Comprehensive for in the Philippines - OSHC€¦ · Admittedly, in the Philippines, TB has grown to...

Comprehensiveand Unified Policy

for TB Control

in the Philippines(C.U.P. 2004)

Department of HealthGovernment of the Philippines

Philippine Coalition Against Tuberculosis

SEPTEMBER 2004

A publication of the Department of Health (DOH), Government of the Philippines,in cooperation with the Philippine Coalition Against Tuberculosis (PhilCAT).

Published September 2004 in Manila, Philippines.

C.U.P. 2004 participating agencies:

Department of Health

Department of the Interior and LocalGovernment

Department of Justice

Department of Agriculture

Department of Science and Technology

Department of Labor and Employment

Department of Education

Department of National Defense

Department of Social Welfare andDevelopment

Department of Agrarian Reform

Philippine Health Insurance Corporation

Government Service Insurance System

Social Security System

Employees Compensation Commission

National Economic and DevelopmentAuthority

Occupational Safety & Health Center

Overseas Workers Welfare Administration

National Commission on Indigenous Peoples

Philippine Coalition Against Tuberculosis

Philippine Medical Association

Employers Confederation of the Philippines

Trade Union Congress of the Philippines

Association of Health MaintenanceOrganizations of the Philippines, Inc.

Published with assistance from Philippine Tuberculosis Initiatives for the Private Sector(Philippine TIPS), a project supported by the U.S. Government through the Office ofPopulation, Health and Nutrition, U.S. Agency for International Development, under theterms of Contract No. 492-C-00-02-00031. The opinions expressed herein are those ofthe DOH and do not necessarily reflect the views of the U.S. Government and the U.S.Agency for International Development.

Editorial Staff

Board of Advisers: Dr. Myrna C. Cabotaje - NCPDC, DOHDr. Rodrigo Romulo - PhilCATDr. Jaime Lagahid - NCPDC, DOHDr. Charles Yu - PhilCAT

Editors: Dr. Marilyn N. Gorra - Philippine TIPSMr. Jose Ibarra Angeles - Philippine TIPSMs. Isabel Paula Patron - Philippine TIPS

Technical DOH: PhilCAT:Working Dr. Rosalind Vianzon Ms. Amelia SarmientoGroup: Dr. Angeles Hernandez Mr. Angelo Albert Concepcion

Dr. Vivian LofrancoDr. Anna Marie Celina GarfinDr. Ernesto Bontuyan, Jr.

Comprehensiveand Unified Policy

for TB Control

in the Philippines(C.U.P. 2004)

Comprehensive and Unified Policy for TB Control in the Philippines

Published by the Department of Health and the Philippine CoalitionAgainst Tuberculosis (PhilCAT)

All rights reserved. No part of this work which is copyright may bereproduced or used in any form or by any means - graphic, electronic,or mechanical, including photocopying, recording, taping or informationstorage and retrieval systems - without the written permission of thePublisher.

ISBN x-xxxxx-xxx-x

i

Foreword

The National Tuberculosis Control Program (NTP) of the Philippines, which put the Philippineson the verge of achieving world targets, is considered by the World Health Organization (WHO)and by other countries as one of the more progressive and admirable programs currently beingimplemented. Central and integral to the success of the program is the cooperative and concertedefforts of all the various stakeholders – “bayanihan”, taking into account the cultural diversityand idiosyncrasies of the Filipinos to make it adaptable and acceptable to the local setting.

The bayanihan spirit has been a trademark for all Filipinos despite unique regional differences.The spirit in itself has been embodied in the picture of people coming together, carrying the heftyweight of a neighbor’s house on their bare shoulders, helping their neighbor in his time of need.Moving a whole house on a shoulder of one is unthinkable. The more people pitching in,contributing to distributing the weight relieves those initially burdened with moving the housearound.

Now, imagine then all these people coming to help but eventually bumping with each other,moving without cohesion or order! Or, imagine all that work of carrying a whole house andrealizing that you’ve been going in the wrong direction all this time! Success is achieved withdirection, organization, and cooperation.

Admittedly, in the Philippines, TB has grown to epidemic proportions despite governmentinterventions for the past 50 years. The National TB Control Program was initially funded in1954 by virtue of the Tuberculosis Law. Two national TB prevalence surveys had been conductedsince which showed the following: in 1981, TB infected more than half, or 27 million, of a 50million population; while in 1987, it has infected 45 million of a 72 million population – 63%.Government alone was unable to remove the problem. And as time slowly moved on, the weightof the problem steadily increased.

Devolution of health services, including delivery of TB services, in 1991 did not help the causeany. It probably even contributed to the gravity of the problem. The weight of TB was thenslowly becoming unbearable. Other contributing factors that further worsened an already awfulsituation included social stigma for TB patients that made patients hide their ailments for fear ofsocietal alienation.

Department of HealthRepublic of the Philipines

ii

It was in this environment of social stigma for patients with TB, a lack of definite direction of theTB program due to devolution and strategic differences, and probably a pervasive indifferencein Government and private sector efforts for the past years, where the spirit of bayanihan wasfinally felt missing and was badly needed. It was here when the need for improving andstrengthening collaboration and partnership with the private and other sectors was sought after.

Executive Order No. 187 series 2003 institutionalized the Comprehensive and Unified Policy forTuberculosis. This is to act as the roadmap on how the bayanihan will move. It is a script toensure that the collaboration among stakeholders – current and future, will continue to be insynergy towards achieving the 70-85 goal. Presently, our CDR is 61% (2003) and cure rate is77%. We are 61-77!

Bayanihan also enshrines another concept that probably is where the word bayanihan got itsroots. Bayanihan. Bayani. Heroes. Who are the heroes here? The Government? Maybe.But it is also Government mandate. We are simply doing our job. The heroic thing is, our peoplein Government are dedicated and committed in their work. They have been working doublyhard. This is heroic. You, our stakeholders, our partners? Definitely heroes! Your generosityin terms of fiscal, organizational, manpower, advocacy, and technical support is one of the mostimportant reasons why we are making headway today. The Health workers. Definitely heroes!The leaps and bounds of the Program are due to the cumulative micro-efforts of each and everyhealth worker servicing each and every TB patient. Putting themselves at risk but nonethelessdoing their job well. And finally, the heroes of heroes are the patients and their families. Howcould you describe the bravery of a TB patient as he faces societal stigma, as he and his familyendure each and every day of undergoing DOTS treatment.

Mabuhay kayong lahat!

MANUEL M. DAYRIT, MD, MScSecretary of Health

v

Table of Contents

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

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

1. TB in the Philippines ......................................................................................................... 3

2. History of TB Control in the Philippines .......................................................................... 4

3. Development of the Comprehensive and Unified Policy for TB Control .......................... 8

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

1. Description ....................................................................................................................... 11

2. Vision, Mission, Goal of the NTP ......................................................................................12

3. Targets of the NTP .............................................................................................................12

4. NTP Strategies .................................................................................................................12

4-1. Political commitment. .......................................................................................13 4-2. Sputum microscopy. ..........................................................................................13 4-3. Standardized chemotherapy. ............................................................................13 4-4. Drug supply. ......................................................................................................13 4-5. Program management. ......................................................................................14 4-6. Data/information system. ..................................................................................14 4-7. Case detection. ..................................................................................................14

5. Roles of Collaborating Agencies ....................................................................................15

5-1. Department of Health (DOH) and Center for Health Development (CHD) ....15 5-2. Philippine Coalition Against Tuberculosis (PhilCAT) ...................................15 5-3. Department of Interior and Local Government (DILG)/LGU ..........................16 5-4. Other Government Agencies .............................................................................16 5-5. Private Sector and NGOs .................................................................................17 5-6. Government Financial Institutions ..................................................................17

6. Functions of NTP Health Workers ...................................................................................17

6-1. DOH TB Staff ......................................................................................................17 6-2. CHD NTP Core Team ..........................................................................................18 6-3. DOH Representatives ..........................................................................................18 6-4. Provincial and City NTP Core Team ..................................................................19 6-5 Health Officer / Medical Officer / Physician ........................................................ 19 6-6. Public Health Nurse/DOTS Nurse ......................................................................19

6-7. Midwives, Other Support Staff ............................................................................ 20 6-8. Medical Technologists or NTP Microscopists ......................................................20

6-9. Barangay Health Workers (BHWs) .....................................................................21 6-10. Hospital-based NTP Core Team .........................................................................21

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

1. Case Finding ..................................................................................................................23

1-1. Objective ............................................................................................................24 1-2. Policies ..............................................................................................................24 1-3. Procedures ........................................................................................................25

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2. Case Holding ...................................................................................................................28

2-1. Objective ............................................................................................................28 2-2. Treatment Regimen ............................................................................................28 2-3. Fixed Dose Combination Anti-TB drugs ...........................................................29 2-4. Policies ...............................................................................................................29 2-5. Tuberculosis during Pregnancy and Lactation ................................................30 2-6. Procedures .........................................................................................................30

2-7. Outcome of Treatment ........................................................................................32

3. Recording and Reporting ................................................................................................33

3-1. Objectives ...........................................................................................................33 3-2. Policies ...............................................................................................................33 3-3. NTP Recording Forms .......................................................................................34

4. Logistics Management .....................................................................................................36

4-1. Recording/reporting of NTP logistics: .............................................................37

5. Monitoring, Supervision and Evaluation .......................................................................38

5-1. Objectives ...........................................................................................................38 5-2. Policies ...............................................................................................................38 5-3. Procedures .........................................................................................................39

6. Quality Assurance for Sputum Smear Microscopy .........................................................41

6-1. Objective ............................................................................................................42 6-2. Policies ...............................................................................................................42

V. Guidelines for Implementation of the NTP by Private Physicians and Health Facilities .........43

1. Introduction .....................................................................................................................43

2. Policies and Guidelines ...................................................................................................44

2-1. Case Finding (Diagnosis) .................................................................................44 2-2. Case Holding (Treatment) .................................................................................45 2-3. Recording and Reporting ..................................................................................46

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

1. Introduction .....................................................................................................................47

2. Profile of Participating Agencies ....................................................................................48

2-1. Department of Education (DepEd) ...................................................................48 2-2. Department of Labor and Employment (DOLE) ...............................................48 2-3. Department of Interior and Local Government (DILG) ....................................49 2-4. Department of National Defense (DND) ...........................................................49 2-5. Department of Justice (DOJ) .............................................................................50 2-6. Department of Social Welfare and Development (DSWD) ................................50 2-7. Department of Agriculture (DA) ........................................................................51 2-8. Department of Agrarian Reform (DAR) ............................................................51 2-9. Department of Science and Technology (DOST) ..............................................51 2-10. National Economic and Development Authority (NEDA) ...............................51 2-11. National Commission on Indigenous Peoples (NCIP) ....................................52

3. Policies and Guidelines ...................................................................................................52

3-1. On Case Finding ................................................................................................52 3-2. On Case Holding ................................................................................................54 3-3. On Recording and Reporting ............................................................................55

3-4. On Training ........................................................................................................56 3-5. On Monitoring and Evaluation ........................................................................57 3-6. Health Education and Advocacy ......................................................................57

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VII. TB Benefits Policy of the ECC, SSS and GSIS ............................................................................59

1. Introduction .....................................................................................................................59

2. Policy, Benefits and Procedures for Claims ....................................................................60

2-1. Employees Compensation Program ..................................................................60 2-2. Social Security System .......................................................................................65

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

1. Introduction .....................................................................................................................73

2. Definitions ........................................................................................................................73

2-1. Tuberculosis (TB) ..............................................................................................73 2-2. Pulmonary TB ....................................................................................................73 2-3. Symptomatic pulmonary TB ..............................................................................74 2-4. Asymptomatic pulmonary TB .............................................................................74 2-5. Extrapulmonary TB ...........................................................................................75 2-6. Qualified TB Patient ..........................................................................................75 2-7. Qualified Provider .............................................................................................75 2-8. Defaulter ............................................................................................................75

3. Policy ...............................................................................................................................75

3-1. NTP Manual of Procedures ...............................................................................75 3-2. Cases covered ....................................................................................................76 3-3. Standards for accreditation ..............................................................................76 3-4. Payment scheme .................................................................................................76 3-5. Monitoring .........................................................................................................76

4. Outpatient Anti-TB DOTS Benefit Package ....................................................................76

4-1. Coverage ............................................................................................................76 4-2. Providers ............................................................................................................77 4-3. Certification and Accreditation ........................................................................77 4-4. Payment ..............................................................................................................78 4-5. Reimbursement Process .....................................................................................78 4-6. National TB Registry .........................................................................................79 4-7. Monitoring .........................................................................................................79

ANNEXES:

Annex 1: Flow of NTP Activities ....................................................................................................83Annex 2: Flowchart for the Diagnosis of Pulmonary TB ..............................................................84Annex 3: Flowchart for the Diagnosis of Smear-Negative Pulmonary TB ...................................85Annex 4: Approach to TB Asymptomatic .......................................................................................86Annex 5: Guide to Case Finding ....................................................................................................87Annex 6: Guide to Diagnosis and Initiation Of Treatment ............................................................88Annex 7: Treatment Regimens ........................................................................................................89Annex 8-A: Drug Dosage and Adjustment .........................................................................................90Annex 8-B: FDC Composition ...........................................................................................................90Annex 8-C: FDC Dosaging ................................................................................................................91Annex 9: FDC Drug Samples .........................................................................................................92Annex 10-A: Schedule of Sputum Smear Follow-Up Examination ....................................................93Annex 10-B: Schedule of Sputum Smear Follow-Up Examination ....................................................94Annex 11: Summary of Treatment Modification Based on Sputum Follow-Up ..............................95Annex 12: Guide in Managing SCC Drugs Side Effects .................................................................96Annex 13-A: Treatment Modifications Based on Sputum Results ......................................................97

