorsed by” with the date and the person picking this up will sign on the space provided for “Received by:” and the date. Upon receipt of the results at the Treatment Center, the staff will check the individual results against the Laboratory Releasing Form. If there is no discrepancy, the Treatment Center staff will affix his initials and date on the form and file it. If there is a discrepancy, he will call the Culture Center or the DST Center and document their agreement on the Laboratory Releasing Form and file it. No DST results are released to Culture Centers, only to Treatment Centers. Below is a sample of the Laboratory Releasing Form being sent to the KASAKA-QI MDR-TB Housing Facility.

MODULE B


From: Culture Center (CC) To: Treatment Center (TC)

DST Center

No. Laboratory no.* Name Test requested

Date

collected

mm/dd/yy

Remarks

1 02-P-050001-2 Balagtas, Jose TBC 04/28/052 02-P-050002-1 Salcedo, Myra TBC 04/28/053 02-P-050002-1 Tan, Vincent TBC 04/28/054 02-P-050003-1 Santos, Sylvia DSSM 04/26/055 02-P-050004-1 Roces, Maria TBC 04/28/056 02-P-050007-1 Mendoza, Tina TBC 04/28/057 02-P-050005-1 Benito, Jamora TBC 04/28/058 02-P-050006-1 Cortez, Juan DSSM 04/27/059 02-P-050007-1 Uy, Susan DSSM 04/27/05

10 02-P-050007-2 Mendoza, Tina TBC 04/28/0511

12

13

14

15

16

17

18

19

20

21

22

23

24

25

DSSM Culture (TBC) DST* Laboratory No. : TC-CC-Year, Accession No-1st or 2nd specimen

Endorsed by: ___________________________ Date: _________________________

Received by: ____________________________ Date: _________________________


Laboratory Releasing Form For Results

PTSI

Francia Gonzales(PTSI) 07/30/05

07/30/05 Mar Rocha (TDF Messenger)

KASAKA-QI

Laboratory Releasing Form for Results

MODULE B


5.1 Record the smear results in the TB Symptomatics Masterlist

Upon receipt of results at the Treatment Center, find the suspect’s name in the TB Symptomatics Masterlist (see example on page 81). Record the results of DSSM for each of the samples in column 16 “Screening (DSSM/culture results)” and write the date (mm-dd-yy) of sputum collection on the row below this. Note that the Laboratory Releasing Form will indicate that a combination of DSSM and culture results are being released at the same time and all results whether DSSM or culture must be recorded on the TB Symptomatics Masterlist promptly as they are received.

The messenger assigned to transport specimens is also assigned to pick up the results.

To record DSSM results, write “0” if negative and write the grading “1+”, “2+”, or “3+”, if positive.

On the next page is an actual DSSM result of a patient, Maria Morelos, that has been released to the LCP-PHDU DOTS Center on February 12, 2007 by the LCP Laboratory. Sputum was collected at the Treatment Center on February 7 and 8, 2007. Results show that the first specimen was 2+ and the second was 3+.

MODULE B


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MODULE B


5.2 Decide on the appropriate action in response to the smear results

Even if an MDR-TB suspect’s DSSM results are negative, the Culture Center will automatically process the specimens to isolate and identify M. tuberculosis. There are many cases of smear-negative but culture-positive cases of TB and when MDR-TB is suspected, it is critical to confirm the suspicion with a DST.

As culture results are available, the Culture Center will fill out individual results using the DSSM and Culture Result Form.

If any of the sputum specimens is smear-positive, this result means that the MDR-TB suspect has infectious pulmonary TB. This result does not signify anything about the possibility of drug resistance for the MDR-TB suspect. The MDR-TB suspect should be informed of the results and reminded to follow up for the culture results in 3-3.5 months from sputum collection. The MDR-TB suspect should also be educated on the infection control precautions to take while at home to avoid spreading TB to those around him. Important messages to give to the patient are described in Module D: Inform Patients about MDR-TB.

If all specimens are smear-negative, the Culture Center also automatically processes them for culture. The MDR-TB suspect can call the Treatment Center for the culture results on or after 3-3.5 months from sputum collection.

5.3 Record the culture results in the TB Symptomatics Masterlist

Upon receipt of culture results at the Treatment Center, find the suspect’s name in the TB Symptomatics Masterlist (see example on page 81). Record the results of culture for each of the samples in column 16 “Screening (DSSM/culture results)”. These entries on culture should already have DSSM results and dates of sputum collection entered previously when the DSSM results were received.

To record culture results, write “0” if negative and write ‘Mtb’ if positive. If the result is less than 10 colonies, write the number of colonies as reported in the result form.

The culture result of the patient Maria Morelos, the example used in Section 5.1 is shown below. This was received by the LCP-PHDU DOTS Center on June 5, 2007 showing both specimens to be positive for M. tuberculosis.

MODULE B


DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

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ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

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lture

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ter:

Dat

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ST c

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r:

Sc

he

du

le:

S

cree

ning

Bas

elin

e

Fol

low

-up:

mon

th o

f tx:

M

onth

s po

st-t

reat

men

t

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

03-L

-070

080-

103

-L-0

7008

0-2

Dat

e of

col

lect

ion

2/7/

2007

2/8/

2007

DSS

M2+

3+TB

cul

ture

MTB

MTB

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Mor

elos

, Mar

ia

45/F

Raym

ond,

Law

renc

e M

.D.

06/0

4/07

Clai

re M

acug

ay, R

MT

Law

renc

e La

qiun

danu

m, R

MT

LCP-

PHDU

DOT

S Ce

nter

Sput

umLC

P la

bora

tory

MODULE B


As soon as this is received at the Treatment Center, write “Mtb” for the February 7 and 8, 2007 specimens after putting a slash to separate this from the DSSM result. See how this is done on page 81, column 16 of the TB Symptomatics Masterlist.

5.4 Decide on the appropriate action in response to the culture results

If a patient has at least one positive sputum culture for M. tuberculosis, this means that the MDR-TB suspect has confirmed pulmonary TB.

If the culture is positive (10 or more colonies), the Culture Center will send the culture isolate to the DST center.

If one sputum culture yields a count of < 10 colonies, the second sputum culture must also have a growth of at least < 10 colonies for the culture to be interpreted as positive. Between these two isolates with both < 10 colonies each, send the isolate with more colonies or more luxuriant growth to the DST Center while keeping the other one at the Culture Center.

If one sputum culture has <10 colonies and the second culture has negative growth, DST will still be performed on the isolate with < 10 colonies as this is a diagnostic specimen. This is not done for follow-up specimens.

If both culture results are negative or have no growth, no further test will be done.

If culture result is negative and smear result is positive, refer to the consilium for further discussion and decision on management.

For screening and baseline specimens, the isolates are sent to the DST Center for DST. However, for follow-up specimens, the isolates are simply kept at the Culture Center unless otherwise requested for DST by the Treatment Center.

When the patient with a positive culture calls the Treatment Center for the results, he should be informed that the culture was positive and that the result of the final stage of diagnostic testing will be available in the following weeks. The patient is advised to make a follow-up call 1-2 months after to find out the results of the DST and asked to come in for further examination.

The Culture Center will send the isolates to the DST Center along with the other isolates for DST. All isolates are listed one by one on the Laboratory Receiving Form for Specimens. Tick the “Isolates” box; write down the names of the patients with positive culture results, indicate the laboratory numbers of the isolates. All isolates will be packed in a biobottle and prepared according to guidelines on proper packing and transportation of infectious materials. The person receiving the box signs the form and brings the box to the DST Center. The DST Center staff will carefully unpack the package in a safety hood and check the isolates against the Laboratory Receiving Form for Specimens. If there is no discrepancy, he affixes his initials and date on the form and files it. However, if there is a discrepancy, the DST Center will call the Culture Center and document their agreement on the form. He then files the form at the DST Center.

MODULE B


6. Receive and record the DST results in the TB Symptomatics Masterlist, Category IV Register and Consiliumex

DST results received at the Treatment Center must be immediately relayed to the referring Treatment Center physician. Should there be any delay in the pick up of results, the DST Center must relay the results of confirmed MDR-TB cases by facsimile or SMS (text message) with the official DST Result Form to follow. Just like the release of culture results, all DST results are also summarized in the Laboratory Releasing Form for Results by the staff at the DST Center. This will be signed by the messenger and brought to the Treatment Center. The staff at the receiving Treatment Center will check the individual results against the Laboratory Releasing Form and contact the DST Center in case of any discrepancy.

6.1 Record DST results in the TB Symptomatics Masterlist

If the DST result shows that the M. tuberculosis is “resistant” to a certain drug, this means that the TB bacilli grew despite the presence of the drug in the culture medium. Drug resistance in the DST test signifies that the patient should not receive that drug as part of the anti-TB regimen because the drug will not have any effect on the strain of bacilli that the patient has. If the result was “susceptible”, this means that the DST test found that the specific drug in the culture medium inhibited the growth of the bacilli and that generally, that specific drug can be expected to help cure the patient of TB when given as part of the TB regimen. The Consilium will make the final decision on the TB regimens that patients must receive for MDR-TB treatment. (See Module C: Treat MDR-TB Patients)

To record the DST results, find the MDR-TB suspect’s name in the TB Symptomatics Masterlist. If susceptible to a drug, write “S” and if resistant, write “R”. Record the results for each drug tested under Column 17 “DST Results”.