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Annex 13-B: Treatment Modifications Based on Sputum Results ......................................................98Annex 13-C: Treatment Modifications Based on Sputum Results ......................................................99Annex 13-D: Treatment Modifications Based on Sputum Results ................................................... 100Annex 14-A: Treatment Modifications for New Smear-Positive Cases ............................................ 101Annex 14-B: Treatment Modification for Relapse and Failure Cases ............................................. 102Annex 15: Guide to Case Holding ................................................................................................ 103Annex 16: Guide to Ensure Treatment .......................................................................................... 104Annex 17: Responsible Persons for the Recording Forms ........................................................... 105Annex 18: Recording and Reporting Forms ................................................................................. 106Annex 18-A: NTP Client List/Target Client List (TCL) .................................................................... 107Annex 18-B: NTP Laboratory Request Form for Sputum Examination .......................................... 108Annex 18-C: NTP Laboratory Register ............................................................................................. 111Annex 18-D: NTP Treatment Card ..................................................................................................... 113Annex 18-E: NTP Identification Card .............................................................................................. 116Annex 18-F: TB Register .................................................................................................................... 118Annex 18-G1: PPMD Referral Form, NTP .......................................................................................... 120Annex 18-G2: PPMD Follow-up Form, NTP ...................................................................................... 121Annex 18-H: Quarterly Report on NTP Laboratory Activities ........................................................ 122Annex 18-I: Counting Sheet for Laboratory Activities Report ....................................................... 123Annex 18-J: Quarterly Report on New Cases and Relapses of Tuberculosis..................................................... 124Annex 18-K: Counting Sheet for Case Finding By Type / Drug Inventory ..................................... 125Annex 18-L: NTP Quarterly Report on the Treatment Outcome of Pulmonary TB Cases ............... 126Annex 18-M: Counting Sheet for Quarterly Report on the Treatment Outcome of Pulmonary TB Cases ................................................................................... 126Annex 19: Program Indicators ...................................................................................................... 127Annex 20-A: Impairment Classification for Respiratory Disease Injuries (Modified from American Thoracic Society Criteria) .................................. 129Annex 20-B: ATS Functional Classification (of Dyspnea) .............................................................. 130Annex 20-C: ATS Ratings of Respiratory Impairment by Spirometry ............................................. 130Annex 21: SSS Guide to Functional Assessment .......................................................................... 131Annex 22-A: TB Benefit Form (DOLE Guidelines) ........................................................................... 152Annex 22-B: TB Benefit Form (Back) ............................................................................................... 153Annex 23-A: TB Diagnostic Committee ............................................................................................ 154Annex 23-B: TB Diagnostic Committee (TBDC) Referral Form ...................................................... 158Annex 23-C: Quarterly TBDC Accomplishment Report Form ......................................................... 160Annex 23-D: TBDC Masterlist Form ................................................................................................ 161Annex 24: NTP Monitoring Checklist .......................................................................................... 162

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List of Acronyms Used

ACCP American College of Chest PhysiciansAFB Acid-Fast BacilliAFP Armed Forces of the PhilippinesAHMOPI Association of Health Maintenance Organizations of the Philippines, Inc.AO Administrative OrderARC Agrarian Reform CommunitiesAUSAID Australian Agency for International DevelopmentBHS Barangay Health StationsBHW Barangay Health WorkersBJMP Bureau of Jail Management and PenologyCAR Cordillera Administrative RegionCARP Comprehensive Agrarian Reform ProgramCDR Case Detection RateCHD Center for Health DevelopmentCHO City Health OfficeCIDA Canadian International Development AgencyCME Continuing Medical EducationCPE Continuing Professional EducationCRUSH-TB Collaboration in Rural and Urban Sites to Halt TuberculosisCUP Comprehensive and Unified Policy ( for TB Control in the Philippines)CXR Chest X-RayDA Department of AgricultureDAR Department of Agrarian ReformDepEd Department of EducationDILG Department of Interior and Local GovernmentDND Department of National DefenseDOH Department of HealthDOJ Department of JusticeDOLE Department of Labor and EmploymentDOST Department of Science and TechnologyDOT Directly Observed TreatmentDOTS Directly Observed Treatment Short CourseDSWD Department of Social Welfare and DevelopmentEC Employees CompensationECC Employees Compensation CommissionECOP Employers Confederation of the PhilippinesEO Executive OrderEPI Expanded Program for ImmunizationEPTB Extra Pulmonary TuberculosisEQA External Quality AssessmentFDC Fixed Dose CombinationFEFO First Expiring, First OutFHSIS Field Health Service Information SystemFIM Functional Independence MeasureGA Government ArsenalGDF Global Drug FacilityGFATM Global Fund on AIDS, TB and Malaria

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GFI Government Financial InstitutionGI Government InstitutionGOCC Government-Owned and -Controlled CorporationGSIS Government Service Insurance SystemHC Health CenterHIV Human Immunodeficiency VirusHMO Health Maintenance OrganizationHR Isoniazid, RifampicinHRZE Isoniazid, Rifampicin, Pyrazinamide, EthambutolHRZES Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, StreptomycinHSRA Health Sector Reform AgendaICD Italian Cooperation for DevelopmentID Identification CardIEC Information Education and CommunicationINH IsoniazidISHNP Integrated School Health and Nutrition ProgramIUATLD International Union Against Tuberculosis and Lung DiseaseJICA Japan International Cooperation AgencyLCE Local Chief ExecutiveLGU Local Government UnitLTI Latent TB InfectionMC Memorandum CircularMHO Municipal Health OfficeMOH Ministry of HealthMOP Manual of ProceduresMTPIP Medium Term Public Investment ProgramNCDPC National Center for Disease Prevention and ControlNCHF National Center for Health FacilityNCIP National Commission for Indigenous PeopleNDCP National Defense College of the PhilippinesNEDA National Economic and Development AuthorityNGO Non-Government OrganizationNHIP National Health Insurance ProgramNIT National Institute of TuberculosisNPC National Police CommissionNPS National TB Prevalence SurveyNSO National Statistics OfficeNTCP National Tuberculosis Center of the PhilippinesNTP National Tuberculosis Control ProgramNTRL National TB Reference LaboratoryOCD Office of Civil DefenseODA Official Development AssistanceOSG Office of the Surgeon GeneralOSHC Occupational Safety and Health centerOSND Office of the Secretary of National DefenseOWWA Overseas Workers and Welfare AdministrationPA Philippine ArmyPAF Philippine Air ForcePAS Para-amino salicylatePCCP Philippine College of Chest PhysiciansPCOM Philippine College of Occupational MedicinePCSO Philippine Charity Sweepstakes OfficePD Presidential Decree

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PHIC/PhilHealth Philippine Health Insurance CorporationPhilCAT Philippine Coalition Against TuberculosisPHO Provincial Health OfficePIDS Philippine Institute for Development StudiesPMA Philippine Medical AssociationPMS Project Monitoring StaffPN Philippine NavyPNP Philippine National PolicePNVSCA Philippine National Volunteer Service Coordinating AgencyPPD Permanent Partial DisabilityPPD Purified Protein DerivativePPM Public-Private MixPPMD Public-Private Mix DOTSPPP Public-Private PartnershipPSMID Philippine Society for Microbiology and Infectious DiseasesPTB Pulmonary TuberculosisPTD Permanent Total DisabilityPTSI Philippine Tuberculosis Society, Inc.PVAO Philippine Veterans Affairs OfficePZA PyrazinamideQAS Quality Assurance SystemQC Quality ControlQI Quality ImprovementQI Quezon InstituteRA Republic ActRAD Return After DefaultRDCS Regional Development Coordinating StaffRHU Rural Health UnitsS&T Science & TechnologySCC Short-Course ChemotherapySDF Single Drug FormulationSDS Social Development StaffSHNC School Health and Nutrition CenterSR Standard RegimenSRTC Statistical Research and Training CenterSSS Social Security SystemTB TuberculosisTBCS TB Control ServiceTBDC TB Diagnostic CommitteeTC Tariff CommissionTCL Target Client ListTIUS Trade, Industry and Utilities StaffTTD Temporary Total DisabilityTUCP Trade Union Congress of the PhilippinesUNICEF United Nations Children’s FundVMMC Veterans Memorial Medical CenterWB World BankWHO World Health Organization

1CHAPTER I : EXECUTIVE SUMMARY

T UBERCULOSIS has been a major cause of illness and death in the Philippines. Despite the significant advances that the National TB Control Program (NTP) of the Department of Health (DOH) has made in improving the quality and extent of its control

efforts, still, by and large, TB control efforts have been fragmented and uncoordinated.Historically, the private sector and even other departments of government have not beenintegrated into overall TB control activities.

Recognizing the need for a more unified and concerted effort, the DOH, with the help of thePhilippine Coalition Against Tuberculosis (PhilCAT), organized various stakeholders into aworking group to develop this Comprehensive and Unified Policy (C.U.P.) for TB Control inthe Philippines. The organizing committee began in January 2002 a series of stakeholders’meetings which culminated on World TB Day in March 2002 with the signing of a Memorandumof Agreement wherein stakeholders committed their support and involvement in the policydevelopment process.

Two main working groups were formed to flesh out operational details using the NTP as thecore policy. The first group developed guidelines for the implementation of the NTP ingovernment agencies other than the Department of Health (DOH). This group was headed bythe DOH and the following as its members: the Departments of Education (DepEd), NationalDefense (DND), Interior and Local Government (DILG), Justice (DOJ), Agriculture (DA),Agrarian Reform (DAR), Social Welfare and Development (DSWD), Science and Technology(DOST), the National Economic and Development Authority (NEDA) and the NationalCommission for Indigenous Peoples (NCIP).

The second group established policies that would formalize the involvement of the privatesector, particularly private physicians, in TB control. This group consisted of the representativesof the Social Security System (SSS), Government Service Insurance System (GSIS),Employees Compensation Commission (ECC), the Philippine Health Insurance Corporation(PHIC/PhilHealth), the Philippine Medical Association (PMA), Association of Health

I. Executive Summary

2 COMPREHENSIVE & UNIFIED POLICY FOR TUBERCULOSIS CONTROL IN THE PHILIPPINES (CUP 2004)

Maintenance Organizations of the Philippines, Inc. (AHMOPI), Employees Confederation ofthe Philippines (ECOP), Trade Union Congress of the Philippines (TUCP), and OccupationalSafety and Health Center (OSHC) and the Overseas Workers and Welfare Administration(OWWA) of the Department of Labor and Employment (DOLE). PhilCAT headed this secondgroup.

This resulting policy presents several significant achievements. First, the “Guidelines forImplementation by Government Agencies” formalizes and operationalizes the collaborationbetween the DOH and other departments of government with regard to the NTP. Second, the“Guidelines for Implementation by Private Physicians” provides clear directions on the clinicalmanagement of TB by private practitioners to comply with NTP policy. The “TB BenefitsPolicy of the SSS/GSIS/ECC” unifies the policies of these different agencies and aligns themwith the NTP. The pioneer “TB Outpatient Benefits Package” of the Philippine Health InsuranceCorporation (PHIC) is presented for the first time in this policy.

The organizing committee concludes with three recommendations: (1) that a one-year graceperiod for dissemination and training regarding the policy beginning August 2004 be implementedprior to full implementation in August 2005; (2) that the organizing committee and all stakeholdersbe reconvened after two full years of implementation to evaluate the policy and recommendany necessary revisions; and (3) to revise and update the existing CUP in accordance with thecurrent and future thrusts and objectives of the NTP.

3CHAPTER II : INTRODUCTION

1. TB in the Philippines

T UBERCULOSIS (TB) is a chronic infectious disease caused by Mycobacteriumtuberculosis, a bacteria transmitted through airborne droplets from the sputum ofpersons with pulmonary tuberculosis while coughing or sneezing. It is a curable disease.

However, if left untreated, it can lead to a disabling condition and even death. Also, partialtreatment of cases may cause multi-drug resistance that can lead to non-cure.

Tuberculosis is a major public health problem in the Philippines. In 1998 it ranked sixth amongthe 10 leading causes of death and also sixth among the ten leading causes of illnesses. Althoughthe mortality rate of tuberculosis has fallen in the past 20 years, from 69 deaths per 100,000population in 1975 to 38.3 deaths per 100,000 in 1997, still, at this rate, around 75 Filipinosdie every day from tuberculosis. Deaths were higher among males (66 %) and among theproductive age group 15-64 years old (60 %). The morbidity rate from tuberculosis shows amore variable trend although it has fallen from 314 cases per 100,000 population in 1975 to179.6 cases per 100,000 population in 1998. Globally, the Philippines is one of the 22 countriesidentified by the World Health Organization (WHO) as having a high burden of tuberculosisranking at 8th worldwide. It ranks third in terms of new smear-positive TB notification rate inthe WHO-Western Pacific Region (WHO report 2003).

The 1997 National Tuberculosis Prevalence Survey (NPS) gave a more accurate measure oftuberculosis in the country. The annual risk of tuberculosis infection (i.e. probability of a childgetting infected with TB within a year), which is generally accepted as a more sensitive indicator,showed a very slight decline in 15 years: from 2.5 % in the 1981-1983 survey to 2.3 % in1997.

II. Introduction


The same survey showed that TB cases are about three times more common among malesthan females and most of these cases are in the 30 to 59 years of age that represents theeconomically productive age group. Prevalence of sputum smear positive cases was at 3.1/1000 population compared to 6.6/1000 population during the initial survey.

2. History of TB Control in the Philippines

1910–1929. Tuberculosis control in the Philippines was started in 1910 by a privateorganization, the Philippine Islands Anti-Tuberculosis, now the Philippine Tuberculosis Society,Inc. (PTSI). The head office was located at Santol area in Quezon City where a TB hospitalwas established. The hospital was later named the Quezon Institute (QI) after President ManuelQuezon who suffered from tuberculosis. The thrust of the control program was case findingand in-patient services. At that time, no specific treatment regimen was available except bedrest isolation or hospitalization.

1930–1949. Cognizant of the increasing incidence of the disease in the country, and to giveadequate attention, the TB Commission was created in 1932 under the Philippine Health Serviceby virtue of Act No. 3743. Later in 1933, the powers and duties of the TB Commission weretransferred to the Bureau of Health. In 1934, Republic Act (RA) 4130, otherwise known asthe Sweepstakes Law, established the Philippine Charity Sweepstakes Office (PCSO) primarilyto raise funds to support the operations of the PTSI. This enabled the establishment of ChestClinics in selected areas of the country and provided accelerated in-patient activities.

In 1949, streptomycin injection was first used as part of the treatment for the illness. In 1950,the TB Commission emerged as the Division of Tuberculosis under the Secretary of Health.The Division established the TB Center at the DOH compound and collaborated with the TBWard of San Lazaro Hospital. Services included chest x-ray, sputum and bronchial washingexaminations and case holding. Treatment at this time consisted of streptomycin injection plusoral Para-amino salicylate (PAS) tablets.

1950–1969. The BCG vaccination program was introduced for the first time in the countrybetween 1951 and 1952 as a preventive measure against tuberculosis. This program wasassisted by the United Nations Children’s Fund (UNICEF).

In 1954, Congress passed the Tuberculosis Law (RA 1136) which became the basis for thecreation of both the Division of Tuberculosis under an appointed Director, and the NationalTuberculosis Center of the Philippines (NTCP) established at the DOH Compound. Thesame law also mandated the provision of funds to support the operations of the National TB

1981-1983 1997

1. Annual risk of TB infection 2.5% 2.3%

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

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

4. Radiographic findings suggestive of TB 4.2% 4.2%


Control Program.

In 1954, Triple therapy was initiated consisting of the following anti-tuberculosis drugs: isoniazid(INH), Para-amino salicylate (PAS), and streptomycin.

The year 1964 marked the conduct of the Minglanilla Prevalence Survey in Cebu Province,which showed the prevalence of smear positive cases at 4/1000. During this period, QI wasoperating at its largest bed capacity at 1,350 beds. In 1968, the National TB Programaccelerated and expanded the control activities at the rural health units (RHUs), which wereestablished under RA 1086.

1970–1989. The mid 1970’ s saw a vigorous nationwide expansion of the Program. TheRHUs were strengthened as the reponsibility for TB control efforts was increasingly passed onto them. The domiciliary care program was launched in 1973 by PTSI, which eventually led tothe reduction of beds at QI to 700. In that same year, the Philippine College of Chest Physicians(PCCP) was formed as an accredited non-governmental organization (NGO) society of thePhilippine Medical Association (PMA) with TB as one of its initial primary concerns.

The partnership between the DOH and PTSI grew intensely as they defined, complementedand supported each other’s roles in the field of TB control. The new thrust emphasized thefollowing: (1) importance of BCG vaccination, (2) case finding through sputum microscopyand, (3) case holding/ treatment through domiciliary means.

Eventually, the new TB Control Program was implemented in all RHUs, thus limiting admissionsat QI only to those seriously ill cases. In 1976, the partnership also fostered the establishmentof the National Institute of Tuberculosis (NIT) in cooperation with WHO and UNICEF.Focusing on human resource development, this Institute undertook operational researches andprovided training to local and foreign health workers on TB Control using the primary healthcare approach. The year was also highlighted by the issuance of a Presidential Decree (PD)requiring compulsory BCG vaccination. This became a prime component of the ExpandedProgram for Immunization or EPI. In 1978, the PTSI adopted the NTP policies and guidelinesin its catchment areas.

The first National TB Prevalence Survey (NPS) was carried out in 1981-1983 by the NITthrough the assistance of the WHO and UNICEF. Also during this period, the Lung Center ofthe Philippines (LCP) was established as a tertiary hospital and became a referral center forpulmonary cases including TB.

In 1986, a new treatment regimen was introduced in the National TB Control Program. This isthe Short-Course Chemotherapy (SCC) which highlighted Rifampicin, 2HRZ/4HR. Duringthis period, a fourth drug, streptomycin or ethambutol, was also being used for the IntensivePhase of the treatment regimen at the QI for confined or in-patients.

After the People Power revolution in 1986, the Ministry of Health (MOH) was renamedDepartment of Health (DOH) and reorganized by Executive Order (EO) 119. The TB ControlService (TBCS) was created under the Office for Public Health Services. A year later, theStrengthened National TB Control Program was launched. Under this program, the TBCSwas provided P200 million-budget for drugs, and the SCC was adopted nationwide. To ensuretreatment compliance, the various drugs were packaged in blister-packs. This ingenuity waslater adopted by our neighboring countries. A revised Manual of Procedures (MOP) of NTP


was formulated and disseminated in 1988. This MOP provided SCC treatment for sputum(+) and cavitary cases, and standard regimen, or SR, for the infiltrative cases.

PTSI adopted in 1987 the expanded community-oriented TB control program which establishedmicroscopy centers in many provinces, and, with the exception of the Cebu Pavilion, led to theconversion of TB Pavilions to Chest Clinics. In 1989, the Tri-Chest organization, led by thePCCP and participated in by various agencies involved in TB prevention and control includingthe DOH, released the first part of its consensus statements regarding the controversial issueson TB. The remaining parts came out in 1990 and 1993.

1990–Present. The NTP got a big boost in 1990 with the financial and technical supportfrom the Italian government and World Bank (WB) under the 5-year Philippine HealthDevelopment Project.

The Local Government Code of 1991 devolved the provision of health services from theDOH to the local government units (LGUs), giving the latter the opportunity to manage the TBprogram and deliver its activities to their constituents. The LGUs, thru the RHUs and theBarangay Health Stations (BHSs), served as the implementers, while DOH was confined topolicy development, regulation and provision of technical and financial assistance.

Under this new paradigm of health service delivery, the Japanese International DevelopmentAgency (JICA) provided the TB control project in Cebu with technical and financial support.The following were accomplished by this project: (1) the WHO-recommended policies andguidelines were tested; (2) laboratory facilities were improved with the establishment of theRegional TB Laboratory in Cebu City and the upgrading of microscopy centers; and (3) TBdata recording and collection was systematized.

A council which was created in1993 by the PCCP to act as its working arm for TB, successfullyreleased in 1994 a set of algorithms on the diagnosis and treatment of tuberculosis. An externalevaluation of the NTP done in 1993 noted that while case-finding activities improvedtremendously, the problem in case holding persisted. In 1995, the TBCS issued throughAdministrative Order (AO) No. 1-A s., 1995 the revised policies and guidelines on the diagnosisand management of TB which, in essence, adopted the WHO recommended policies. Thethrust adopted by NTP was to improve case holding activities.

The era of the 90’ s saw active interactions among the various sectors fighting TB. In 1994, thePhilippine Coalition Against Tuberculosis (PhilCAT) was organized under the initiative of thePCCP, DOH, Philippine Society for Microbiology and Infectious Disease (PSMID), PTSI,Cure TB, and the American College of Chest Physicians (ACCP)-Philippine Chapter. It wasentrusted with the main objective of serving as a coordinating body for the various governmentand non-government agencies, private groups, academe, and other concerned institutions intheir fight against tuberculosis. By end of 2004, the membership of PhilCAT had grown to 61.

Mid 1990’s. The mid-1990’s witnessed an intensified national campaign to increaseawareness about the disease, and to mobilize support for its prevention and control. In 1995,the TB Clinic of the University of Santo Tomas (UST) initiated the use of directly observedtreatment (DOT) in managing its out-patient TB cases. In 1996, DOH piloted the DirectlyObserved Treatment Short Course (DOTS) strategy in three areas. WHO provided financialand technical support to enhance the implementation of NTP, with DOTS as the primarystrategy. The Collaboration in Rural and Urban Sites to Halt Tuberculosis (CRUSH TB) Project


was pilot-tested in Iloilo City, Antique and Batangas. Results from this project paved the wayfor the expansion of the new NTP to other areas and enabled the nationwide implementation ofDOTS.

The NTP officially adopted DOTS as a strategy with the issuance of A.O. No. 24 s., 1996. Inthe same year, the President of the Philippines issued Proclamation No. 840: ProclaimingAugust 19 of every year as the National TB Day. Additionally, March 24 is observed asWorld TB Day. PhilCAT spearheads the observance of these special days aside from organizingannual conventions on TB.

DOTS was subsequently replicated in 30 areas in 1997-1998 and in all public sector healthfacilities of the country by year 2001. The DOTS expansion was facilitated by the activeparticipation of LGUs, the utilization of DOTS by BHWs as treatment partners, and by thesupport from various international agencies such as the WHO, WB, JICA, World Vision-Canadian International Development Agency (CIDA), Australian Aid (AUSAID) and Medicosdel Mundo.

The second national prevalence survey was conducted in 1997. In 1999, a new consensus onTB diagnosis, treatment and control was forged through a consultative process coordinated bythe PSMID, PCCP and DOH under the auspices of PhilCAT.

In September 1998, the National TB Control Program became one of the flagships of theDOH. Memorandum Circular (MC) No. 98-155 issued by the President, then the concurrentSecretary of the Department of Interior and Local Government (DILG), pronounced the TBControl Program as the highest priority health program of the LGUs and prescribed the DOTSstrategy.

In 1999, DOH embarked on the Health Sector Reform Agenda (HSRA) to improve deliveryof health services through the following:

· To secure funding for priority public health programs;

· To promote the development of local health systems and to ensure its effective performance;

· To provide fiscal autonomy to government hospitals;

· To strengthen the capacities of health regulatory agencies; and,

· To expand the coverage of the National Health Insurance Program (NHIP).

Under the HSRA, the National TB Control Program was one of the top priority among thepublic health programs. The organizational reform attained through re-engineering, led to theclustering of various public health programs, merging of offices, and significant reduction inmanpower. The regional office was renamed Center for Health Development (CHD).

Initiatives to strengthen the NTP included the delivery of quality DOTS services through expansionof DOTS implementation in all government health facilities. The National TB ReferenceLaboratory (NTRL) was established in 2001 to improve quality assurance of microscopythrough the established network of microscopy facilities. It is also spearheading the nationaldrug resistance survey (DRS). The current NTP has been in strong collaboration with othergovernment agencies and key private agencies to unify TB policies adaptable for implementationin both sectors.


It has likewise gained access to international resources, such as the Global Drug Facility (GDF)and Global Fund on AIDS, TB and Malaria (GFATM), to augment supply of anti-TB drugs.In 2003, the NTP started the shift from single dose formulation (SDF) to Fixed Dose Combination(FDC) drugs. This simplifies treatment, prevents development of drug resistance, and ensuresregular and complete drug delivery to DOTS centers. The NTP is also upgrading the variousCHD TB Reference Centers to improve its microscopy component.

3. Development of the Comprehensive and Unified Policy for TBControl

Despite efforts by the Philippine Coalition Against Tuberculosis (PhilCAT), a standard nationalpolicy to guide all stakeholders was still perceived to be lacking. Most of the large governmentinstitutions that have their own health programs and those in the private health sector failed tofollow the NTP. To address this concern, PhilCAT obtained the approval from the DOH toinitiate the development of the Comprehensive and Unified Policy (CUP) for TuberculosisControl in the Philippines. Through a Department Order signed by the Secretary of Health, theDOH created a Committee to develop the policy. The committee was headed by the pastchairman of PhilCAT and included the head of the National Center for Disease Prevention andControl and representatives from the government and the private sectors.

Two subcommittees were formed. The Government Institution (GI) Subcommittee was taskedto identify government agencies that were conducting, or in need of, TB control activities, andto assist them in adopting the NTP in their respective institutions. The second subcommittee,the Public-Private Partnership (PPP) Subcommittee, was tasked to identify the stakeholdersinvolved in the care of TB patients, to consult private physicians, and to work with them inestablishing mechanisms for the sustained participation of private physicians in the NTP.

Headed by the DOH, the subcommittee working with government agencies includedrepresentatives from the Departments of Education (DepED), Interior and Local Government(DILG), Justice (DOJ), National Defense (DND), Agriculture (DA), Agrarian Reform (DAR),Labor and Employment (DOLE), Social Welfare and Development (DSWD), Science andTechnology (DOST), the National Economic and Development Authority (NEDA), and theNational Commission on Indigenous Peoples (NCIP).

The PPP subcommittee was headed by the PhilCAT and included representatives from thePhilippine Medical Association (PMA), Association of Health Maintenance Organizations ofthe Philippines, Inc. (AHMOPI), the Social Security System (SSS), Government ServiceInsurance System (GSIS), the Philippine Health Insurance Corporation (PHIC/PhilHealth),Employers Confederation of the Philippines (ECOP), Occupational Safety and Health Center(OSHC), Employees Compensation Commission (ECC), Trade Union Congress of thePhilippines (TUCP), the Philippine College of Occupational Medicine (PCOM) and theOverseas Worker and Welfare Administration (OWWA).

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1. Description

THE National Tuberculosis Program (NTP) is a nationwide controlprogram spearheaded by the Department of Health (DOH) and implemented by thelocal government units (LGUs) in accordance with the devolution of health services as

mandated under the Local Government Code of 1991. Other government agencies, government-owned and -controlled corporations (GOCCs), government financial institutions (GFIs), non-governmental organizations (NGOs) and the private sector are also involved in theimplementation of the program.

The DOH retains the function of policy formulation and technical provision through monitoringand supervision of program plans, policies and guidelines. Through its regional offices nowcalled the Center for Health Development (CHD), the DOH also ensures the provision oftechnical assistance, monitoring of the program, provision of anti-TB drugs and other TBsupplies. The Philippine Coalition Against Tuberculosis (PhilCAT) supports TB control activitiesto strengthen private sector participation in TB control by providing the venue for interactionbetween the public and the private sectors.

Program implementation is based on the DOTS strategy recommended by the World HealthOrganization (WHO) and the International Union Against Tuberculosis and Lung Disease(IUATLD), which depends on the implementation of a five-point package:

· Sustained political commitment to increase human and financial resources;

· Quality-assured TB sputum microscopy for case detection among personspresenting with or found to have symptoms of TB;

· Standardized short-course chemotherapy (SCC) to all cases of TB underproper case-management conditions including direct observation oftreatment or supervised treatment;

III. The National Tuberculosis Program(NTP)

CHAPTER III : THE NATIONAL TUBERCULOSIS PROGRAM


· Uninterrupted supply of quality-assured anti-TB drugs with reliableprocurement and distribution systems, and,

· Standardized recording and reporting system enabling assessment of everypatient and of the overall program performance.

Tuberculosis case finding services using sputum microscopy as the primary diagnostic tool andcase holding using directly observed treatment (DOT) are now available in DOTS centerslocated nationwide. A DOTS Center is a health facility providing the five key elements ofDOTS Strategy. It can be a public, a private or a public-private mix. TB-DOTS services areprovided in this Center or can be outsourced from a nearby health facility (i.e., sputum microscopyor directly observed treatment) through a referral system. The flow chart describing the NTPActivities is shown in Annex 1: Flow of NTP Activities (page 83).