Since DST is the final step in confirming that a patient is MDR-TB, the date when the Treatment Center received this information is very important. Hence, upon receipt of DST results, the Treatment Center should mark this date on the individual DST result form and record this on the TB Symptomatics Masterlist column 18 “Registration date” sub-column “Date DST released”. This should also be recorded in the Category IV Register column 16 which will be discussed later.

MODULE B


The

DST

resu

lt of

the

sam

e pa

tient

, Mar

ia M

orel

os, i

n Se

ctio

n 5.

3 is

sho

wn

belo

w. T

his

was

rece

ived

by

the

LCP-

PHD

U D

OTS

Cen

ter o

n Ju

ly 1

0, 2

007

show

ing

that

the

patie

nt w

as re

sist

ant t

o H

, R a

nd S

and

sus

cept

ible

to Z

, E, K

m, A

m, C

fx a

nd L

fx.

As s

oon

as th

e D

ST re

sult

is re

ceiv

ed, s

taff

at th

e LC

P-PH

DU

DO

TS C

ente

r sho

uld

fill o

ut C

olum

n no

. 17

“DST

Res

ults

“ of t

he T

B Sy

mpt

omat

ics M

aste

rlist

with

“S” t

o m

ean

“sus

cept

ible

” and

“R” t

o m

ean

“res

ista

nt”.

DR

UG

SU

SC

EP

TIB

ILIT

Y T

ES

T (

DS

T)

RE

SU

LT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Lab

orat

ory

ID n

o.

Spec

imen

:Cu

lture

cen

ter:

Dat

e co

llect

edD

ST c

ente

r:

Sc

he

du

le:

S

cree

ning

Bas

elin

e

Fol

low

-up:

mon

th o

f tx:

M

onth

s po

st-t

reat

men

t

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

Dru

g S

usc

ep

tib

ilit

y T

est

ing

ME

TH

OD

US

ED

:

Ison

iazi

d (H

) 0.1

ug/m

lSt

rept

omyc

in (S

) Ka

nam

ycin

(Km

) 6ug

/ml

Rifa

mpi

cin

(R) 5

ug/m

lO

floxa

cin

(Ofx

)O

ther

2nd

line

dru

gs:

Etha

mbu

tol (

E) 5

ug/m

lCi

profl

oxac

in (C

fx )

Am

ikac

in (A

k)

Pyra

zina

mid

e (Z

) ___

___

Levo

floxa

cin

(Lfx

)

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Mor

elos,

Maria

45/F

Raym

und,

Law

renc

e M.D

.

LCP-

PHDU

DOT

S Ce

nter

03-L

-070

080-

1

Sput

um

Disc

Elut

ion /

7H1

0

LCP

Labo

rato

ry

2/7/

2008

TDF

Labo

rato

ry

07/1

0/07

Mich

ael S

. Eva

ngel

ista

Clau

dett

e Gu

ray

MODULE B


Belo

w, y

ou w

ill fi

nd th

e co

mpl

eted

Col

umns

16,

17

and

18 o

f the

TB

Sym

ptom

atic

s Mas

terli

st fo

r pat

ient

, Mar

ia M

orel

os.

Colu

mn

18 “R

egis

trat

ion

date

” ref

ers t

o th

e da

te th

at c

onfir

med

the

need

for C

ateg

ory

IV tr

eatm

ent e

ither

by

a) th

e D

ST re

sult

or, b

) con

siliu

m d

ecis

ion

even

with

out t

he

DST

resu

lt by

virt

ue o

f a h

igh

clin

ical

sus

pici

on fo

r MD

R-TB

. For

the

latt

er g

roup

of p

atie

nts,

writ

e th

e da

te w

hen

the

Cons

ilium

dec

ided

to s

tart

Cat

egor

y IV

trea

tmen

t un

der

“Con

siliu

m d

ate”

of t

he s

ame

colu

mn,

and

kee

p bl

ank

the

boxe

s fo

r “D

ST re

sults

” and

“Dat

e D

ST re

leas

ed”.

Both

gro

ups,

whe

n pr

esen

ted

to th

e Co

nsili

um, a

re

gene

rally

app

rove

d fo

r tre

atm

ent a

nd a

ll pa

tient

s be

long

ing

to e

ither

gro

up w

ill b

e as

sign

ed a

Pre

-enr

ollm

ent N

o. w

hich

will

be

expl

aine

d in

the

next

few

pag

es.

Prog

ram

mat

ic M

anag

emen

t of

Dru

g - R

esis

tant

TB

(PM

DT)

TB

Sy

mp

tom

ati

cs

Ma

ste

rlis

t

Risk factors

Symptoms

CXR

res

ult

sSc

reen

ing

(DSS

M/ c

ult

ure

res

ult

s) (1

6)D

ST r

esu

lts

(17

)R

egis

trat

ion

dat

e

(mm

/dd/

yy)

(18)

Pre

-en

roll

men

t #

(19)

YY-

NN

NN

Dat

e do

ne

Dat

e sp

utu

m c

olle

cted

(mm

/dd/

yy)

HR

ZE

SK

mO

fxCf

xLf

xO

ther

Am

Oth

erEn

roll

ed?

If Y

ES, i

ndi

cate

tre

atm

ent

star

t da

te. I

f NO,

indi

cate

rea

son

.(1

3)(1

4)(1

5)D

ate

DST

rele

ased

Con

siliu

m

date

41,

2,3,

4,5,

61,

2,7

2+

/ M

TB3+

/ M

TB/

/R

RS

SR

SN

DS

SS

7/10

/07

7/12

/07

07-0

419

2/2/

0702

/07/

0702

/08/

07 /

/ /

/ 7/

21/0

7

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

//

//

/

/

/

/

/

/

/

/

/

/

/

/

/

/

MODULE B


For Treatment Site staff, skip Exercie E and continue reading from section 6.2, page 92

until the Summary of important points and tell your facilitator

when you have reached that point.

For Treatment Center StaffExercise E – Written Exercise

When you have reached this point in the module, you are ready to do Exercise E. Follow the instructions for Exercise E. Do this exercise by yourself.

Exercise E

Recording Results on the TB Symptomatics Masterlist

In this exercise you will practice recording the results of the laboratory tests in the TB Symptomatics Masterlist for three patients. Use the information written on actual result forms provided to you. Work individually on this exercise. If any of the instructions are unclear, ask a facilitator for clarification.

The DSSM, culture and DST results for Cases 1, 2 & 3 who were MDR-TB suspects listed on the TB Symptomatics Masterlist in Exercise C page 37 are shown in the next pages. The results for the other MDR-TB suspects, Cases 5 & 6 have not yet been released.

Record the results of the sputum examination of the patients on columns 16, 17 and 18 of the TB Symptomatics Masterlist provided to you in the previous exercise.

MODULE B


DSSM

resu

lt:

DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

:Cu

lture

cen

ter:

Sc

he

du

le:

S

cree

ning

Bas

elin

e

Fol

low

-up:

mon

th o

f tx:

M

onth

s po

st-t

reat

men

t

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

Dat

e of

col

lect

ion

DSS

M

TB c

ultu

re

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Sari

wa,

Son

ia S

.

34/

F

Verz

osa,

Dav

e, M

D

12/0

7/07

John

Um

ali,

RMT

Clau

dett

e Gu

ray,

RM

T

TDF-

MM

C DO

TS C

linic

Sput

umTD

F La

bora

tory

MODULE B


DSSM

resu

lt:

DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

:Cu

lture

cen

ter:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

Dat

e of

col

lect

ion

DSS

M

TB c

ultu

re

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Relo

z, R

olan

do R

.

49/F

Verz

osa,

Dav

e, M

D

12/0

8/07

John

Um

ali,

RMT

Clau

dett

e Gu

ray,

RM

T

TDF-

MM

C DO

TS C

linic

Sput

umTD

F La

bora

tory

MODULE B


DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

:Cu

lture

cen

ter:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

Dat

e of

col

lect

ion

DSS

M

TB c

ultu

re

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Sant

os, S

antia

go S

.

45/

M

Verz

osa,

Dav

e, M

D

12/1

0/07

John

Um

ali,

RMT

Clau

dett

e Gu

ray,

RM

T

TDF-

MM

C DO

TS C

linic

Sput

umTD

F La

bora

tory

DSSM

resu

lt:

MODULE B


Cultu

re re

sult:

DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

:Cu

lture

cen

ter:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

Dat

e of

col

lect

ion

DSS

M

TB c

ultu

re

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Sari

wa,

Son

ia S

.

34/

F

Verz

osa,

Dav

e, M

D

03/1

5/08

John

Um

ali,

RMT

Clau

dett

e Gu

ray,

RM

T

TDF-

MM

C DO

TS C

linic

Sput

umTD

F La

bora

tory

MODULE B


Cultu

re re

sult:

DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

:Cu

lture

cen

ter:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

Dat

e of

col

lect

ion

DSS

M

TB c

ultu

re

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Relo

z, R

olan

do R

.

49/F

Verz

osa,

Dav

e, M

D

03/2

5/08

John

Um

ali,

RMT

Clau

dett

e Gu

ray,

RM

T

TDF-

MM

C DO

TS C

linic

Sput

umTD

F La

bora

tory

MODULE B


Cultu

re re

sult:

DS

SM

AN

D C

ULT

UR

E R

ES

ULT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Spec

imen

:Cu

lture

cen

ter:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

DSS

M

T

B Cu

lture

1st s

peci

men

2nd

spec

imen

3rd

spec

imen

Lab

No.

Dat

e of

col

lect

ion

DSS

M

TB c

ultu

re

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


San

tos,

Sant

iago

S.