2. Vision, Mission, Goal of the NTP

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

Mission Ensure that TB-DOTS services are available, accessible and affordable to TB clients through the health services provided by the government agencies, non-governmental organizations and the private sector involved in TB control.

Goal Reduction of the prevalence of sputum smear positive TB cases and TB mortality to half in 2015.

3. Targets of the NTP

a) Cure at least 85% or more of new sputum smear-positive TB cases detected in all DOTS Centers.

b) Detect at least 70% of the total estimated new sputum smear-positive TB cases.

c) Achieve 100% DOTS coverage in both public and the private sectors.

4. NTP Strategies

To achieve its objectives, the NTP shall focus on the following strategies and activities:

4-1. Political commitment.Advocate for political commitment at all levels of the health system including the privatesector by:

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a) Mobilizing additional human, financial, and technical resources for TB control;

b) Fostering local, national and international partnerships;

c) Fostering communication among all health care providers, patients and the publicat large;

d) Providing opportunities for strengthening the NTP in relation to its clients; and,

e) Involving key leaders in the overall implementation of the NTP.

4-2. Sputum microscopy.Provide access to quality-assured TB sputum microscopy by:

a) Providing functional microscopes

b) Conducting training programs for microscopists on basic sputum microscopy;

c) Maintaining and sustaining a Quality Assurance System (QAS) on TB microscopy;and,

d) Organizing a network of all TB laboratories.

4-3. Standardized chemotherapy under DOT.

Provide standardized chemotherapy to all confirmed cases of TB under DirectlyObserved Treatment (DOT)/ supervised treatment by:

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

b) Monitoring treatment response and progress and assessing treatment outcomesthrough quality-assured sputum microscopy;

c) Establishing a mechanism or a referral system for DOT;

d) Ensuring client health education at initiation and continuation of treatment; and,

e) Providing enablers and recognition of DOTS centers and cured TB patients.

4-4. Drug supply.

Ensure uninterrupted supply of quality-assured anti-TB drugs through reliableprocurement and distribution system by:

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

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

c) Supplementing the drugs from other sources (e.g., LGUs, Private Sectors); and,

d) Developing a public-private referral system to enable clients to access NTP drugs.

4-5. Program management.

Improve the program management capability of health workers by:



a) Provide technical assistance to all DOTS centers, including the TB DiagnosticCommittee;

b) Providing training on service provision and TB management; and,

c) Monitoring and supervising DOTS implementation at all levels.

4-6. Data/information system.

Improve the data/information system by:

a) Implementing the standardized DOTS recording and reporting system;

b) Developing an effective and efficient information processing system;

c) Analyzing the NTP data in relation to their DOTS implementation; and,

d) Strengthening public-private referral system.

4-7. Case detection.

Improve TB case detection by :

a) Establishing an effective public-private mix DOTS (PPMD) strategy;

b) Developing and disseminating effective IEC materials for community; and,

c) Improving and expanding hospital-based NTP.

5. Roles of Collaborating Agencies

5-1. DOH-NCDPC and CHD

a) Formulate plans, policies and standards for the NTP.

b) Provide technical assistance, including training to DOTS implementing levels.

c) Advocate for political commitment and alerts the community for mobilization.

d) Oversee program implementation in coordination with the other TB partners (e.g.,LGUs, other government organizations, private agencies, international partners).

e) Provide the necessary logistics such as: anti-TB drugs, laboratory supplies, NTPrecording forms (registers, treatment cards), and educational/IEC materials(prototypes).

f) Monitor regularly, supervise and evaluate the NTP activities, including QualityAssurance System (QAS) to ensure quality implementation, incorporating client-centered values in DOTS service delivery.

g) Collate and analyze data from the regularly submitted quarterly reports and providefeedback of findings and recommendations to all concerned agencies.

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h) Forge partnerships with other government agencies, NGOs, private entities andinternational communities for a more comprehensive NTP implementation.

i) Develop PPM-DOTS in communities in partnership with PhilCAT and other privategroups.

j) Coordinate with CHD’s and Sentrong Sigla in the conduct of DOTS CenterCertification.

k) Initiate resource-generation campaigns for TB-DOTS and facilitate access tointernational donor assistance.

5-2. PhilCAT

a) Participate in the development of policies for NTP and strategies for private sectorparticipation.

b) Develop local coalitions in support of Public-Private Mix DOTS (PPM-DOTS)in communities.

c) Provide technical assistance in the development of PPM-DOTS in communities,including training of private sector on DOTS.

d) Provide a venue for interaction between the Department of Health, non-governmentagencies, other private organizations and the private sector.

e) Conduct advocacy activities in support of the NTP.

f) Participate in the certification of private DOTS facilities and DOTS referringphysicians.

g) Participate in the monitoring/evaluation of the NTP activities.

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

a) DILG

· Implement measures to undertake TB control among members of the PNP,inmates in jails nationwide and its employer, staff and clientele.

· Issue corresponding orders, memo circulars mandating LGUs to implementNTP-DOTS in all health centers and hospitals under their jurisdiction.

· Participate in NTP activities and events at central and regional levels.

b) LGUs

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

· Advocate for political commitments and community alertness.

· Create the TB Core Team composed of the Physician, Nurse and Medtech/Microscopist that will oversee and implement the NTP as planned, in theirlocality.

· Provide funds for monitoring, supervision, evaluation, training, NTP drugs andsupplies.



· Prepare, submit and analyze all required NTP quarterly reports.

· Implement a standardized Quality Assurance System for microscopy work.

· Build partnerships with other government agencies, NGOs, private entitiesand international communities for a more comprehensive NTP implementation.

· Invest in continuing quality improvement and certification of LGU health facilitiesas DOTS centers.

· Promote and maintain a client-centered DOTS service delivery system.

· Provide enablers to local community health volunteers and TB DiagnosticCommittee (TBDC) activities to sustain private sector interest and participationin the NTP.

5-4. Other Government Agencies

a) Implement program components of NTP at all levels in accordance with the corepolicies for case finding, case holding, recording and reporting.

b) Provide effective health education services to their respective clients.

c) Integrate facts and information about TB and the DOTS strategy into theirrespective policies and health programs.

d) Spearhead TB research in consultation with the DOH.

e) Ensure capacity development of staff about NTP in coordination with the DOHand other key TB agencies.

f) Ensure the timely release of funds for efficient NTP implementation within theiragency.

g) Initiate the forging of partnerships with the DOH, NGOs, private entities andinternational communities for a more comprehensive NTP implementation.

h) Refer problematic cases to experts as the case may be.

5-5. Private Sector and NGOs

a) Ensure the implementation of the DOTS strategy in their respective areas, inaccordance with the Comprehensive and Unified Policy (CUP) on TB.

b) Advocate the implementation of the DOTS strategy in accordance with the CUPon TB.

c) Establish access to the appropriate DOTS center in the public sector, throughstandardized referral mechanism.

d) Allow access to relevant NTP records for data analysis.

e) Participate in NTP activities involving partnerships for community mobilization andadvocacy.

f) Coordinate with, and consult the public sector regarding NTP activities as necessary.

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5-6. Government Financial Institutions (GFIs) andGovernment-owned and -Controlled Corporations (GOCCs)

a) Provide reimbursable TB benefit packages for income loss and cost of diagnosisand treatment.

b) Ensure the timeliness and regularity of payments to the accredited DOTS facilities(PhilHealth).

c) Conduct regular DOTS accreditation services for availment of the TB benefitDOTS package (PhilHealth).

6. Functions of NTP Health Workers

6-1. DOH TB Staff

a) Participate in the program planning of activities, policy-making and budgetpreparation at national level.

b) Promote advocacy activities for political commitment at the national and localgovernments.

c) Coordinate the overall NTP implementation among participating stakeholders.

d) Ensure the regular availability of all NTP supplies.

e) Provide regular technical assistance including training, monitoring, supervision, andevaluation to all TB partners in the government and private sectors.

f) Collate and analyze pertinent data for future planning and policy development.

g) Coordinate with Sentrong Sigla all activities related to the certification of DOTScenters.

6-2. CHD NTP Core Team

(NTP Medical, Nurse and Supervising Medtech Coordinators)

a) Participate in program planning of activities and budget preparation at CHD level.

b) Promote advocacy activities for political commitment at LGUs and for communityawareness.

c) Coordinate the overall NTP implementation within the region in consultation withthe DOH (Central Office), including private sector activities (i.e., PPM-DOTS).

d) Ensure the regular availability of all NTP supplies.

e) Provide regular technical assistance to other government agencies, NGO’s andthe private sector, including training and planning.

f) Monitor, supervise, evaluate the implementation of NTP; and recommendappropriate remedial measures as necessary.

g) Collate and analyze pertinent data for future planning.



h) Submit on time the required NTP reports to the DOH (Central) level forconsolidation and analysis.

i) Participate in Sentrong Sigla as certifiers/assessors of DOTS centers.

j) Update periodically the directory of DOTS facilities for use as reference innetworking and other purposes.

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

a) Liaise with the CHD and the Provincial/City NTP Core Teams on issues pertainingto the implementation of NTP in their respective assigned areas.

b) Participate in the monitoring of NTP implementation in coordination with theProvincial/City NTP Core Team and concerned health center staff.

c) Assist in the conduct of other key NTP activities, like training, in coordination withthe CHD/Provincial/City NTP Core Teams.

d) Monitor regularly the quality of DOTS implementation in the DOTS units.

e) Collect quarterly NTP data from the DOTS Centers (public, private, PPM-DOTS)and analyze these together with the health center staff.

f) Submit and analyze data to the respective Provincial/City Core Team and discussresults as necessary.

g) Submit and analyze the provincial/city data to the CHD Core Team and discussresults as necessary.

h) Provide technical assistance to facilitate certification of LGU health facilities asDOTS centers.

6-4. Provincial and City NTP Core Team

(Medical, Nurse, Medtech Coordinators)

a) Coordinate all NTP activities within the Province/City, including that of the privatesector.

b) Implement advocacy activities to strengthen political commitments and intensifycommunity awareness.

c) Ensure regular availability of all NTP supplies at the health centers.

d) Monitor, supervise and evaluate the implementation of NTP and ensure theimplementation of corrective or remedial measures as necessary.

e) Implement Quality Assurance System (QAS) on laboratory to maintain the qualitymicroscopy service of the microscopy centers. Act as the validator/controller forQAS (for the medtech coordinator).

f) Ensure the timely preparation and submission of NTP reports to CHD.

g) Provide technical assistance to facilitate certification of LGU health facilities asDOTS centers.

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6-5. Health Officer/Medical Officer/Physician (Public andPrivate)

a) Supervise respective health workers when applicable to ensure the proper andquality implementation of NTP core policies such as:

· Case finding

· Case holding

· Analysis and timely submission of NTP reports

· Referral of TB cases to other health services as needed

· Management of NTP logistics

b) Participate in Continuing Medical Education (CME) related to TB-DOTS.

c) Provide continuous health education to all TB patients, their families and to thecommunity to strengthen their participation in TB control activities.

d) Coordinate with the local chief executives (LCEs), other government agencies,locally existing TB organizations, private sector and NGOs in the area to ensuresupport for the TB program.

6-6. Public Health Nurse/DOTS Nurse (Public and Private)a) Assign, educate and supervise the designated treatment partner of a TB patient.

b) Supervise support staff like Midwives, to ensure the proper implementation of theDOTS strategy/NTP core policies.

c) Maintain and update the NTP Case Register.

d) Facilitate the timely requisition and distribution of drugs and supplies.

e) Provide continuous health education to all TB patients, their families and to thecommunity to strengthen their participation in the TB control.

f) Prepare the NTP reports and analyze date together with the Physician and otherstaff to improve implementation and to plan for future activities.

g) Facilitate the conduct of meetings and consultations among center staff.

h) Act as Treatment Partner.

6-7. Midwives, Other Support Staff (i.e., Field TreatmentSupervisor / Field Treatment Coordinator)On Case Finding:

· Identify TB symptomatics and collect sputum specimens for microscopy.

· Maintain and update the relevant NTP forms (Treatment Cards, ID Cards,NTP Client List).



b) On Case Holding:

· Supervise the daily treatment of TB patients or the patient’s treatment partnerto ensure proper implementation of DOTS strategy/NTP core policies.

· Provide continuous health education to all patients placed under treatment,their family members and to the community, to strengthen their participation inthe TB control program.

· Consult/Update weekly the Physician or Nurse while the patient is on his/hercourse of treatment.

· Collect sputum specimen for follow-up examinations as scheduled.

· Report and retrieve defaulters within two (2) days.

· Refer patients with adverse drug reactions to the Physician for evaluation andmanagement.

· Refer all diagnosed TB cases to the medical officer or nurse for clinical evaluationand initiation of appropriate treatment.

6-8. Medical Technologists or NTP Microscopists

a) Do sputum smear examination for diagnosis and follow-up.

b) Submit the results of the sputum smear examination to the requesting staff.

c) Maintain and update the NTP Laboratory Register.

d) Prepare and analyze the laboratory reports in coordination with the other Staff toimprove/maintain quality of microscopy services and to plan for future laboratoryactivities.

e) Submit quarterly slides to the designated sputum smear validator for quality assurancecheck.

6-9. Barangay Health Workers (BHWs)

BHWs are key-role players in the NTP especially since they contribute voluntaryhealth services to the community.

a) Refer TB symptomatics to health staff for sputum collection.

b) Act as Treatment Partner and undertake the Directly Observed Treatment (DOT).

c) Keep and update the NTP ID Cards of assigned TB patients.

d) Report and retrieve defaulters within two (2) days from time of default.

e) Consult/Update the Midwife weekly while the patient is on his/her course oftreatment.

f) Attend the patient’ s weekly consultation with the Midwife.

g) Refer any patient’ s complaint or any untoward reaction while on treatment to thehealth staff.

h) Provide health education to the patient and family members. Participate in thehealth education of the community.

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6-10. Hospital-based NTP Core Team (Physician, Nurse,Medical Technologist)

a) Coordinate NTP activities within the hospital with the assistance of any of thefollowing: TB Staff, DOH-NCHF Staff, CHD NTP Core Team, Provincial/CityNTP Core Team.

b) Implement the hospital-based NTP-DOTS policies.

c) Advocate to hospital management the provision of resources to maintain and sustainimplementation of hospital-based NTP DOTS.

d) Supervise the NTP implementation of other hospital staff/workers to ensure theproper implementation of the DOTS strategy/NTP core policies such as:· Identification and initial examination of TB symptomatics through sputum smear

examination.