45/M

Verz

osa,

Dav

e, M

D

03/1

7/08

John

Um

ali,

RMT

Clau

dett

e Gu

ray,

RM

T

TDF-

MM

C DO

TS C

linic

Sput

umTD

F La

bora

tory

MODULE B


DST r

esul

t:

DR

UG

SU

SC

EP

TIB

ILIT

Y T

ES

T (

DS

T)

RE

SU

LT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Lab

orat

ory

ID n

o.

Spec

imen

:Cu

lture

cen

ter:

Dat

e co

llect

edD

ST c

ente

r:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

Dru

g S

usc

ep

tib

ilit

y T

est

ing

ME

TH

OD

US

ED

:

Ison

iazi

d (H

) St

rept

omyc

in (S

) Ka

nam

ycin

(Km

)

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mpi

cin

(R)

Oflo

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n (O

fx)

Oth

er 2

nd li

ne d

rugs

:

Etha

mbu

tol (

E)Ci

profl

oxac

in (C

fx )

Am

ikac

in (A

m)

Pyra

zina

mid

e (Z

) Le

voflo

xaci

n (L

fx)

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Sari

wa,

Son

ia

34/F

Verz

osa,

Dav

e, M

D

04/2

0/08

Mich

ael S

. Eva

ngel

ista

Clau

dett

e Gu

ray

TDF-

MM

C DO

TS C

linic

01-T

-079

781-

1

Sput

umTD

F La

bora

tory

11/2

9/20

07TD

F La

bora

tory

Disc

Elut

ion /

7H1

0

MODULE B


DST r

esul

t:

DR

UG

SU

SC

EP

TIB

ILIT

Y T

ES

T (

DS

T)

RE

SU

LT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Lab

orat

ory

ID n

o.

Spec

imen

:Cu

lture

cen

ter:

Dat

e co

llect

edD

ST c

ente

r:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

Dru

g S

usc

ep

tib

ilit

y T

est

ing

ME

TH

OD

US

ED

:

Ison

iazi

d (H

) St

rept

omyc

in (S

) Ka

nam

ycin

(Km

)

Rifa

mpi

cin

(R)

Oflo

xaci

n (O

fx)

Oth

er 2

nd li

ne d

rugs

:

Etha

mbu

tol (

E)Ci

profl

oxac

in (C

fx )

Am

ikac

in (A

m)

Pyra

zina

mid

e (Z

) Le

voflo

xaci

n (L

fx)

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Relo

z, R

olan

da

49/F

Verz

osa,

Dav

e, M

D

04/2

5/08

Mich

ael S

. Eva

ngel

ista

Clau

dett

e Gu

ray

TDF-

MM

C DO

TS C

linic

01-T

-079

781-

1

Disc

Elut

ion /

7H1

0

Sput

umTD

F La

bora

tory

12/3

/200

7TD

F La

bora

tory

MODULE B


DST r

esul

t:

DR

UG

SU

SC

EP

TIB

ILIT

Y T

ES

T (

DS

T)

RE

SU

LT

Cate

gory

IV R

egis

trat

ion

No.

Patie

nt’s

nam

e:

Age/

Sex:

Requ

estin

g ph

ysic

ian:

Trea

tmen

t cen

ter:

Lab

orat

ory

ID n

o.

Spec

imen

:Cu

lture

cen

ter:

Dat

e co

llect

edD

ST c

ente

r:

Sc

he

du

le:

S

cree

ning

B

asel

ine

F

ollo

w-u

p: m

onth

of t

x:

Mon

ths

post

-tre

atm

ent

En

roll

ed

:

Y

es

N

o

C

ate

go

ry:

N

ew

R

etre

atm

ent

EX

AM

INA

TIO

N D

ON

E:

Dru

g S

usc

ep

tib

ilit

y T

est

ing

ME

TH

OD

US

ED

:

Ison

iazi

d (H

) St

rept

omyc

in (S

) Ka

nam

ycin

(Km

)

Rifa

mpi

cin

(R)

Oflo

xaci

n (O

fx)

Oth

er 2

nd li

ne d

rugs

:

Etha

mbu

tol (

E)Ci

profl

oxac

in (C

fx )

Am

ikac

in (A

m)

Pyra

zina

mid

e (Z

) Le

voflo

xaci

n (L

fx)

Dat

e Re

leas

ed:

mm

/dd/

yy

L

abor

ator

y Te

chni

cian

Labo

rato

ry S

uper

viso

r


Sant

os, S

antia

go

45/M

Verz

osa,

Dav

e M

.D.

04/2

8/08

Mich

ael S

. Eva

ngel

ista

Clau

dett

e Gu

ray

TDF-

MM

C DO

TS C

linic

01-T

-079

783-

1

Sput

umTD

F La

bora

tory

12/5

/200

7TD

F La

bora

tory

Disc

Elut

ion /

7H1

0

MODULE B



For Treatment Center Staff

Read through until the Summary of important points in the module and tell your facilitator when you have reached that point.

6.2 Assign a Pre-enrollment No. to the patient if confirmed to have MDR-TB

A patient confirmed to be MDR-TB either by DST or by consilium decision should be put on treatment as soon as possible. However, this does not always happen for various reasons, e.g., the patient may have a) gone back to the province and cannot be located (“early default”), b) died, or c) refused treatment.

It is important to track the waiting time of patients from consultation or screening to diagnosis to the time they are treated as MDR-TB. If this is too long, the Treatment Center will have to review its process of diagnosis and enrolment.

The last column, Column 19, of the TB Symptomatics Masterlist is entitled “Pre-enrollment No.”. Not all patients will be assigned this number. As discussed in section 6.1 above, the Pre-enrollment No. is given only to two groups of patients entered in the TB Symptomatics Masterlist, namely a) those who have been confirmed to be MDR-TB by DST and b) those with consilium decision to treat even if not confirmed to be MDR-TB by DST but highly suspected to be MDR-TB from the clinical standpoint. The latter includes critically ill patients who have either pending culture or DST results and cannot wait for these results to be released and immediate treatment needs to be started. This also includes patients who have negative cultures due to intake of drugs with anti-TB action prior to sputum collection, and those with non-viable or contaminated culture in the laboratory.

If the patient with the Pre-enrollment No. is enrolled, write the treatment start date under the Pre-enrollment No. If the patient is not enrolled, indicate the reason why under the Pre-enrollment No. These reasons can be that the patient is lost or has gone back to the province, the patient has died while waiting for treatment, or has decided not to start the treatment at all for whatever reason, etc.

The Pre-enrollment No. is coded as YY (current year)-NNNN (accrual number which starts with 0001 at the start of every year). For example, a patient bearing the Pre-enrollment No. 08-0329 means that the patient qualified for start of treatment in year 2008 and was the 329th patient to be given a Pre-enrollment number in 2008.

Once a patient with a Pre-enrollment No. is started on treatment, he is entered into the Category IV Register. All patients put on treatment will be entered into the Category IV Register and each one is assigned a unique Category IV Registration No. See Module C: Treat MDR-TB Patients and the Reference Booklet for instructions on how to fill out the Category IV Register.

MODULE B


6.3 Record the results in the patient’s chart and in the Consiliumex

Patients who are confirmed to be MDR-TB by DST and those who are critically ill and highly suspected for MDR-TB need to be presented to the Consilium. The consilium determines treatment regimens, assesses response to treatment and treatment outcome through a consensus utilizing WHO Guidelines for drug-resistant TB.

The Treatment Center physician will fill out the Consiliumex for one case in preparation for presentation to the Consilium. An example of the Consiliumex can be found on the following pages. There are many sections of the Consiliumex. At this point, the physician will be completing first the patient’s general information, TB treatment history, DST pattern and chest x-ray results, then Consilium Discussion 001 – Recommendation on Enrollment Regimen.

6.4 Schedule a case for presentation at the next Consilium meeting

The Consilium normally meets every week to discuss cases. The Treatment Center physician must prepare the necessary documents such as the Consiliumex, laboratory results and x-ray films and schedule the case to be presented in the next meeting. The Consilium will make the final decision on what the course of action for the MDR-TB patient will be, particularly the MDR-TB regimen design following the principles in the WHO guidelines.

An example of how to fill out the Consiliumex can be found on the following two pages.

MODULE B


Category IV Registration No:

GENERAL INFORMATION:

NAMEBalagtas Jose Amorsolo

(Last) (First) (Middle)

50 SEX M F WEIGHT ON SCREENING 49.2 KGS

METRO MANILA ADDRESS2425 Buendia Street, Balut Tondo, Manila

(No., street, barangay, district, city, ZIP code)

PERMANENT ADDRESSSame as above

(No., street, barangay, district, city, ZIP code)

REGION NCR

TREATMENT CENTER KASAKA

MD IN CHARGE DAR (initials of Dr. Dan A. Rivera)

TB TREATMENT HISTORY, CHEST X-RAY RESULTS AND DST PATTERN:

TB TREATMENT

HISTORY AND

REGISTRATION

GROUP

1997 – 2HRZE, 4HR Government hospital, non-DOTS, unknown2003 – 2HRZES, 4HRZE, health center DOTS, failed2004 – 3HRZES, 3HRZES, health center DOTS, failedAfter cat II failure

CHEST X-RAY RESULTS Cavity on upper right lung, in ltrates BLL and brothorax on LUL

NAME OF OTHER

LABORATORYLCP DATE DST RELEASED 10 / 10 / 05

DST RESULT Resistant to: HRES Susceptible to: Z Km Lfx Clr

CULTURE CENTER

(Screening)TDF DATE SPECIMEN

COLLECTED10/18/06

DST CENTER

(Screening)TDF DATE DST RELEASED 02/26/07

DST RESULT

(Screening)

Resistant to: HRES

Susceptible to:Z Km Cfx Ofx Lfx

DST RESULT (Baseline)

Note: to be filled in

once available

Resistant to:Not available

Susceptible to:Not available

WEIGHT MONITORING: (TO BE CONSTANTLY UPDATED EVERY CONSILIUM MEETING BY THE SECRETARIAT)

CONSILIUM

DISCUSSIONDATE WEIGHT (KGS)

CONSILIUM

DISCUSSIONDATE WEIGHT (KGS)

001 (E) 03 / 01 / 07 49.2 006

002 007

003 008

004 009

005 010 (TO)

National Tuberculosis ProgramProgrammatic Management of Drug - Resistant TB (PMDT)

CONSILIUMEX

Must be completely filled out by the Treatment Center physician prior to consilium presentation

TB treatment history is important in making decisions regarding the patient’s regimen design.

MODULE B


Example of a Consiliumex showing Consilium decision on treatment regimen.

An example of a completed Category IV Register is shown in the next few pages.

CONSILIUM DISCUSSION 001 – RECOMMENDATION ON ENROLMENT REGIMEN

RECOMMENDED REGIMEN AND DRUG INTRODUCTION GUIDE:

LATEST WEIGHT 49.2 KGS REGIMEN ZKmOfxPtoCs MD IN CHARGE DAR

SECOND-LINE DRUG SYMBOL DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

Cycloserine Cs 1 cap 1 cap 1 cap 2 caps 2 caps 2 caps FD

Prothionamide Pto 1 tab 1 tab 1 tab 2 tabs 2 tabs 2 tabs FD

PASER PAS 1 sachet 1 sachet 1 sachet 2 sachets 2 sachets 2 sachets 2 sachets

DRUGS IN REGIMEN (USE SYMBOL) PREPARATION NO. OF UNITS PER DAY

Z 500 mg 5Km 1 G 750Ofx 200 mg 4Pto 250 mg 2Cs 250 mg 2

COMMENTS: For enrollment

CONSILIUM OFFICER Ma. Imelda D. Quelapio MD DATE 03 / 01 / 07

CONSILIUM DISCUSSIONS

Make sure all consilium decisions are signed by the Consilium Officer who ensures that all entries are correct.

Clearly indicate the recommended regimen and dosage for the patient


Dat

e

scre

ened

mm

/dd/

yy

(1)

Cate

gory

IV

Reg

istr

atio

n N

o.

TC-Y

Y-N

NN

N

(2)

Trea

tmen

t

star

t da

te

mm

/dd/

yy

(3)

Nam

e

(4)

Sex

(5)

Age

(yr

s)

(6)

Add

ress

(7)

Site

of

dise

ase

(8)

Ches

t x-

ray

resu

lt

(9)

Reg

istr

atio

n

grou

p

(10)

Pre

viou

s TB

trea

tmen

t

(11)

Dat

e D

ST

spec

imen

colle

cted

mm

/dd/

yy

(12)

t

Last

nam

eD

ate

of b

irth

mm

/dd/

yy

Stre

et n

o. a

nd n

ame

Dat

e do

ne

mm

/dd/

yyFi

rst n

ame

and

mid

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ity,

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ion

4/29

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502

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NTO

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02 /

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//

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//

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//

/

Prog

ram

mat

ic M

anag

emen

t of

Dru

g - R

esis

tant

TB

(PM

DT)

Ca

teg

ory

IV

Re

gis

ter

(5)

Se

x(9

) C

he

st x

-ra

y r

esu

lt(1

0)

Re

gis

tra

tio

n g

rou

p

1- M

ale

2- F

emal

eN

orm

al0–

Cavi

tary

1–

Infil

trat

e2–

Nod

ule

3– M

iliar

y TB

4– In

trat

hora

cic

5– ly

mph

aden

opat

hyEn

dobr

onch

ial s

prea

d

6– Fi

bros

is

7–

Fibr

otho

rax

8–

Bulla

e9–

Pl

eura

l effu

sion

10–

Pneu

mot

hora

x11

– Br

onch

iect

asis

12–

Ate

lect

asis

13

– Co

nsol

idat

ion

14–

Mas

s15

– O

ther

s, sp

ecify

16

– __

____

____

____

_

1-N

ew2-

Aft

er C

at I

failu

re3-

Aft

er C

at II

failu

re4-

Aft

er C

at IV

fa

ilure

5-A

fter

def

ault

6-

Cat I

rela

pse

7-Ca

t II r

elap

se8-

Cat I

V re

laps

e

9-

Tran

sfer

-in

10-O

ther

pat

ient

w/

10.1

Non

-DO

TS10

.2 O

ther

(+)

10.3

Oth

er (-

)

(11

) P

rev

iou

s T

B t

rea

tme

nt

1- N

ew2-

Firs

t lin

e dr

ugs

only

3- F

irst

and

seco

nd-li

ne

drug

s

Category IV Register/ Page 1 of 3

Patie

nt’s

uniq

ue C

ateg

ory

IV R

egis

trat

ion

No.

is g

iven

on

ce tr

eatm

ent i

s st

arte

d.


Prog

ram

mat

ic M

anag

emen

t of

Dru

g - R

esis

tant

TB

(PM

DT)

CA

TE

GO

RY

IV

RE

GIS

TE

R |

page

2 o

f 3

Dat

e D

ST

spec

imen

coll

ecte

d

mm

/dd/

yy

(12)

Dru

g Su

scep

tibi

lity

Test

ing

(DST

) (13

)

D

ate

DST

rele

ased

mm

/dd/

yy

(14)

Dat

e re

ceiv

ed b

y

Tx c

ente

r

mm

/dd/

yy (1

5)

Follo

w-u

p D

SSM

an

d cu

ltu

re m

onit

orin

g du

rin

g tr

eatm

ent

(16)

mo

0m

o 1

mo

2m

o 3

mo

4m

o 5

mo

6m

o 7

mo

8m

o 9

S - S

usc

epti

ble

R

- R

esis

tan

t

ND

- N

ot D

one

s/c

s/c

s/c

s/c

s/c

s/c

s/c

s/c

s/c

s/c

s/c

HR

ZE

SK

mO

fxCf

xLf

xO

ther

Oth

erm

m/d

d/yy

mm

/dd/

yym

m/d

d/yy

mm

/dd/

yym

m/d

d/yy

mm

/dd/

yym

m/d

d/yy

mm

/dd/

yym

m/d

d/yy

mm

/dd/

yy

04/2

9/05

RR

SR

SS

SS

SN

DN

D9/

23/0

59/

26/0

5

2+/MTB

2+/MTB

/

/

/

/

09/2

8/05

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/

/

09/2

9/05

04/2

7/05

RR

RR

RR

RR

SN

DN

D10

/5/0

510

/10/

05

3+/MTB

3+/MTB

/

/

/

/

11/0

4/05

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/

/

11/0

7/05

04/2

8/05

RR

SR

RS

SS

SN

DN

D10

/10/

0510

/11/

05

4+/MTB

3+/MTB

02+/

00/

00/

00/

00

0 /

/

/

/

10/2

1/05

11/2

4/20

0512

/22/

2005

1/25

/200

62/

23/2

006

3/24

/200

64/

20/2

006

/ /

/ /

/ /

/

/

10/2

2/05

/

/

/

/

/

/

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/

/

/ /

/

/

/

/

/

/

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/

/

/ /

(13

) D

rug

Su

sce

pta

bil

ity

Te

stin

g (

DS

T)

Ro

w 1

: S

cre

en

ing

DS

T o

r D

ST

re

sult

av

ail

ab

le p

re-t

rea

tme

nt

Ro

w 2

: B

ase

lin

e D

ST

or

DS

T d

on

e w

ith

in 3

0 d

ay

s p

rio

r to

tre

atm

en

t st

art

or 7

day

s po

st-t

reat

men

t sta

rt (r

esul

t not

yet

ava

ilabl

e up

on tr

eatm

ent)

Ro

ws

3 a

nd

4:

Oth

er

DS

Ts

du

rin

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t, us

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sults

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cord

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Mon

thly

DSS

M a

nd

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re re

sults

are

re

cord

ed.

MODULE B


Prog

ram

mat

ic M

anag

emen

t of

Dru

g - R

esis

tant

TB

(PM

DT)

CA

TE

GO

RY

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R |

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(19)

/

//

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egat

ive

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th 0

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w 2

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ym

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tive

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re-n

egat

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onth

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erS-

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al

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ed1

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ied

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rogr

esse

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peci

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cod

es in

(9)

4. F

aile

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ble

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lted

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rece

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reat

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e.

MODULE B


6.5 Return an updated Acknowledgement Form to the referring DOTS facility

As soon as a definitive diagnosis has been made at the Treatment Center, you need to inform the referring DOTS facility of the diagnosis and plan for the patient. This is done using the same Acknowledgement Form that is used during screening. This is accomplished in duplicate copies, one for the referring facility through the patient and the other attached to the patient’s records in the Treatment Center. Tick the box for “Final diagnosis”. On this form the physician writes the name of the referred patient, the pertinent laboratory findings particularly DST, the final diagnosis, and the recommendations. If however, the patient has not called or returned to the Treatment Center to pick up his results, the Acknowledgement Form will be sent by facsimile to the referring facility with request for assistance to locate the patient. All efforts should be done to contact the patient, e.g., by land or cell phone, or by a visit. An example of the Acknowledgement Form for final diagnosis is shown in the next page.