· Undertaking of the directly observed treatment (DOT) for TB cases applicablewithin the hospital setting.

· Availability and regularity of NTP drugs and supplies for those cases to betreated within the hospital.

· Referral of patients to health centers/other health facilities, for diagnosis, initiation/continuation of treatment or for supervised treatment using NTP Referral /Transfer Form which should be properly filled-up by the hospital-based NTPcoordinator.

· Prepare and submit NTP reports to the PHO/CHO levels.

e) Conduct regular health education and advocacy activities to TB patients.


21CHAPTER IV : NTP CORE POLICIES AND PROCEDURES

1. Case Finding

CASE finding is an essential component of tuberculosis control. Its purpose is toidentify the sources of infection in the community, that is, to find the personsdischarging the tubercle bacilli and initiate proper treatment to render them non-infectious

initially and ultimately cure them.

The basic step in TB control is the identification and diagnosis of TB cases among individualswith suspected signs and symptoms of TB. This is referred to as case finding. Fundamental tocase finding is the detection of infectious cases through direct sputum smear examination assmear positive TB cases are about 20 times more infectious than the smear negative patients.One undiagnosed and untreated smear positive patient can infect 10 persons in one year andhalf of them will die within two years.

Sputum examination is the principal diagnostic method adopted by the NTP because of thefollowing reasons: (1) it provides a definitive diagnosis of active TB; (2) procedure is simple;(3) economical and (4) a microscopy center could be organized even in remote areas. Studiesthrough the years have established its high specificity (97.5 percent to 99.8 percent). Sputumexamination is done prior to initiation of treatment, regardless of whether they have readilyavailable x-ray results or whether symptomatics are suspected of having extrapulmonarytuberculosis. TB cannot be diagnosed with certainty by x-ray. Other diseases often look verysimilar. It is a major error to diagnose TB based on x-ray alone and fail to examine the sputum.

The result of the sputum examination is crucial not only for diagnosis but is also one of thebases, together with history of treatment in categorizing TB patients for treatment. It is alsoused to monitor the patient’ s response to treatment.

Sputum quality is very important. Three sputum specimens should be collected under thesupervision of a health worker. This should come from the lungs and patients should be givenproper instructions on sputum induction. Increasing yield were observed in terms of findings

IV. NTP Core Policies and Procedures


with the second and third smears.

Microscopy centers are available in Rural Health Units (RHUs) and other non-governmentalagencies nationwide. Sputum microscopy services are offered for free as part of the NTPservices in all RHUs even to patients of private practitioners.

There are two types of case finding, passive and active case finding. Passive case findingrefers to finding TB cases from among the TB symptomatics who present themselves at thehealth facility while active case finding is a purposive effort by a health worker to find TBcases from among the TB symptomatics in the community who do not seek consultationsrelated to TB in the health facility.

N.B. Refer to Annex 2: Flowchart for the Diagnosis of Pulmonary TB to Annex 4: Approachto TB Asymptomatic, pages 84 to 86.

1-1. Objective

The general objective of case finding is the early identification and diagnosis of TBcases.

1-2. Policies

a) Direct sputum smear examination (primary diagnostic tool in NTP case finding):

1) Sputum smear examination is the preferred method for the diagnosis of TB.All symptomatics identified shall be made to undergo smear examination fordiagnosis prior to initiation of treatment, regardless of whether they haveavailable X-ray results or whether they are suspected of having extra-pulmonaryTB. The only contraindication for sputum collection is massive hemoptysis.

It is only after a pulmonary TB symptomatic has undergone a sputumexamination for diagnosis with three sputum specimens and subsequently yieldednegative results that he shall be made to undergo other diagnostic tests such asX-ray, culture and others, if necessary.

2) All health facilities shall be encouraged to establish and maintain a microscopyunit in their areas of jurisdiction. In areas where this is not possible, referral toan NTP microscopy service provider shall be encouraged.

3) Quality of sputum microscopy shall be maintained and sustained through theregular quality assurance system at the provincial/city level.

b) Chest X-ray:

1) Chest x-ray examination shall be the secondary diagnostic tool for TB casefinding. However, no diagnosis of pulmonary tuberculosis shall be made basedof the result of X-ray examinations alone.

2) Smear negative cases whose chest x-ray examination result is suspected to bepositive for TB lesions shall be referred to the TB Diagnostic Committee that


shall decide on the appropriate action to take. Comparative reading of previousand current X-rays is highly recommended for confirming diagnosis of TB insuch situations.

3) In each province/city, the creation of a TB Diagnostic Committee (TBDC) isrecommended. The TBDC shall provide diagnostic services to TB smearnegative cases whose chest x-ray results are consistent with active TB.

c) Skin test for TB infection (PPD skin tests) should NOT be used as a basis for thediagnosis of TB in adults.

d) Passive case finding shall be implemented in all health facilities.

e) Sputum smear examination (smearing, fixing and staining of sputum specimens,reading the smear) shall be performed only by adequately-trained medicaltechnologist or NTP microscopist.

1-3. Procedures

a) Identification of TB Symptomatics is the responsibility of the staff of all healthfacilities involved in NTP.

1) The responsible person shall identify TB symptomatics among patients consultingat the health facility. These are persons having continuous cough, for two ormore weeks, and those with or without the following signs and symptoms:

· Fever

· Sputum expectoration

· Significant weight loss

· Hemoptysis or recurrent blood-streaked sputum

· Chest and/or back pains not referable to any musculo-skeletal disorders

· Other symptoms such as sweat with chills, fatigue, body malaise, shortnessof breath

2) The responsible person shall educate and encourage identified TB symptomaticsfor sputum examination.

3) The responsible person shall encourage household members of identified TBcases, who are also TB Symptomatics, to undergo sputum examination.

4) The responsible person shall utilize the NTP client list for providing service toTB clients.

b) Collection and transport of sputum specimens to the Microscopy Center are theresponsibilities of the health staff.

1) The responsible health staff member who is in-charge of the initial consultationshall explain the purpose of the sputum examination to the TB symptomaticsbefore collecting his/her sputum. It is crucial for the TB symptomatics tounderstand the importance of submitting three sputum specimens during theirconsultation.

2) The responsible health staff shall label the body of the sputum cup with thepatient’scomplete name and the serial number, seal each sputum specimen


container, pack it securely and transport it to a microscopy unit or laboratoryas soon as possible or not later than four days from collection. Otherwise, thespecimens should be properly stored in cool, dark and safe place. No specimenshall remain unexamined over the weekend. The specimen should be senttogether with the NTP Laboratory Request Form for Sputum Examinationto the microscopy center.

3) The responsible health staff shall demonstrate how to produce good sputum.It is essential to obtain quality sputum specimen for proper diagnosis of TB.Good sputum could be obtained by asking the patient to do the followingsteps:

· Rinse his/her mouth;

· Breathe deeply two times, holding the breath for few seconds after eachinhalation and then exhaling slowly; and

· After inhaling deeply on the third time, at the height of inspiration, coughstrongly and spit the sputum in the container.

4) The responsible health staff shall supervise the patient from behind during theprocedure and observe contamination precautions. It is recommended to collectsputum specimen outside where aerosols containing TB bacilli are diluted andsterilized by direct sunlight in order to prevent health workers from inhalationhazards.

5) The responsible health staff shall collect three specimens within two daysaccording to these procedures:

· First specimen, which is also referred to as first spot specimen, is collectedat the time of consultation, or as soon as the TB symptomatics is identified.

· Second specimen, or early morning specimen, is the very first sputumproduced in the morning and is collected by the patient according to theinstructions given by the midwife.

· Third specimen, which is also referred to as second spot specimen, iscollected at the time TB symptomatics comes back to health facility tosubmit the second specimen.

· If the responsible health worker fails to collect 3 sputum specimens within2 days, he or she is given 1 week to complete the 3 specimen collections.

c) Smearing, fixing, staining and reading of sputum specimens are the responsibilitiesof the trained medical technologist or TB microscopist at the microscopy centers.They will do the following:

1) Record the information in the NTP Laboratory Register.

2) Smear, fix, stain and read the slides.

3) Interpret smear examination result or the individual readings of the threespecimens and the final written laboratory diagnosis in the sputum microscopyresults portion of the returned Laboratory Request Form for SputumExamination to determine the diagnostic classification such as:


· A smear positive result occurs when at least two sputum smear results arepositive. When the sputum collection unit receives this positive result, theresponsible health staff shall inform the patient of the results of the sputumexamination and refer him/her to the doctor for assessment and initiationof treatment.

· A doubtful result occurs if there is only one positive sputum smear resultout of the three sputum specimens examined. The responsible health staffshall inform the patient of the results of the sputum examination and explainthe collection of another three sputum specimen within one week.

If at least one specimen from the second set of specimens turns out to bepositive, the laboratory diagnosis is positive. Refer the patient to the doctorfor assessment and initiation of treatment.

If all three specimens from the second set of specimens turn out to be negative,the laboratory diagnosis is negative. Refer the patient to the doctor for furtherassessment. The physician may request for chest X-ray to confirm diagnosis.If the chest X-ray is suggestive of TB, the physician may recommend treatmentand classification of patient as smear positive. Further observation isrecommended when chest X-ray results are not suggestive of active TB (seeAnnex 2: Flowchart for the Diagnosis of Pulmonary TB, page 84).

A smear negative result shows that all three sputum smear results are negative.The responsible health staff shall inform the TB symptomatic about the resultsof the sputum examination and refer the patient to the doctor for furtherassessment. The doctor may treat the patient symptomatically/empirically orwith antibiotics and or other medications as necessary. If the symptompersists, collect another set of three sputum specimens for repeat smearexaminations.

4) Record the examination results in the NTP Laboratory Register and in thelower portion of the NTP Laboratory Request Form for Sputum Examination.

5) Inform the responsible person of the results of the examination as soon asthese are available by sending back the accomplished Laboratory RequestForm for Sputum examination.

6) Refer to the TB Diagnostic Committee smear negative CXR positive TBsuspects.

The physician shall decide on the referral of smear negative patients to the TBDiagnostic Committee for further diagnosis and management (see Annex 23-A: TB Diagnostic Committee, page 154).

N.B. Refer to Annex 5: Guide to Case Finding (page 87), and Annex 6: Guide toDiagnosis and Initiation Of Treatment (page 88).

2. Case Holding

The procedure that ensures that patients complete treatment is referred to as case holding.Chemotherapy is the only way to stop the transmission of TB. It is senseless to search forcases if they could not be treated properly after they have been found. It would only encouragefalse hopes on the part of the patient. While effective anti-TB drugs are available in the country,


there are still many TB patients who are not cured. This is due to irregular or completestoppage of TB drug intake by many patients. The long duration of treatment, six months onthe average, makes it most likely for patients to be remiss in drug intake. Treatment complianceis necessary to cure TB and avoid drug resistance.

Poor treatment compliance may lead to the following outcomes: chronic infectious illness,death or drug resistance. Second line anti-TB drugs for drug resistant cases are very expensiveand most are not available in the country. The best way to prevent the occurrence of drugresistance is through regular intake of drugs for the prescribed duration. The only proven wayof ensuring adherence is through direct observation of treatment (DOT), one of the elements ofDOTS strategy which is the WHO recommended policy package for TB control. DOT worksby assigning a responsible person to observe or watch the patient take the correct medicationsdaily during the whole course of treatment.

All TB cases, especially the smear positive TB cases, should undergo DOT for the wholeduration of treatment. Anyone of the following could serve as a treatment partner:

· Staff of a health facility.

· Member of the community such as the BHW, local government official, religious group, orformer (cured) TB patient.

· Member of the patient’s family

Supervised treatment can be done in any accessible and convenient place (e.g. health facility,treatment partner’s house, patient’s place of work, patient’s house) as long as the treatment partnercan effectively ensure the patient’s daily intake of the prescribed drugs and monitor his/her responseto the treatment regimen. For those without a mechanism to do supervised treatment, patientsmay be referred to the nearest DOTS Center.

2-1. ObjectiveThe general objective of chemotherapy is to treat TB cases effectively and completely,especially pulmonary sputum smear positive cases.

2-2. Treatment RegimenThe treatment regimen to be followed according to the type of TB case is shown inAnnex 7: Treatment Regimens (page 89). The different first-line anti-TB drugs underthe NTP are the following:

H – ISONIAZID (75 mg) E – ETHAMBUTOL (275 mg),

R – RIFAMPICIN (150mg), S – STREPTOMYCIN (750 mg).

Z – PYRAZINAMIDE (400 mg),

2-3. Fixed Dose Combination Anti-TB drugs

The fixed dose combination (FDC) drugs are anti-TB drug preparations, wherebytwo or more first line anti-TB drugs are combined in one tablet. There are 2, 3, or 4


FDCs. The NTP utilizes the 4 and 2 drug combinations which are called FDC-A andFDC-B respectively.

The World Health Organization (WHO) and the International Union Against Tuberculosisand Lung Disease (IUATLD) have endorsed the use of FDCs by the NTP since 1994.The 4-drug and 2-drug combinations are included in the WHO Model List of Essentialdrugs since 1999.

For the composition of FDCs, categories of treatment regimens and drug dosagesusing FDCs, see Annex 7: Treatment Regimens (page 89) and Annex 8-A: DrugDosage and Adjustment (page 90), Annex 8-B: FDC Composition (page 90), andAnnex 8-C: FDC Dosaging (page 91).

2-4. Policies

a) Treatment of all TB cases shall be primarily based on reliable diagnostic technique,namely, sputum smear examination aside from clinical findings. Chest x-rayexamination is used only as a secondary diagnostic tool.