MODULE B


To be accomplished In duplicate copies: One copy for the Referring physician or facility and one copy attached to the Screening Form at the Treatment Center

Date: Initial Diagnosis Final Diagnosis

To:

Thank you for referring your patient , for further TB diagnosis/management.

Pertinent findings/ Laboratory examinations:

Plans/Recommendations:

Clinic Physician:

Contact numbers:

Treatment Center:



October 11, 2005

Dr. A. Madrid

Sampaguita Health CenterTondo, Manila

Jose A. Balagtas

AFS Culture DST (released Oct.10, 2005)

4/25/05 3+ M. tuberculosis Resistant to H,R,E,S 4/26/05 4+ M. tuberculosis susceptible to Z Km, Cfx, Ofx, Lfx

Final diagnosis is MDR-TB

Dr. Dan. A. Rivera 742-1534/ 781-3761 to 65 loc. 146

KASAKA-QI MDR-TB Housing Facility

For category IV treatment

Please inform patient that he is ready for enrollment.Please contact the number below for any queries and further instructions.

}

Notify referring MD/ treatment facility regarding the patient’s diagnosis and plan of treatment.

Tick final diagnosis for patients with results of sputum test

MODULE B


7. Inform MDR-TB suspects of laboratory test results

7.1 Patients with drug resistance

If the TB suspect has confirmed drug resistance to one or more TB drugs, inform him clearly and in a sensitive way. It is important to inform the DR-TB suspect as soon as possible about drug resistance and the next steps that will be taken to start treatment. If a DR-TB suspect does not call or return to the Treatment Center to find out the results on the scheduled time, and the DST result shows drug resistance, a highly proactive search to find the patient needs to be done. All efforts should be made to contact or locate him as soon as possible. Call the patient or his contacts using the numbers recorded in the TB Symptomatics Masterlist within that week. Or you can call the referring DOTS facility to help locate the patient. This may also require you to visit the patient’s address. Patients with MDR-TB who are left untreated can infect many others; moreover, delays in treatment can lead to worse treatment outcomes. Hence, it is imperative not to lose confirmed MDR-TB cases.

7.1.1 Inform the patient of the results and explain the Consilium process

When you inform the patient that the DST showed resistance to TB drugs, explain in simple terms what drug resistance is, and what that means for treatment. Reassure the patient that MDR-TB can be cured, but that it will take dedication and many months of treatment. Drug-resistant TB is a very serious disease but it can be cured and, treatment is given free of charge. It is also important to ensure that the patient will be ready to start treatment once his case has been discussed and is approved for enrollment. Explain that this process may take some time but that they should be ready to begin treatment in the near future.

This is a very important meeting with the MDR-TB patient. At this initial discussion, you will begin to provide important information and support and tell the patient about the future treatment. This is the beginning of a long relationship with the patient, one that is essential for the successful treatment of the disease. All communication must be kind, supportive and medically correct.

Inform the patient about MDR-TB, supervised treatment, the treatment regimen, possible adverse drug reactions, TB transmission, etc. Discuss the patient’s main worries or doubts and answer any questions clearly and positively to encourage him as he prepares to start a long and difficult treatment course. See Module D: Inform Patients about MDR-TB.

7.2 Patient with no drug resistance

A patient who has positive culture but does not show resistance to TB drugs can begin treatment for TB according to the standard guidelines of the National TB Program. The Treatment Center physician should refer the patient to the appropriate DOTS facility to begin treatment immediately, explaining well to the patient why treatment need not be done at the MDR-TB Treatment Center.

MODULE B


8. Trace household contacts

8.1 Obtain a written consent from the patient in Kasunduan/”Contract” for treatment and

to interview the patient’s household contacts

The MDR-TB patient will now be asked to sign a contract for treatment. Read the Kasunduan/Contract to the patient and his family member or relative in a way that they can understand. This Contract with the patient is very important because it is another opportunity to explain to the patient what MDR-TB treatment entails, that MDR-TB, although difficult to treat, is curable, and that his adherence to treatment is crucial to treatment success. Answer any questions that the patient might have. Also explain to the patient his rights and responsibilities as a TB patient.

The patient should also be informed of the possibility that his or her household contacts have been infected with a drug-resistant strain of TB and the need to interview and examine all these contacts particularly:

all children aged less than five years even without symptoms1. Studies have shown the increased vulnerability to TB of children less than five years of age among family contacts and the increased estimated risk of progression to disease after infection. Hence, even without the manifestation of symptoms, children of this age group should be screened

five years and above who have cough of greater than two weeks2.

Cough of more than two weeks is a cardinal symptom of TB and any person regardless of age manifesting with such should be investigated.

If you are sure that the patient has no more questions, ask him to affix his signature on the second page with the date. The family member or relative should also sign together with the Treatment Center staff. For more information about how to speak with a patient see Module D:Inform Patients about MDR-TB.

Before any contact tracing can be performed, a Kasunduan/Contract must be signed by the patient. Patients may not want to sign or may be wary about doing so. You should explain to the patient the reasons for asking for his signature.

In order to talk to contacts of the patient, consent is required to respect the patient’s privacy.If the patient signs in agreement to undergo treatment, it means that he understands the potential side effects of the drugs, pledges to adhere to the requirements of treatment and follow-up.Each patient has certain rights and responsibilities when receiving treatment for MDR-TB and these need to be explained and agreed upon.

The Kasunduan/Contract is shown on the next page and can also be found in the Reference Booklet.

MODULE B


KASUNDUAN/ “CONTRACT” PARA SA PASYENTENG MAY MDRTB | page 1 of 2


KASUNDUAN/ “CONTRACT” PARA SA PASYENTENG MAY MDRTB

1. Ako si _____________________ay napaliwanagan na may sakit na Multidrug-resistant tuberkulosis.Ito ay nakakahawa sa iba. Ito ay di madaling gamutin at nangangailangan ng mahabang panahong gamutan (18-24 buwan o higit pa).

2. Upang gumaling:Kinakailangan kong magpagamot sa pamamagitan ng pag-inom ng gamot araw-araw sa itinakdang TREATMENT CENTER para sa akin. Kung ako ay di nakatira sa Lungsod kung saan nandoon ang Treatment Center, kinakailangang lumipat ako ng tahanan na malapit dito sa loob ng dalawang taon o higit pa upang mas maging madali para sa akin ang pagpunta sa klinika.Kung hindi posible para sa akin ang paglipat ng tahanan ay mananatili ako pansamantala sa half way house sa loob ng 6 na buwan o hanggang sa itinakdang araw sa akin ng klinika.Iinom ako ng 4 o higit pang klaseng gamot ( > 10 tableta o kapsula) sa loob ng 18 buwan o higit pa, at bibigyan din ako ng ineksyon araw-araw sa loob ng anim na buwan o higit pa depende sa aking timbang at kondisyon.Ang mga gamot ay maaaring makapagdulot ng mga kakaibang pakiramdam o side effects kung kaya’t kailangan kong makipagtulungan at ipagbibigay alam agad sa mga staff ng klinika upang malunasan ang mga ito.

3. Kung di ko itutuloy o kukumpletuhin ang paggagamot:Maaari kong mahawa ang aking pamilya at ang mga taong nakapaligid sa akin. Ako ay makakahawa sa pamamagitan ng aking pag-ubo, pagbahin, pagsasalita at pagkanta.Ang patigil-tigil na pag-inom ay mas lalong makakapagpalala ng aking kalagayan.

4. Ang mga gamot na tinatawag na second-line drugs para sa tuberkulosis na gagamitin para sa akin ay mahal at di madaling bilihin at nagkakahalaga ng P200,000 o higit pa.

Ito ay galing pa sa ibang bansa at kinakailangan pa ng tulong ng Green Light Committee (GLC) at ng World Health Organization (WHO) upang makamit.

5. Upang masubaybayan ang aking paggaling ako ay:Kukunan ng plema buwan-buwan. Ipinaliwanag sa akin na ang eksaminasyong ito ay nagkakahalaga ng higit pa sa 900 Piso bawat isa. Kukunan ng dugo sa braso kada 3 o 6 na buwan o kung kinakailangan. Ipinaliwanag sa akin na ito’y nagkakahalaga ng mahigit-kumulang 2000 piso, ngunit ako’y hindi na pagbabayarin ukol dito upang tulong ng DOTS clinic sa akin.Kukunan ng x-ray sa baga kada anim na buwan o kung kinakailangan habang ako ay nagpapagamot at kada anim na buwan sa loob ng dalawang taon matapos ang panahon ng aking paggagamot.Babalik sa klinika kada anim na buwan sa loob ng dalawang taon matapos ang panahon ng aking paggagamot (ibig sabihin apat na beses pagkatapos ng aking gamutan).

6. Ang mga sakit katulad ng diabetes, high blood at iba pang sakit na walang kinalaman sa TB ay di na sakop ng klinikang ito. Ito’y maaaring ipakonsulta at ipagamot sa ibang doktor.

7. Ang aking kalagayang pinansyal ay aalamin ng mga social worker upang maging basehan ng kakayahan ko sa pagpapatuloy sa aking gamutan at kakayahang tustusan ang iba ko pang pangangailangan habang ako ay nagpapagamot.

8. Kabutihang dulot ng paggagamot:Malaki ang pag-asa ko na ako ay gumaling at hindi na makakahawa pa sa iba. Ako ay makakabalik sa aking trabaho at magiging kapakipakinabang sa aking pamilya at komunidad. Ngunit kung malaki na ang sira ng aking baga dahil sa TB, maaaring hindi na ito bumalik sa normal kagaya ng dati kahit ang aking TB ay nagamot na.

MODULE B


TDF - MMC DOTS Clinic

Tel: 893-6066 Address:

KASAKA - QI MDR-TB Housing Facility

Tel: 742-1534 / 781-3761 to 65 Address: PTSI Compound, E. Rodriguez Ave, Quezon City

LCP - PHDU DOTS Center

Tel: 929-8324 Address:

DJNRMH DOTS Center (TALA Hospital)

Tel: 962-9877 loc. 217 Address:

PTSI - Tayuman DOTS Center

Tel: Address

Others, please specify,____________________ Tel: Address:

9. Upang mas lalong masiguro ang aking kalusugan at kalusugan ng aking mga kasambahay, dadalhin ko ang aking mga kasambahay sa itinakdang Treatment Center upang suriin sa sakit na tuberkulosis. Kukunan ng x-ray at eksaminasyon sa plema ang aking mga kasambahay kung kinakailangan.

10. Kung ako ay titigil sa gamutan:ipapaalam sa aking mga kasambahay, katrabaho, barangay official for health o sa pinakamalapit na health center sa aming komunidad ang aking kalagayan upang matulungan akong makabalik sa klinika.at nagdesisyon na muling bumalik para magpagamot, maaaring ang tsansang ibinigay sa akin upang makakuha ng libreng gamutan ay mawala na.

11. Hihingin sa akin ang lokasyon at adres ng health center na pinakamalapit sa aking tinitirahan: upang matulungan ang klinika na pabalikin ako sa paggagamot kung sakaling lumiban ako sa pag-inom. Para sa posibilidad na ako ay maendorso upang ipagpatuloy ang aking gamutan sa health center.

12. Kapag ang smear at culture ng aking plema ay negatibo na, ipagpapatuloy ko ang aking gamutan sa pinakamalapit na health center sa aming lugar.

Pangalan at lagda ng Pasyente

Pangalan at lagda ng Clinic Staff

Pangalan at lagda ng kamag-anak okasambahay ng pasyente

Petsa

Petsa

Petsa

Treatment Center Staff to please check accordingly and write the telephone and address.

Programmatic Management of Drug - Resistant TB (PMDT)KASUNDUAN/ “CONTRACT” PARA SA PASYENTENG MAY MDRTB | page 2 of 2

Jose A. Balagtas

Normando C. Cuervo

Marites S. Sisaldo

Oct. 23, 2005

Oct. 23, 2005

Oct. 23, 2005Make sure that both the patient and family members understand the importance of daily DOT and completion of treatment.

MODULE B


8.2 Complete the list of the patient’s contacts on the Contact Initial Investigation Form and conduct

interviews

A Contact Initial Investigation Form (CIIF) records all of the patient’s household contacts eligible for contact tracing which include a) all children less than five years even without symptoms, and b) five years and above who have cough for more than 2 weeks. Information on each of the patient’s eligible household contacts should be recorded on the CIIF as shown in the example on the next page.

On the right upper corner of the CIIF, note the total number of contacts regardless of criteria for contact tracing. From this number, note the number eligible for contact tracing and list their names down. Then, note how many among the eligible were actually traced since not all contacts will be able to come.

MODULE B


Prog

ram

mat

ic M

anag

emen

t of

Dru

g - R

esis

tant

TB

(PM

DT)

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nta

ct

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ial

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est

iga

tio

n F

orm

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egor

y IV

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r:

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re

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e

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sist

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MODULE B


8.3 Instruct patients’ symptomatic household contacts to receive appropriate care and follow-up

A household contact of an MDR-TB patient with symptoms possesses a risk factor for MDR-TB. He is therefore regarded as an MDR-TB suspect and because he has symptoms, he will need to be entered into the TB Symptomatics Masterlist during screening. This household contact must begin the process of TB detection as other patients in the high-risk groups for MDR-TB. If the contact is confirmed MDR-TB or will be empirically treated with second-line drugs after Consilium approval, then the contact will be entered in the Category IV Register.

All household contacts of a confirmed MDR-TB patient should be interviewed at the Treatment Center for symptoms of TB. Those who are eligible for contat tracing should be evaluated by a physician by history and physical examination.

For all ages with cough of more than two weeks, sputum smear and culture will be done. For children less than five years old with or without symptoms, the following procedures will be done:

An evaluation by a physician, including history and physical examination.Tuberculin skin testing (TST) Chest x-ray examination (antero-posterior and lateral position)

TB and to a greater extent, MDR-TB are very difficult to diagnose in children. Many times children are unable to produce or expectorate sputum on their own for examination. Other methods of collection such as sputum induction and gastric aspiration are necessary. See Annex B: Procedures for obtaining sputum specimens in children.

8.4 Evaluate children by physical exam, chest x-ray and TST

Evaluation of children who are contacts of MDR-TB patients aims to detect those who are infected and those who have active disease. A TST is first done to determine infection, not disease. If TST induration is 10 mm or greater, TST is positive. This child may need preventive therapy (when the appropriate regimen becomes available) if he has no symptoms and if the chest x-ray is normal. Otherwise, if he has three of five symptoms listed below, or he has an x-ray consistent with TB disease, he may need to be treated.

The five symptoms of TB in young children can be nonspecific, manifesting as any of the following:

Chronic cough or wheeze for 1. >2 weeksUnexplained fever for 2. >2 weeks Weight loss/failure to gain weight/loss of appetite 3. Failure to respond to 2 weeks appropriate antibiotic for lower respiratory infection4. Failure to regain previous state of health 2 weeks after a viral infection or exanthem, e.g., measles 5.

A child may also have extrapulmonary (EPTB) disease and may manifest with enlarged perihilar lymph nodes by chest x-ray examination.

Patients with three of the five clinical symptoms should be entered into the TB Symptomatics Masterlist. Once all of the diagnostic information has been obtained (physical exam, TST and chest x-ray results) the attending physician in concurrence with the Consilium will come up with a consensus decision as to diagnosis for young children.

All children approved by the Consilium for MDR-TB treatment will be assigned a Pre-enrollment No. recorded on Column 19 of the TB Symptomatics Masterlist. Once enrolled, the treatment start date will be written under the Pre-enrollment No. and as in adults, the patient will be entered in the Category IV Register and a Category IV Registration No. will be assigned. All patients entered in the Category IV Register should have been entered first into the TB Symptomatics Masterlist.

MODULE B


Summary of important points

Health workers should keep in mind that all previously treated patients, as well as non-converters of Category II, symptomatic contacts of MDR-TB, and HIV-positive patients with symptoms of TB, are considered MDR-TB suspects.

Any person in these high-risk groups for MDR-TB should be immediately referred to the appropriate Treatment Center using the MDR-TB Suspects Referral Form for screening and diagnosis.

At the Treatment Center, screen every MDR-TB suspect and fill out an MDR-TB Screening Form. This includes a physical examination by a physician and his preliminary diagnosis and plans for further diagnosis and/or treatment.

Be sure to write down the complete name and complete address of every MDR-TB suspect in the TB Symptomatics Masterlist, so that the TB suspect can be located once the results of the various tests show that the patient has TB and in case the TB suspect does not return.

Inform the MDR-TB suspect about the process and discuss the Paunawa or Terms of Understanding with him to continue the diagnosis.

Collect two sputum samples from every MDR-TB suspect for diagnosis. Use the Mycobacteriology Request Form and the Laboratory Receiving Form for Specimens to request for sputum examinations and to send the samples to the corresponding Culture Center. When the results of the smear, culture and DST are received from the laboratory, record the results in the TB Symptomatics Masterlist.

All specimens will be cultured at the Culture Center automatically regardless of the smear result. –If culture results are positive, the culture isolate will be sent for DST to a DST Center –If the culture results are negative, the treatment center Physician may refer the patient to the Consilium –for clinical assessment on whether or not sputum should be recollected or empiric treatment should be given.If the DST shows that the DR-TB suspect has confirmed MDR, the patient will be assigned a Pre-enrollment –No. by the Treatment Center. Likewise, a patient not confirmed to be MDR-TB by DST but highly suspected to be MDR and decided by the –Consilium to start treatment will be assigned a Pre-enrollment No. by the Treatment Center.

A patient who has confirmed drug resistance or MDR-TB or those decided by the Consilium to be started on treatment must be informed immediately. If he does not call or visit the Center, locate this patient as soon as possible. Assign a Pre-enrollment No.

Present MDR-TB cases confirmed by DST to the Consilium to be able to start treatment immediately to prevent the spread of the disease to others in the household and community and to improve the condition of the patient. Assign a Pre-enrollment No.

MODULE B


Present also to the Consilium cases highly suspected to be MDR-TB even without DST confirmation as not all patients can wait for DST results and there are some culture-negative patients who deserve Category IV treatment.

A patient who is started on treatment is entered into the Category IV Register and is assigned a Category IV Registration No.

Ask patients with confirmed drug resistance to bring to the DOTS facility all his contacts for interview of symptoms.

The following household contacts will be checked for TB and MDR-TBChildren less than five years regardless of symptoms –Those five years and above who have cough for more than 2 weeks –

MODULE B


Self-assessment questions

List 7 different high-risk groups for MDR-TB who should be referred for testing.1.

How many sputum samples are needed for examination for diagnosis? ___________2. When and where are these samples collected? ____________

The3. __________________________________ is an individual form for each MDR-TB suspect that holds a large amount of background information about the patient. The __________________________________ is a record of all TB suspects, including TB and MDR-TB suspects seen at the MDR-TB Treatment Center.