Treatment of all sputum smear negative CXR positive cases shall be based uponthe decision of the TB Diagnostic Committee.

b) Domiciliary treatment shall be the preferred mode of care.

c) Patients recommended for hospitalization are those with the following conditions:

1) Massive hemoptysis

2) Pleural effusion obliterating more than half (1/2) of a lung field

3) Miliary TB

4) TB meningitis

5) TB pneumonia

6) Those requiring surgical intervention

7) Those with complications

d) No patient shall initiate treatment unless the patient and health workers have agreedupon a case holding mechanism for treatment compliance.

e) For all patients to be started on treatment, provision of the complete drugrequirement should be ensured. The complete drug allocation of each patient shallbe secured before treatment is started.

f) The DOH shall ensure the provision of FDC drugs to the health centers, includingPPMD units and other health facilities giving priority to sputum smear positivecases. However, the health facilities (including LGUs) shall be encouraged to procureSDF preparations (at least 5% of the expected cases), intended for those whomay develop adverse reactions to FDCs.

g) Quality of FDCs shall be ensured by ordering them from a source with trackrecord of producing FDCs according to World Health Organization (WHO)prescribed standards.

h) The dosage for FDCs shall be in accordance to the WHO recommended dosages.


i) Chemoprophylaxis is not recommended by the NTP.

2-5. Tuberculosis during Pregnancy and Lactation

Pregnant women and lactating or breastfeeding mothers suffering from tuberculosisshould also be treated with anti-TB drugs. It is even more harmful if they are leftuntreated, as the fetus may also be affected with tuberculosis. Based on the NationalTB Consensus in 1999, the following are the recommendations to manage tuberculosisamong these special conditions:

a) For sputum AFB smear (+) and/or TB culture (+)cases, with or without CXRevidence of active PTB, the regimen should consist of rifampicin, isoniazid andethambutol for at least nine months or at least six months beyond culture conversionwhichever is longer. However, if the organisms are proven sensitive to bothrifampicin and isoniazid, ethambutol could be instituted during the initial three monthsonly.

The use of pyrazinamide must be avoided except in situations where resistance torifampicin or isoniazid is highly suspected and resistance to pyrazinamide is unlikely.If ever it is to be utilized, it must be given after the first trimester of pregnancy.

Streptomycin should not be used as previously stated in the National TB ConsensusPart I because it is potentially hazardous not only during the first trimester butthroughout gestation. It induces ototoxicity.

b) Women who are taking rifampicin, and who need contraceptive precautions, areadvised not to use oral contraceptive steroids. They should consider using analternative method of contraception because of observed drug interaction betweenoral contraceptives and rifampicin.

2-6. Procedures (for the health worker)

a) Registration and Initiation of Treatment:

1) Inform the patient that he/she has TB and motivate the patient to undergotreatment.

2) Refer the patient to a physician for pre-treatment evaluation and initiation oftreatment.

3) Refer to the NTP Treatment Card and prepare two NTP ID Cards (one is forthe treatment partner and the other is for the patient). Start the treatmentusing any of the three treatment regimens best suited to the patient’s diseaseclassification, type and previous history of treatment.

4) Register the patient in the NTP TB Register. Refer the patient to the mostaccessible health facility where he/she can have his/her treatment supervised.

b) Ensuring Treatment Compliance through DOT:

Directly Observed Treatment (DOT). DOT is a strategy developed to ensuretreatment compliance by providing constant and motivational supervision to TBpatients. DOT works by having a responsible person, referred to as treatment


partner, who watches the TB patient take the medicines everyday during the wholecourse of treatment. The following are the responsibilities of the treatment partner:

2) Administer the patient’s drugs at their agreed treatment facility everyday, andensure that the patient swallows his/her drugs daily. After intake of the drugs,the treatment partner shall check and sign the patient’s NTP ID Card and his/her own copy of the NTP ID Card.

3) Ensure that on Saturdays, Sundays and holidays when the health facility isclosed, treatment is done at home but shall be supervised by a family member.The family member shall sign the patient’s NTP ID Card.

4) Regularly motivate the TB patient to continue treatment by emphasizing keymessages, such as:

· TB can be cured but requires regular drug intake for the prescribedduration.

· The patient should report any adverse reaction of the drugs to his/hertreatment partner immediately.

· The patient should undergo follow-up sputum examination on specifieddates (see Annexes 10-A and 10-B: Schedule of Sputum Smear Follow-up Examination, pages 93-94).

5) Regularly confer (preferably weekly) with the treatment partner and the patientfor treatment evaluation at the health facility.

6) Exert effort together with all health workers to immediately retrieve a patientwho fails to report on the day the patient is expected.

7) Monitor the response to treatment and ensure that follow-up sputumexamination is done on the specified date (see Annexes 10-A and 10-B:Schedule of Sputum Smear Follow-up Examination, pages 93-94). Sputumsmear examination for follow-up requires only one specimen collection,preferably collected in the early morning.

c) Management of Chronic TB Cases, and HIV Co-Infected Cases:

1) Chronic case: a patient who is still sputum smear positive at the end of a re-treatment regimen. He/she should be referred to a higher facility for properevaluation and management.

2) For those HIV co-infected cases, work up the patient for TB and start TBtreatment accordingly in accordance with the agency’s protocol.

d) Management of Adverse Reactions to Drugs:

Closely monitor the occurrence of minor and major reactions to drugs, especiallyduring the intensive phase (see Annex 12: Guide in Managing SCC Drugs SideEffects in page 96). There are major side effects that necessitate withdrawal of theresponsible drug. In this case, FDC must be changed to SDF.

e) Monitoring Patient Response to Treatment:

Monitor the sputum smear status of all patients under treatment, including initiallysputum smear negative patients, according to the standard schedule (see Annexes10-A, 10-B, and 10-C: Schedule of Sputum Smear Follow-Up Examination, pages


93-94) and modify treatment based on the sputum follow-up examination results(see Annexes 13-A to 13-D: Treatment Regimen Modifications for Category Iand II, with and without modifications, pages 97 to 100).

f) Management of Defaulter and Referred Cases:

1) Perform routine smear examination to defaulted/lost cases that come back forchemotherapy. Refer patients to a physician for re-evaluation and re-treatment.

2) New smear positive patients who interrupted treatment should be managedaccording to the recommended schedule (see Annex 14-A: TreatmentModifications for New Smear Positive Cases Who Interrupted Treatment,page 101).

3) Relapse and failure cases that have interrupted treatment shall be managedaccording to recommended schedule on Annex 14-B: Treatment Modificationfor Relapse and Failure Cases Who Interrupted Treatment (page 102).

4) Treatment shall be continued for patients who were properly referred ortransferred using the NTP referral slip. However, sputum smear examinationfor diagnosis should be performed for patients without an accompanyingproperly accomplished NTP referral/transfer form.

2-7. Outcome of Treatment

A patient who undergoes treatment may achieve any of the following treatment outcomes:

a) Cure: A sputum smear positive patient who has completed treatment and is sputumsmear negative in the last month of treatment and on at least one previous occasion.

(Note: We have changed the definition of “cure” as above, however, we have notchanged the policy to collect follow-up sputum specimen with three occasions forsmear positive case: (a) at the end of the Intensive Phase, (b) at the middle of theMaintenance Phase, and (c) at the end of the Maintenance Phase.)

b) Treatment Completed: A patient who has completed treatment but does not meetthe criteria to be classified as cure or failure. This group includes:

· An initially sputum smear-positive patient who has completed treatment withoutfollow-up sputum examinations during the treatment, or with only one negativesputum examination during the treatment, or without sputum examination inthe last month of treatment;

· A sputum smear-negative patient who has completed treatment.

c) Died: A patient who died for any reason during the course of treatment.

d) Treatment Failure:

· A patient who is sputum smear-positive at five months or later during thetreatment.

· An initially sputum smear-negative patient before starting treatment andbecomes smear-positive during the treatment.

(Note: This case will be re-registered as “other” with a new TB case number.)


e) Defaulter: A patient whose treatment was interrupted for two consecutive monthsor more and remains unreached for continuing treatment.

f) Transfer Out: A patient who has been transferred to another facility with properlyaccomplished NTP referral/transfer form for continuation of current treatment.

3. Recording and Reporting

Records that contain accurate, complete and up-to-date information on patient diagnosis,treatment, follow-up examinations and treatment outcome must be made available to ensurethe provision of appropriate and effective patient’s care. Such records are also important inthe implementation of a successful TB control program.

Records enable health workers to ensure that each TB symptomatic found is examined andmore importantly, that TB patients get cured. Reports are important sources of information onpatient coverage and care; program efficiency and effectiveness; and availability of drugs andother NTP supplies at health service units. In this manual, recording and reporting is designedto generate and provide the minimum set of information required for program planning atdifferent levels.

3-1. Objectives

a) To provide program implementers with information to serve as basis for planningon how best to assist their clients and patients.

b) To provide program supervisors with information to serve as basis for planning onhow best to assist TB control program implementers.

3-2. Policies

a) Recording and reporting for NTP shall be implemented at all health facilities, includingPPMD units, government and private hospitals.

b) Reporting TB cases should be made mandatory to private physicians and privateclinics after agreement with parties concerned shall have been made.

c) Recording and reporting shall include all cases of TB, classified according tointernationally accepted case definitions.

d) Recording and reporting for NTP shall use, as much as possible, the Field HealthService Information System (FHSIS) network for routine reporting and feedback.

e) Records and reports should allow for the calculation of the main indicators forprogram evaluation (see Annex 19: Program Indicators, page 127).

f) All four quarterly reports should be sent to DOH through the CHD. PPMD reportsshould be disaggregated to reflect additions to total cases reported in the province/city/municipality where PPMDs are installed.

g) The DOH shall make an Annual consolidation, analysis, interpretation anddissemination of information to all partners, stakeholders and general public asnecessary.


3-3. NTP Recording Forms

Note: Refer to Annex 17: Responsible Persons for the Recording Forms (page 105).

a) NTP Client List (Target Client List/TCL):

The NTP client list is a record of all clients in the health facility who were assessedfor TB. This includes clients who are for sputum microscopy or for referral to theTBDC. At the RHU, this corresponds to the Target Client List or the TCL. This isa tool to confirm the three sputum collection at the sputum collection unit (RHU /BHS / Private Health Facility). This list is maintained by the health staff in thefacility to keep track of accomplished sputum-smear examinations for threespecimens and confirmed diagnosis of TB Symptomatics (see Annex 18-A: NTPClient List/Target Client List (TCL), page 107). The Target Client List of FHSISwould be used in facilities where this is already available such as the RHUs andBHSs.

b) NTP Laboratory Request Form for Sputum Examination:

The nurse and the midwife shall accomplish this form when they request for sputum-smear examination (diagnosis or follow-up). Laboratory Request Form shall beattached to all specimen sent to the microscopy center. The NTP medicaltechnologist and microscopist shall fill-in the form with the result of the sputumsmear examinations which has to be returned to the referring unit. (see Annex 18-B: NTP Laboratory Request Form for Sputum Examination, page 108).

c) NTP Laboratory Register:

This register contains all information on sputum-smear examinations done by theNTP trained medical technologist and microscopist on TB Symptomatics (fordiagnosis) as well as TB patients undergoing treatment (for follow-up). It can beused to check microscopy data recorded on the NTP TB Register. The NTPmedical technologist and microscopist shall maintain the forms at the microscopycenter or referral laboratory unit (see Annex 18-C: NTP Laboratory Register,page 111).

d) NTP Treatment Card:

All TB patients admitted to the treatment program should have an NTP treatmentcard. This card should be filled-in completely with all the necessary informationabout the TB patient and the treatment he/she is receiving including daily drugintake as well as the results of sputum follow-up examinations. This NTP TreatmentCard is maintained and updated by the health staff /PPMD treatment coordinator/responsible person at the health facility where the patient is receiving treatment.This is kept at the facility (see Annex 18-D: NTP Treatment Card, page 113).

e) NTP Identification Card:

Once a patient is diagnosed as a TB case, he will be issued an NTP IdentificationCard. The NTP ID Card is a handy source of information on the patient’s diagnosis,treatment regimen, schedule of daily drug intake and follow-up results of sputumsmear examinations. The treatment partner initials the NTP ID Card each time he/she sees the patient take his/her drugs. In addition, the treatment partner keepsand maintains the same NTP ID Card for him/her to monitor the patient’s compliance


to treatment. Both the TB patient and the treatment partner has a copy of the NTPID Card. The treatment partner signs on both copies of the NTP ID cards (seeAnnex 18-E: NTP Identification Card, page 116).

f) NTP TB Register:

The nurse assigned at the health facility/PPMD unit maintains this register. It givesinformation on the type and classification of TB cases, treatment regimen, monitoringof sputum follow-up and treatment outcomes of all patients in a catchment area.This is one of the main sources of data in the calculation of the treatment outcomeand other main epidemiological indicators in NTP (see Annex 18-F: TB Register,page 118).

g) NTP Referral / Transfer Form:

The nurse or the physician/PPMD coordinator fills-in this form in duplicate (onecopy is for the receiving unit and the other is for the referring unit). This form isneeded when a patient is referred to another health unit for continuation of treatment.The receiving unit completes the lower portion of the form upon receipt from thepatient, and sends it back to the referring unit. It is recommended that the referringunit ask for the treatment outcome of the patient from the receiving unit afterwards,in order to confirm the final outcome (see Annex 18-G2: PPMD Follow-up Form,page 121).

h) NTP Reporting Forms:

1) Quarterly Report on Laboratory Activities:

This report is made by the NTP trained medical technologist or microscopistat the microscopy center. It provides information on the total number of TBsymptomatics examined, the total number of TB symptomatics collected threesputum specimens and the total number smear-positive cases discovered everyquarter (see Annex 18-H: Quarterly Report on NTP Laboratory Activities,page 122).

This Quarterly Report is sent from the health facility/PPMD unit to the Provincialor City NTP Coordinators quarterly. Then the Provincial or City NTPCoordinators consolidate and analyze the data and send them to the CHDNTP Coordinators. The CHD NTP Coordinators consolidate and analyze thedata prior to submission to DOH.

2) Quarterly Report on New TB Cases and Relapses:

This report is prepared by the nurse/PPMD coordinator and noted by thephysician of the health facility and submitted to the Provincial or City NTPCoordinators quarterly. It is the summary report on the NTP case finding onnew smear-positive cases (age and gender specific), relapses, new smear-negative cases and extra-pulmonary cases.

The information is used by the provincial, city, CHD, central NTP Coordinatorsto evaluate case finding of new smear-positive, relapse cases, new smear-negative cases and extra-pulmonary cases (see Annex 18-J: Quarterly Reporton New Cases and Relapses of Tuberculosis, page 124).


Treatment failure cases are not included in this report as they have alreadybeen reported when they were then new cases. Transfer-in patients are countedin the health facility where they came from.

This data is consolidated and analyzed prior to submission by the respectivelevels.