List the data recorded in the 4. TB Symptomatics Masterlist before sputum examination.(For TC staff only)

What are the three tests that are generally to be performed to diagnose MDR-TB? 5.

Under what circumstances can a patient be enrolled in treatment without these tests?

If an MDR-TB suspect’s DST results show resistance to H, R and E, the __________________ should be completed 6. to present the case to the _____________ in order to make a decision about treatment. (for TC staff only)

What should the health worker tell the patient, if an MDR-TB suspect’s DST results show resistance to H, R 7. and E ?

If an MDR-TB suspect’s culture result is negative but the patient is clinically deteriorating, what should you do?8.

If culture results show that an MDR-TB suspect is positive for TB and the DST results show resistance to H and R, 9. but the suspect does not return to the health facility, what should the health worker do?

Why is it important for the health worker to take this action?

An MDR-TB suspect who is found to have confirmed MDR-TB may have infected other people with MDR-TB. Who 10. should the confirmed MDR-TB patient ask to come to the health facility to be screened for MDR-TB?

Now compare your answers with those on the next page.

MODULE B


Answers to self-assessment questions

The following groups are considered high risk for MDR-TB and should be referred for testing at a Treatment Center1.

Retreatment casesFailure1. - Category I failure - Category II failure (chronic TB case)

Relapse of category I or II2.

Return after default3.

“Other” type of patients: 4. a) Non-DOTS patientsb) “Other –positive”c) “Other-negative”

Non-converters of category II 5.

New or retreatment cases

Symptomatic contacts of a drug-resistant case6.

HIV-positive patients who have pulmonary or extra-pulmonary TB symptoms or have chest x-ray 7. findings suggestive of TB

2. Two samples are needed. They are collected as follows: First sample (spot sputum specimen): on Day 1 at the Treatment Center.Second sample (early morning sputum specimen): on Day 2 at the MDR-TB suspect’s home, first thing after waking.

3. The MDR-TB Screening Form is an individual form for each MDR-TB suspect that holds a large amount of background information about the patient. The TB Symptomatics Masterlist is a record of all TB suspects, including TB and MDR-TB suspects seen at the MDR-TB Treatment Center.

4. Screening Code, date of screening, complete name and address, age, date of birth, and sex, no. of previous TB treatment, source of referral (site or doctor), site where last treated for TB, registration group, risk factors, symptoms, chest x-ray results (if available)

5. Smear, Culture and DST – Clinically deteriorating patients may need to be started on treatment urgently before the DST results are available or they will be at risk of dying. These patients should be identified by the physician, and their cases presented to the Consilium immediately.

6. If an MDR-TB suspect’s DST results show resistance to H, R and E, the Consiliumex should be completed to present the case to the Consilium in order to make a decision about treatment.

7. Inform the patient clearly and in a sensitive way. It is important to inform the MDR-TB suspect as soon as possible about drug resistance and the next steps that will be taken to start treatment.

8. The physician must present the case to the Consilium immediately. Either the culture needs to be repeated or empiric treatment needs to be started.

MODULE B


9. All efforts should be made to contact or locate the person. Call the patient or his contacts within the week. You may ask the referring DOTS facility to help locate the patient. This may require you to visit the patient’s address recorded in the TB Symptomatics Masterlist.

Patients with MDR-TB who are left untreated can infect many others with MDR-TB and delays in treatment can lead to worse treatment outcomes.

10. If possible, all household contacts of a confirmed MDR-TB patient should be interviewed at the Treatment center for symptoms of TB. All those with symptoms regardless of age, and all children less than five years even without symptoms should be evaluated by a physician by history and physical examination. For all ages with cough of more than two weeks, sputum smear and culture will be done.

End of Module BCongratulations on finishing this module!

MODULE B


References

Guidelines for the Programmatic Management of Drug-resistant Tuberculosis, 1. World Health Organization, Geneva, Switzerland, 2006. (WHO/HTM/TB/2006.361)

National Tuberculosis Control Program Revised Manual of Procedures. Manila, 2. Department of Health, 2005.

Balane, G. I., Pancho, J. S. R., Tupasi, T. E., et al. Tuberculosis among household contacts of infectious multi-drug 3. resistant TB patients. The International Journal of Tuberculosis and Lung Disease. Vol. 11, No. 11, (November) 2007, Supplement 1: S252

Quelapio, M. I. D., Auer, C., Tupasi, T. E., et al. Mainstreaming DOTS-Plus to DOTS: when is culture indicated in 4. DOTS? The International Journal of Tuberculosis and Lung Disease. Vol. 9, No. 11, (November) 2005, Supplement 1: S291

Auer, C., Lagahid, J. Y., Tupasi, T. E., et al. Smear positivity at two/three months of treatment: does it indicate 5. MDR-TB? The International Journal of Tuberculosis and Lung Disease. Vol. 9, No. 11, (November) 2005, Supplement 1: S245

Concepcion, A. A. L., Maramba, E. K., Tupasi, T. E., et. al. Internal consilium: a standardized approach for MDR-6. TB management. The International Journal of Tuberculosis and Lung Disease, Vol. 10, No. 11, (November) 2006, Supplement 1: S126

Concepcion, A. A. L., Quelapio, M. I. D., Tupasi, T. E., et. al. Case management discussions in an internal 7. consilium. The International Journal of Tuberculosis and Lung Disease, Vol. 10, No. 11, (November) 2006, Supplement 1: S125

Concepcion, A. A. L., Quelapio, M. I. D., Tupasi, T. E., et. al. Impact of Union Management Courses: Internal 8. Consilium – opportunity for learning, coordination and peer support. The International Journal of Tuberculosis and Lung Disease, Vol. 11, No. 11, (November) 2007, Supplement 1: S203

Orillaza – Chi, R. B., Concepcion, A. A. L., Tupasi, T. E., et. al. Internal consilium for programmatic MDR-TB 9. management: Makati, Philippines. The International Journal of Tuberculosis and Lung Disease. Vol. 11, No. 11, (November) 2007, Supplement 1: S263

Guidelines for National TB Programmes on the Management of TB in Children, 10. World Health Organization, Geneva, Switzerland, 2006. (WHO/HTM/TB/2006.371; WHO/FCH/CAH/2006.7)

Rieder, H. L. Contacts of TB patients in high-incidence countries. 11. The International Journal of Tuberculosis and Lung Disease. 2003, S333 – S336

van Rie, A., Beyers, N., Gie, R. P., et. al. Childhood TB in an urban population in South Africa: burden and risk 12. factors. Arch Dis Child. 1999, 80: 433 – 437

Miller, F. J. W., Seal, R. M. E., & Taylor, M. D. (1963).13. Tuberculosis in children. Boston: Little, Brown and Co.

Guidelines for the Implementation of the Programmatic Management of Drug-resistant Tuberculosis (PMDT). 14. Administrative Order No. 2008-0018. Department of Health, Manila, Philippines, May 26, 2008.

Annexes

A: Proper collection of specimen for the diagnosis of TB

B: Procedures for obtaining sputum specimens in children

C: Proper labeling, sealing and transportation of sputum

MODULE B


PROPER COLLECTIONOF

SPECIMENFOR THE DIAGNOSIS

OF

TB

What is TB ?

“TB” (tuberculosis) is a disease that is caused by a bacterium known as Mycobacterium tuberculosis.

It can affect any organ of the body, with the lungs being the most common causing “pulmonary TB” or TB of the lungs.

It is an infectious disease that can be acquired / transmitted by airborne spread of infectious droplets.

A person with TB of the lungs who is coughing is a source of infection.

What is AFB smear/DSSM?

Acid-fast bacilli (AFB) smear is a microscopic examination of the patient’s sputum for the presence of bacteria. It is a preliminary test and results are obtained within 24 hours after collection. If positive for AFB, it is a presumptive indication of an infection.

Annex A.

MODULE B


What is TB culture?

TB culture is a procedure that detects the presence of the bacteria causing TB by allowing it to grow in a system designed for its isolation. Since it grows very slowly compared to other disease-causing bacteria, it may take eight (8) weeks or two (2) months for its growth to be detected. If it is positive for growth, an additional four (4) weeks is required for its final identification.

To be able to do the test, clinical samples from the patient suspected to have TB are collected. Sputum (“phlegm”) is the most common and the specimen of choice.

Collection of sputum samples

Two (2) consecutive early morning sputum samples are preferred but “spot-collection” is acceptable since the finding of the organism is greater with two (2) sputum samples (Diagnostic specimens) than a single collection only.

Proper collection:

Rinse your mouth with sterile distilled water before entering the collection booth.1. Once inside the collection booth, take about three (3) deep breaths and cough forcefully simultaneously 2. upon exhale with the third deep breath.Hold the sputum cup close to the lips and expectorate into it gently after a productive cough.3. Collect about 5-10ml. (At least up to the first line of the container).4. Collect only sputum not saliva. Sputum is usually thick and mucoid and produced from deep in the lungs. 5. Saliva is thin, clear and is of little diagnostic value for tuberculosis.

MODULE B


When the required volume has been collected, close the container tightly to avoid spilling of contents.6. Allow one minute to stand.7. Leave the collection booth immediately and submit the specimen to the medical technologist in-charge.8.

When the physician requests for sputum induction:

When the patient is totally unable to expectorate sputum, induction with saline solution can be done. The attending physician will indicate in the request if there is a need for such procedure:

Rinse your mouth with sterile distilled water before entering the collection booth.1. Collect sputum inside the collection booth.2. Inhale the vapor coming out of the induction machine for about 10 minutes.3. Forcefully cough and collect about 5-10ml sample.4. The sample will appear like saliva but it is acceptable since it is an “induced sputum. 5.

(For the health-care worker)

Proper labeling of specimen:

Use the PMDT sticker to label the sputum cup.1. Indicate the following on the label:2. Patient’s nameName of the Treatment centerDate of collectionLab ID numberPaste the label on the body of the cup, not on the cover.3. Transport the sputum cup with the collected specimen in an ice box to maintain the viability of the 4. organisms – a styropore box with ice or refrigerants will do.

Keep the sputum cups in upright position during transport.

MODULE B


Annex B. Procedures for Obtaining Sputum Specimens in Children

(Ref: Guidance for National TB Programmes on the Management of TB in Children, WHO/HTM/TB/2006.371; WHO/FCH/CAH/2006.7)

Procedures for obtaining clinical samples for smear microscopy

This annex reviews the basic procedures for the more common methods of obtaining clinical samples from children for smear microscopy: expectoration, gastric aspiration and sputum induction.

A. Expectoration

Background

All sputum specimens produced by children should be sent for smear microscopy and, where available, mycobacterial culture. Children who can produce a sputum specimen may be infectious, so, as with adults, they should be asked to do this outside and not in enclosed spaces (such as toilets) unless there is a room especially equipped for this purpose.

Procedure (adapted from Laboratory services in tuberculosis control. Part II. Microscopy (1))

Give the child confidence by explaining to him or her (and any family members) the reason for sputum 1. collection.Instruct the child to rinse his or her mouth with water before producing the specimen. This will help to remove 2. food and any contaminating bacteria in the mouth.Instruct the child to take two deep breaths, holding the breath for a few seconds after each inhalation and then 3. exhaling slowly. Ask him or her to breathe in a third time and then forcefully blow the air out. Ask him or her to breathe in again and then cough. This should produce sputum from deep in the lungs. Ask the child to hold the sputum container close to the lips and to spit into it gently after a productive cough.If the amount of sputum is insufficient, encourage the patient to cough again until a satisfactory specimen is 4. obtained. Remember that many patients cannot produce sputum from deep in the respiratory tract in only a few minutes. Give the child sufficient time to produce an expectoration which he or she feels is produced by a deep cough.If there is no expectoration, consider the container used and dispose of it in the appropriate manner.5.

B. Gastric aspiration

Background

Children with TB may swallow mucus which contains M. tuberculosis. Gastric aspiration is a technique used to collect gastric contents to try to confirm the diagnosis of TB by microscopy and mycobacterial culture. Because of the distress caused to the child, and the generally low yield of smear-positivity on microscopy, this procedure should only be used where culture is available as well as microscopy. Microscopy can sometimes give false-positive results (especially in HIV-infected children who are at risk of having nontuberculous mycobacteria). Culture enables the determination of the susceptibility of the organism to anti-TB drugs.

Gastric aspirates are used for collection of samples for microscopy and mycobacterial cultures in young children when sputa cannot be spontaneously expectorated nor induced using hypertonic saline. It is most useful for young hospitalized children. However, the diagnostic yield (positive culture) of a set of three gastric aspirates is only about 25–50% of children with active TB, so a negative smear or culture never excludes TB in a child. Gastric aspirates are collected from young children suspected of having pulmonary TB. During sleep, the lung’s mucociliary system beats mucus up into the throat. The mucus is swallowed and remains in the stomach until the stomach empties. Therefore, the highest-yield specimens are obtained first thing in the morning.

MODULE B


Gastric aspiration on each of three consecutive mornings should be performed for each patient. This is the number that seems to maximize yield of smear-positivity. Of note, the first gastric aspirate has the highest yield. Performing the test properly usually requires two people (one doing the test and an assistant). Children not fasting for at least 4 hours (3 hours for infants) prior to the procedure and children with a low platelet count or bleeding tendency should not undergo the procedure.

The following equipment is needed:glovesnasogastric tube (usually 10 French or larger)5, 10, 20 or 30 cm3 syringe, with appropriate connector for the nasogastric tubelitmus paperspecimen containerpen (to label specimens)laboratory requisition formssterile water or normal saline (0.9% NaCl)sodium bicarbonate solution (8%) alcohol/chlorhexidine.

Procedure

The procedure can be carried out as an inpatient first thing in the morning when the child wakes up, at the child’s bedside or in a procedure room on the ward (if one is available), or as an outpatient (provided that the facility is properly equipped). The child should have fasted for at least 4 hours (infants for 3 hours) before the procedure.

Find an assistant to help.1. Prepare all equipment before starting the procedure.2. Position the child on his or her back or side. The assistant should help to hold the child.3. Measure the distance between the nose and stomach, to estimate distance that will be required to insert the 4. tube into the stomach.Attach a syringe to the nasogastric tube.5. Gently insert the nasogastric tube through the nose and advance it into the stomach. 6. Withdraw (aspirate) gastric contents (2–5 ml) using the syringe attached to the nasogastric tube.7. To check that the position of the tube is correct, test the gastric contents with litmus paper: blue litmus turns 8. red (in response to the acidic stomach contents). (This can also be checked by pushing some air (e.g. 3–5 ml) from the syringe into the stomach and listening with a stethoscope over the stomach.)If no fluid is aspirated, insert 5–10 ml sterile water or normal saline and attempt to aspirate again.9.

If still unsuccessful, attempt this again (even if the nasogastric tube is in an incorrect position and water or normal saline is inserted into the airways, the risk of adverse events is still very small).Do not repeat more than three times.

Withdraw the gastric contents (ideally at least 5–10 ml).10. Transfer gastric fluid from the syringe into a sterile container (sputum collection cup).11. Add an equal volume of sodium bicarbonate solution to the specimen (in order to neutralize the acidic gastric 12. contents and so prevent destruction of tubercle bacilli).

After the procedure

Wipe the specimen container with alcohol/chlorhexidine to prevent cross-infection and label the container.1. Fill out the laboratory requisition forms.2. Transport the specimen (in a cool box) to the laboratory for processing as soon as possible (within 4 hours).3. If it is likely to take more than 4 hours for the specimens to be transported, place them in the refrigerator (4–8 4. °C) and store until transported.Give the child his or her usual food.5.

Safety

Gastric aspiration is generally not an aerosol-generating procedure. As young children are also at low risk of transmitting infection, gastric aspiration can be considered a low risk procedure for TB transmission and can safely be performed at the child’s bedside or in a routine procedure room.

MODULE B


C. Sputum induction

Note that, unlike gastric aspiration, sputum induction is an aerosol-generating procedure. Where possible, therefore, this procedure should be performed in an isolation room that has adequate infection control precautions (negative pressure, ultraviolet light (turned on when room is not in use) and extractor fan).

Sputum induction is regarded as a low-risk procedure. Very few adverse events have been reported, and they include coughing spells, mild wheezing and nosebleeds. Recent studies have shown that this procedure can safely be performed even in young infants (2), though staff will need to have specialized training and equipment to perform this procedure in such patients.

General approach

Examine children before the procedure to ensure they are well enough to undergo the procedure. Children with the following characteristics should not undergo sputum induction.

Inadequate fasting: if a child has not been fasting for at least 3 hours, postpone the procedure until the appropriate time.Severe respiratory distress (including rapid breathing, wheezing, hypoxia).Intubated.Bleeding: low platelet count, bleeding tendency, severe nosebleeds (symptomatic or platelet count <50/ml blood).Reduced level of consciousness.History of significant asthma (diagnosed and treated by a clinician).

Procedure

Administer a bronchodilator (e.g. salbutamol) to reduce the risk of wheezing.1. Administer nebulized hypertonic saline (3% NaCl) for 15 minutes or until 5 cm2. 3 of solution have been fully administered.Give chest physiotherapy as necessary; this is useful to mobilize secretions.3. For older children now able to expectorate, follow procedures as described in section A above to collect 4. expectorated sputum.For children unable to expectorate (e.g. young children), carry out either: (i) suction of the nasal passages to 5. remove nasal secretions; or (ii) nasopharyngeal aspiration to collect a suitable specimen.

Any equipment that will be reused will need to be disinfected and sterilized before use for a subsequent patient.

MODULE B


Annex C. Proper Labeling, Sealing and Transportation of Specimen

Use wide-mouthed sterile 1. screw-capped container

Prepare label with Treatment 2. center, Lab ID no, Patient Name, Date

Attach label on the container, do 3. not put the label on the cover. Tighten cap4.

Secure in a plastic so that specimen 5. does not leak in case of spillage.

Place the sputum container in an 7. upright position.

Ready for transport to Culture 8. center.

Prepare an ice box or ice pack.6.

PMDT

Tx center: __________________Lab No.: ___________________Name: ____________________Date collected: _____________


Introduction

Detect Cases of MDR-TB

Treat MDR-TB Patients

Inform Patients about MDR-TB

Ensure Continuation of MDR-TBTreatment

Manage Drugs and Supplies for MDR-TB

Monitor MDR-TB Case Detection andTreatment

Field Exercise – Observe MDR-TB Management

Reference Booklet on the Management of MDR-TB

A

B

C

D

E

F

G

H

Department of HealthGovernment of Philippines

Tropical Disease Foundation, Inc.Makati, Metro Manila, Philippines

World Health OrganizationOffice of the Representative in the Philippines PRINTED IN THE PHILIPPINES

Documents

Tuberculosis Treatment MODULE-B