3) Quarterly Report on Treatment Outcome:

This report shows information on the outcome of treatment of a group ofpatients who were treated 13-15 months earlier. It serves as the basis forevaluating the effectiveness of chemotherapy through the cure rate (see Annex18-L: NTP Quarterly Report on the Treatment Outcome of Pulmonary TBCases, page 126).

This report is made by the nurse and noted by the physician of the healthfacility and submitted to the provincial/city NTP coordinators every quarter.The provincial and city NTP coordinators consolidate and analyze the dataprior to submission to the CHD NTP coordinators.

4. Logistics Management

Health facilities/PPMD units should have an adequate supply of anti-TB drugs and other NTPsupplies in order to provide quality NTP services. The latter includes sputum cups, glassslides, syringes, reagents and recording and reporting forms. The buffer stock must also bemaintained at all levels to avoid stock-outs. The adequate reserve level are prescribed asfollows:

DOH / CHD level Six months

Provincial / City level Three month

Rural Health Unit / City Health Unit / PPMD unit Three months

Anti-TB drugs and laboratory supplies shall be procured by the DOH. These will be sentdirectly to the CHD and distributed to the provinces or cities that will in turn distribute them tothe DOTS centers. To avoid stock-outs or oversupply, the Quarterly Report on New Casesand Relapses of Tuberculosis and on Drug Inventory and Requirement (see Annex 18-J: DrugInventory and Requirement, page 124) must be carefully prepared and submitted on time bythe implementing units to the provincial or city NTP Coordinators and the consolidated dataare sent to the CHD NTP Coordinator on time.

The number of FDC Blister Packs to be requested can be determined using the QuarterlyReport on New Cases and Relapses of Tuberculosis and on Drug Inventory and Requirementas guide to compute for the quarterly drug requirement. This is accomplished as follows:

a) Compute the total number of FDCs blister packs (FDC-A, FDC-B, PZA, Ethambutol)and Streptomycin Vials needed, based on the number of patients registered in the previousquarter.

35

b) Multiply this by two (include the buffer stock).

c) Deduct the drugs from the stock on hand, to come up with the number of drugs to beordered.

Number of FDC Blister Packs Required per Patient per Regimen

FDC-A RHZE FDC-B RH Z E Streptomycin No. of blister packs No. of vials

Regimen 1 6 12

Regimen 2 9 15 10 56

Regimen 3 18 6

Reminders:

· Drugs must be stored in a secure, clean and cool place at all times.

· Always observe the First Expiring, First Out (FEFO) rule.

· Secure and give the entire supply of drugs required for the entire duration of treatment perTB patient to the midwife in charge of the patient.

4-1. Recording/reporting of NTP logistics:

The logistics for the NTP shall be reported using the Quarterly Report on New Casesand Relapses of Tuberculosis and on Drug Inventory and Requirement (see Annexes18-J: Quarterly Report on New Cases and Relapses of Tuberculosis and on DrugInventory and Requirement, page 124). This is the summary report on the number ofcases according to the regimen applied, namely, Regimen I, Regimen II, and RegimenIII. The information is used by the provincial, city and CHD NTP coordinators tocalculate the number of anti-TB drugs needed at the health facility. The CHD NTPcoordinator distributes anti-TB drugs to each province and city. The provincial or cityNTP coordinators in turn, distribute the drugs to their catchment health facilities.

This report is made by the nurse and noted by the physician of the health facility andsubmitted to the provincial/city NTP coordinators every quarter. The provincial andcity NTP coordinators consolidate and analyze the data prior to submission to theCHD NTP coordinators.

5. Monitoring, Supervision and Evaluation

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

CHAPTER IV : NTP CORE POLICIES AND PROCEDURES


Supervision is an essential management tool to ensure that the implementers correctly,effectively and efficiently carry out policies, standards and procedures of the program. It isalso an opportunity for supervisors to do the following:

· Discuss with health workers important issues related to the program.· Check records and reports.· Acknowledge and re-enforce good performance.· Help health workers identify and correct inadequacies or weaknesses in performance.· Provide exit feedback with corresponding recommendations to the problems identified to

improve program implementation.

· Provide on-the-job training

Evaluation is the regular assessment of the process or development of any program orproject with particular focus on its effectiveness and impact. This process is carried out byeach of the NTP Coordinators by analyzing indicators, data and relevant information fromrecords and reports and feedbacks from field health implementers, surveys and studies fromother agencies.

5-1. Objectives

a) To supervise and monitor on a regular basis, the health status of patients fromrecords and reports in order to improve and maintain the NTP activities at all level.

b) To evaluate on a regular basis, all NTP activities by using indicators derived fromrecords and reports in order to identify problems recommend and institute possiblesolutions.

5-2. Policies

a) The provincial or city NTP coordinators are the NTP supervisors of the healthfacilities, PPMD units and accredited DOTS centers. They shall visit regularly (atleast quarterly) these implementing facilities to monitor the progress andperformance of NTP. This activity shall be done in coordination with the DOH/CHD NTP Coordinators.

b) The physician and nurse are the NTP supervisors at the health facility levels. Theyshall visit their catchment areas regularly. Regular supervisory visits to the healthfacilities will create good working relationships between the supervisors and thehealth workers. The frequency of the visit will depend on the level of performanceof the health unit as well as the performance of the health workers.

c) Relative to Quality Assurance System (QAS) , the CHD/PHO/CHO shall monitorregularly (at least quarterly) the performance of laboratory services and functionalityof the TB Diagnostic Committee.

d) The health staff concerned with NTP implementation at each level shall regularlyanalyze the data of quarterly reports using standard program indicators and providefeedback of findings with corresponding recommendations to the staff or authoritiesconcerned.


e) Advocate on commitment for counterpart share in the purchase of anti-TB drugs,other NTP logistics and costs of NTP operations.

5-3. Procedures

a) Procedures for the Conduct of Monitoring and Supervision Activities:

Identify the areas to be visited and determine the frequency of the visits. Thosewith problems should be visited more frequently. Use the following guidelines forsupervisory visits:

1) Compare and verify the 3 key records of NTP implementation, namely, (1)NTP TB Case Register, (2) NTP Treatment Cards and (3) NTP LaboratoryRegister. Check for correctness and consistency of written data.

2) Review the NTP treatment cards.

· TB Case Number

· Previous TB treatment history

· Type and classification of patient

· Regimen /category of treatment

· Sputum examination results on diagnosis and on follow-up

· Drug collection

· Treatment outcome

3) Review the NTP TB Register.

· TB Case Number

· Type and classification of patient

· Sputum examination results on diagnosis and for follow-up

· Conversion rate at the end of the 2nd and 3rd month of treatment

· Treatment outcome

4) Review NTP Laboratory Register.

· TB Case Number for the follow-up examination

· Rate of three sputum specimen collection

· Positivity rate

5) Observe health workers.

6) Interview health workers and patients.

7) Conduct physical inventory of NTP drugs and other logistics.

After gathering all relevant information, the supervisor must inform or advisethe health worker of the findings from the visit. Recommendations shouldpreferably be furnished in writing. Courses of action to address deficiencies,mistakes and negligence must be discussed and solutions agreed upon by bothsupervisor and the concerned health worker.


b) Procedures for evaluation:

1) During the first week of each quarter, the nurse at the health facility shall preparethe Quarterly Report on New Cases and Relapses of Tuberculosis and theQuarterly Report on the Treatment Outcome of Pulmonary TB Cases. Themedical technologist or microscopist shall also prepare the Quarterly Reporton NTP Laboratory Activities of the cases registered during the previousquarter.

The physician, nurse and medical technologist/NTP microscopist shall analyzeall the quarterly reports to evaluate the performance of the NTP activities attheir health facility. All staff concerned shall evaluate their performance byanalyzing indicators such as the proportion of pulmonary smear positive casesout of all pulmonary cases; three sputum collection rate; positivity rate; casedetection rate (CDR), sputum conversion rate at the end of two (three) monthsof treatment for new smear positive cases and cure rate.

Treatment Failure cases are not included in the Quarterly Report in New Casesand Relapses of TB, as they have been already reported, when they were thentyped as new cases. Transfer-in cases are counted in the health facility wherethey were referred from.

The NTP reports prepared by the Provincial/City NTP Coordinator shouldbe disaggregated as to public and private contribution, to reflect the additionsin the PPMD units to the total cases reported in the province/city/municipality,where the PPMD is being implemented.

2) All quarterly reports are prepared from the NTP TB Register and the NTPLaboratory Register. Therefore, the information in the report is only as accurateas the information recorded in these registers. The quarterly reports are basedon the following coverage period:

1st Quarter January 1- March 31

2nd Quarter April 30 - June 30

3rd Quarter July 1 - September 30

4th Quarter October 1 - December 31

The provincial and city NTP Coordinators shall consolidate and analyze allquarterly reports coming from the implementing health facilities. Theconsolidated data by province and city reports shall be sent to the CHD NTPCoordinators for analysis. The CHD NTP Coordinators shall consolidate andanalyze all quarterly reports prior to submission to the DOH. Recommendedalternative courses of action anchored on relevant findings and based onstandard program indicators (see Annex 19: Program Indicators, page 127)shall be used or applied to ensure the effective implementation of the TB controlprogram.


c) Monitoring Forms:

A standardized monitoring tool/checklist based on the established program indicatorsshall be used during the monitoring and supervision activities. This contains thebasic program indicators that measure the status and progress of programimplementation (see Annex 24: NTP Monitoring Checklist, page 162)

6. Quality Assurance for Sputum Smear Microscopy

For a laboratory to maintain high quality results, its overall performance should be monitoredthrough a series of regular activities, which in combination, make up the laboratory’s qualityassurance system (QAS).

In NTP, the sputum smear microscopy result is used to categorize a symptomatic patientaccording to standard definition. In addition, it is utilized to monitor progress of patient whohave positive sputum smears while they are receiving anti-TB treatment and to confirm thecure of the patient at the end of treatment.

Such is the importance of microscopy; it follows that errors will be highly significant – not onlyfor the patient but also for the NTP. It is therefore essential that the QA system (1) ensures thatthe reported results are accurate, (2) identifies any practices that are potential sources of errorand (3) ensures that appropriate corrective actions are initiated.

QA for sputum smear microscopy includes the following:

· Quality control (QC);

· External quality assessment (EQA); and

· Quality improvement (QI).

6-1. Objective

The general objective of quality assurance in sputum microscopy is to ensure highquality of sputum smear examination services in the NTP.

6-2. Policies

a) In the health facility, the NTP medical technologist/microscopist shall maintain qualityroutine work or quality control (QC).

b) Provincial/City health offices are responsible for the external quality assessment(EQA) which includes blinded slide rechecking and on-site evaluations.

c) CHDs and other regional TB laboratories shall support provincial/city QA centers.

d) The National TB Reference Laboratory (NTRL) has a key role in ensuring thequality of the services provided by microscopy centers.

e) (For procedures and forms, refer to the Manual on the Quality Assurance forSputum Smear Microscopy, NTP, March 2004.)

41

1. Introduction

P RIVATE physicians in the Philippines have not always been in agreement with the Department of Health regarding the management of tuberculosis. However, since the formation of the Philippine Coalition Against Tuberculosis (PhilCAT) in 1994 and

the development of the Philippine Clinical Practice Guidelines on the Diagnosis, Treatment andControl of Pulmonary Tuberculosis (National Consensus on TB) in 2000, representatives ofthe public and private sectors have worked closely to unify the approach to managing TB inthe country.

The 1997 National TB Prevalence Survey highlighted the importance of private physicians inTB control in the Philippines when it showed that 46 percent of individuals with TB-likesymptoms who sought health care consulted private physicians. This was greater than the 30percent that consulted at public health centers.

Despite the large proportion of TB patients consulting private physicians, the appropriateinfrastructure for TB control has yet to be established in the private sector. This refers to asystem using standardized diagnostic criteria and supervised treatment regimens, recordingand reporting and access to an uninterrupted supply of anti-TB drugs, all of which are includedin the World Health Organization-recommended strategy of Directly Observed Treatment,Short-course (DOTS).

These guidelines developed in 2002 hope to link private physicians more closely to the NationalTB Program by aligning the diagnostic criteria and treatment regimens used and by promotingDOTS. In so doing, these guidelines will lay the foundation for the TB control infrastructure inthe private sector. These guidelines cover the management of TB in older children, adolescentsand adults. A multi-sectoral “Task Force for TB in Children” was organized by the DOH,which included representatives from the private sector. The Task Force developedrecommendations for the Management of TB in Children, which now requires validation in

CHAPTER V : GUIDELINES FOR IMPLEMENTATION OF THE NTP BY PRIVATE PHYSICIANS AND HEALTH FACILITIES

V. Guidelines for Implementation of theNTP by Private Physicians and Private

Health Facilities


pilot projects. Once validated, these recommendations may potentially be integrated into thecomprehensive policy for TB control.

2. Policies and Guidelines

2-1. Case Finding (Diagnosis)

Case finding is the identification and diagnosis of TB cases among individuals withsuspected signs and symptoms of TB. Sputum examination for acid-fast bacilli (AFB)or direct microscopy is the most important diagnostic test to request for a patientclinically suspected to have PTB. It is reliable, economical and may be made availableeven in remote areas where a microscopy center could be organized. Patients must bemade aware of the importance of sputum quality. The chances of obtaining a goodspecimen are better when patients are supervised either by their doctor or by laboratorypersonnel. At least three sputum specimens should be submitted for direct microscopy.Ideally, specimens should be submitted to the laboratory within 24 hours from the timeof collection.

A chronic cough, significant weight loss, sweat and chills, fatigue and body malaise,and fever are found in over half of patients suffering from PTB. These clinical signs andsymptoms should raise the possibility of PTB. Only a chronic cough consistently indicatesPTB over non-TB respiratory disease. No other sign is discriminative for PTB. PTBdoes not have to be symptomatic. Even among culture proven PTB cases, a smallpercentage (5-14 percent) may have no symptoms. Asymptomatic PTB is morefrequently observed in older age groups.

Approach to an asymptomatic individual suspicious for TB is more difficult. This scenariois often encountered in persons who had chest x-rays taken in relation to employmentor for other reasons like an annual check-up or part of a pre-operative evaluation. Asingle chest film can only suggest the presence of PTB. It cannot confirm the diagnosisnor establish disease activity; the physician should ask for and compare previous CXRfilms. Any previous treatment for PTB should be asked, the regimen as well as thetreatment duration. The patient should be subjected to sputum collection.

N.B.Refer to Annexes 2- 6, pages 84 to 88.

a) Policies:

1) Direct sputum examination shall be the primary diagnostic tool for case finding.

· Patients with TB symptoms shall be made to undergo smear examinationregardless of whether they have available x-ray results or whether theyare suspected of having extra-pulmonary TB. Three sputum specimensshall be collected.

· Individuals without TB symptom, but who for some reasons (e.g. screeningfor employment, annual employment check-up, medical clearance for asurgical procedure, etc.) obtained a chest x-ray which shows abnormalitiesconsistent with pulmonary TB, shall also be subjected to sputum

43CHAPTER V : GUIDELINES FOR IMPLEMENTATION OF THE NTP BY PRIVATE PHYSICIANS AND HEALTH FACILITIES

examination. Sputum induction may be done as necessary.

· No diagnosis of TB shall be made based on the result of x-ray examinationalone. Skin test for TB infection (PPD) should not be used as a basis forthe diagnosis of TB in adults.

2) Only trained medical technologist or NTP microscopist shall perform sputumexamination.

2-2. Case Holding (Treatment)

Case holding does not only refer to treatment per se, but also means making sure thatthe TB patient religiously takes all their anti-TB drugs everyday without fail until theycomplete their treatment. Adherence to treatment regimen is a key factor in cure andsuccess. The strategy developed to ensure treatment compliance is Directly ObservedTreatment (DOT). It is one of the five key elements of the DOTS strategy, which is theWHO recommended policy package for TB control. This means that a responsibleperson, referred to as the treatment partner, will observe or watch the patient take thecorrect medications daily during the course of treatment.

With direct observation of treatment, the patient doesn’t bear the sole responsibility ofadhering to treatment. The treatment partner may be a health worker or a communitymember who is willing, trained, responsible, acceptable to the patient and accountableto the TB control services. Actual observation of treatment can be done in any accessibleand convenient place (e.g. health facility, treatment partner’s house, patient’splace of work, patient’ s house) as long as the treatment partner can effectively ensurethe patient’s intake of the prescribed drugs and monitor his/her reactions to the drugs.

a) Policies:

1) Treatment of TB cases shall consist of at least four anti-TB drugs during theintensive phase and two (2) drugs in the maintenance phase.

· Symptomatic PTB – Treatment to be given shall be the same as in NTP(see Annex 7: Treatment Regimens, page 89).

· Asymptomatic PTB – Category III (see Annex 7: Treatment Regimens,page 89).

· Extrapulmonary TB – as in NTP.

N.B. For a patient classified as relapse or failure case, the culture and sensitivitytest should be done by a reputable laboratory whose fees are affordable forthe patient. This, however, is not reimbursable by PhilHealth or the NationalTB Program.

2) Drugs to complete the full course of treatment shall be ensured for each patient.

3) Direct observation of treatment shall be adopted in the treatment of a TBpatient. Private physicians who are unable to provide direct supervisionthemselves are encouraged to refer the patient to the nearest DOTS center orto establish a new DOTS service in their community.


4) Sputum follow-up examination shall be done to all TB cases, as scheduled tomonitor treatment response (see Annexes 10-A and 10-B, pages 93-94).

Latent TB Infection (LTBI): The diagnosis and treatment of LTBI is presentlyNOT a priority of the NTP or this comprehensive policy for TB control. If aprivate physician wishes to carry out such diagnosis and treatment, neither theNational TB Program nor the Philippine Health Insurance Corporation isauthorized to subsidize it at this time.

2-3. Recording and Reporting

The recording and reporting system is used to systematically evaluate patient progressand treatment outcome, as well as overall program performance. The system consistsof: a laboratory register that contains a log of all patients who have had a smear testdone; patient treatment cards that detail the regular intake of medication and follow-upsputum examinations; and the TB register, which contains the list of patients startingtreatment and the record of their individual and collective progress towards cure. Thequarterly reports give managers timely, concrete indicators of achievement or problemsrequiring action.

a) Policies:

1) Records and reports shall be adopted from the National TB Control Program.

2) The prescribed NTP treatment card shall be used for each TB patient forindividual assessment of treatment response of patient and as a proof oftreatment of TB patients.

3) The standard NTP referral form shall be used in referring TB symptomaticsfor diagnosis or for treatment to a public health facility.

4) Patients diagnosed with TB disease shall be reported to the DOH, the LGUs,or other bodies designated to manage the National Data Base.

45CHAPTER VI : GUIDELINES FOR IMPLEMENTATION OF THE NTP BY GOVERNMENT AGENCIES

1. Introduction

T HE problem of tuberculosis is a national concern. Both the private sector andgovernment agencies, other than the Department of Health, play a vital role in thecontrol of tuberculosis. Tuberculosis case finding and treatment services are delivered

largely through the health services provided by the local government administered rural healthunits (RHUs) and health centers nationwide under the supervision of the Department of Interiorand Local Government (DILG). On top, other government agencies - e.g., Department ofEducation (DepEd) and Department of National Defense (DND)– also provide tuberculosiscase finding and treatment services to their employees and dependents. Tuberculosis diseasemay also be occurring among the employees of other government agencies such as DSWD,DOJ, DAR, DA, DOST, NEDA and NCIP as well as among their dependents and clienteles,hence the need for the establishment of TB Control Program in the said agencies.

One of the problems identified in the implementation of the tuberculosis control program bygovernment agencies is the lack of uniformity in the procedures applied for case finding andtreatment. This lack of uniformity often times has resulted in both inaccurate diagnosis andpoor treatment. Standardizing the approach to tuberculosis control will make the programmore efficient. This will result in accurate diagnosis of TB disease, proper treatmentregimentation, higher cure rates and ultimately a greater reduction in the TB problem.

A government agency could participate in the implementation of the National TuberculosisControl Program (NTP) in various ways. First is by establishing a DOTS Center, which willprovide two TB services: (1) case finding by direct sputum microscopy and (2) TB treatmentusing DOT (Direct Observed Treatment) to employees, dependents and their clientele.Secondly, those agencies that may not be able to set up a DOTS Center, employees, dependentsand clientele with symptoms of TB may establish referral links with the nearest local governmentDOTS center for sputum microscopy and/or proper treatment.

VI. Guidelines for Implementationof the NTP by Other Government

Agencies


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

2. Profile of Participating Agencies

2-1. Department of Education (DepEd)

DepEd through its School Health and Nutrition Center (SHNC) provides effectivehealth and nutrition services to their students, teachers and non-teaching personnel.The SHNC takes charge of the over-all management of the Integrated School Healthand Nutrition Program (ISHNP), which is a comprehensive education and servicepackage delivered to the schools, eventually to the homes and communities. The mainobjective of ISHNP is to promote, protect and maintain the health and nutritionalstatus of students and school personnel through the provision of various health andnutrition services and education.

Among the communicable disease programs presently implemented by DepEd istuberculosis control. The program components implemented are case finding, treatment,information education and communication (IEC), capability building, and monitoringand evaluation. TB case finding and treatment services are provided to elementary,secondary teachers and non-teaching personnel through the DepEd Division and SchoolClinics nationwide.

2-2. Department of Labor and Employment (DOLE)

DOLE is the agency mandated to formulate policies, implement programs and serveas the policy-coordinating arm of the Executive Branch in the field of labor andemployment. Its vision is to ensure decent and productive employment for everyFilipino worker. Its primary responsibilities are: (1) the promotion of gainful employmentopportunities and the optimization of the development and utilization of the country’smanpower resources; (2) the advancement of worker’s welfare by providing for justand humane working conditions and terms of employment; and (3) the maintenance ofindustrial peace by promoting harmonious, equitable, and stable employment relationsthat assure equal protection for the rights of all concerned parties.

An attached agency to the DOLE is the Occupational Safety and Health Center (OSHC)which is responsible for undertaking: (a) continuing research and studies on occupationalsafety and health; (b) the development and implementation of programs, policies andstandard in the field of occupational safety and health; and (c) medical examination ofworkers and necessary testing for safe use of personal protective and other safetydevices for the prevention of occupational accidents and diseases. In particular, OSHCassists government agencies and institutions in the formulation of policies and standardson occupational safety and health and other matters related thereto and issue technicalguidelines for the prevention of occupational diseases and accidents.


2-3. Department of Interior and Local Government (DILG)

authority over 108,000 members of the Philippine National Police (PNP), the NationalPolice Commission (NPC), the Bureau of Fire Protection, the Philippine Public SafetyCollege and the Bureau of Jail Management and Penology.

The main function of DILG is to oversee and monitor the implementation of the LocalGovernment Code of 1991, enhance the capabilities of the LGUs for self-governance,and implement plans and programs for local autonomy. As part of its overall function,DILG undertakes relevant measures regarding fire protection and jail managementand penology; ensure humane treatment and rehabilitation of inmates. Among the relevantmeasures that may be undertaken, is tuberculosis control among the members of thePhilippine National Police, the inmates in jails nationwide and employees and clienteleof the other attached agencies.

A Memorandum Circular 98-155 had been signed which mandates the local governmentunits to implement DOTS strategy in the control of TB in their respective areas.

2-4. Department of National Defense (DND)

DND was formally organized on November 1, 1939 pursuant to Executive OrderNo. 230, to implement the National Defense Act (Commonwealth Act No. 1) passedby the National Assembly on December 31, 1935 and Commonwealth Act No. 340creating the Department.

DND is tasked with the responsibility of providing the necessary protection of theState against external and internal threats; directing, planning and supervising the NationalDefense Programs; and performing other functions as may be provided for by law.

It exercises supervision over the Armed Forces of the Philippines (AFP), the Office ofCivil Defense (OCD), the Philippine Veterans Affairs Office (PVAO), the NationalDefense College of the Philippines (NDCP), and the Government Arsenal (GA).

Its mission is to provide and maintain the conditions of security, stability and peace andorder conducive to economic growth and national development. It envisions a modern,technology-driven national defense force in the 21st century capable of providing asecure and stable internal and external security environment.

Health service delivery is one of the major concerns in effectively realize this vision.Health service is primarily distributed to 3 categories of beneficiaries, namely: thesoldiers, veterans and civilian employees, to include their dependents. Each group isprovided with healthcare facilities to address their medical concerns.

The AFP has its own medical system, under the supervision of the Office of the SurgeonGeneral (OSG), that caters to the health needs of the soldiers and their dependents.The three major services of the AFP namely: Philippine Army (PA), Philippine Navy(PN), and the Philippine Air Force (PAF) have their own Chief Surgeon’s Office thatsupervises the delivery of medical services to the respective units. The flagship medical


facility in the AFP is the AFP Medical Center where V. Luna General Hospital islocated. This is allied with 31 other hospitals (8 PAF, 3 PN, 9 PA and 11 AFP WideService Support Units) and 28 medical dispensaries strategically located around thearchipelago.

Catering to the country’s living heroes is the sprawling and tranquil Veterans MemorialMedical Center (VMMC) in Quezon City. Supervised by the Philippine VeteransAffairs Office, this medical facility addresses the health concerns of the more than240,000 veterans, AFP retirees and their dependents. The Office of the Secretary ofNational Defense (OSND) Clinic also keeps the Department employees’ and theirdependents health in check. And finally, the Government Arsenal has its own hospitalfacilities.

2-5. Department of Justice (DOJ)

The different agencies and offices of the DOJ serve as the instrumentalities by whichprograms and services instituted by the Department are delivered to the people. Amongthe eleven (11) agencies under the DOJ is the Bureau of Corrections that is chargedwith custody and rehabilitation of national offenders sentenced to serve a term ofimprisonment of more than three (3) years. Among its mandate is to provide humanetreatment by supplying the inmates’ basic needs and implementing a variety ofrehabilitation programs designed to change their pattern of criminal and anti-socialbehavior. Headed by a Director, the Bureau has a strength of 2,362 employees, 61percent of whom are custodial officers, 33 percent are administrative personnel and 6percent are members of the medical staff.

The Bureau of Correctional has seven (7) operating units located nationwide, namely:The New Bilibid Prison in Muntinlupa, the Correctional Institution for Women inMandaluyong City, Iwahig Prison and Penal Farm in Puerto Princesa, Sablayan Prisonand Penal Farm in Occidental Mindoro, San Ramon Prison and Penal Farm inZamboanga City, Leyte Regional Prison in Abuyog, Leyte and Davao Prison andPenal Farm in Panabo, Davao Province. A TB control program among inmates in theNew Bilibid Prison in Muntinlupa is presently being implemented.

2-6. Department of Social Welfare and Development (DSWD)

DSWD is the lead government agency in formulating national social welfare anddevelopment policies, plans and statistics, especially as these relate to familydevelopment and poverty groups. DSWD is an advocate for social welfare anddevelopment concerns, to include disadvantaged families, children/youth, women, seniorcitizens, persons with disabilities and similarly situated individuals.

DSWD provides assistance to local government units, non-government organizations,and other members of civil society in effectively implementing programs including health,projects and services that will alleviate poverty and empower disadvantaged individuals,families and communities for an improved quality of life. Among the attached agenciesare: the Council for the Welfare of Children, Inter-country Adoption Board and theNational Council for the Welfare of Disabled Persons.


2-7. Department of Agriculture (DA)

The DA is the principal agency of the Philippine government responsible for the promotionof agricultural development and growth. In pursuit of this, it provides the policyframework, helps direct public investments, and in partnership with local governmentunits (LGUs) provides the support services necessary to make agriculture and agri-based enterprises profitable and to help spread the benefits of development to thepoor, particularly those in rural areas. There are 21 agencies affiliated with the DA andthese include the National Food Authority, the National Nutrition Council, the NationalTobacco Administration, and the Philippine Coconut Authority.

2-8. Department of Agrarian Reform (DAR)

DAR is the principal agency responsible for implementing the Comprehensive AgrarianReform Program (CARP). Its mission is to improve land tenure through better accessto and more equitable distribution of land and the fruits thereof. It shall also enhancethe welfare and promote the development of Program beneficiaries through coordinateddelivery of essential support services. DAR has a grand total workforce of 13,574,974 from the central office and 12,590 from Regions I to XII including CAR andCARAGA. DAR also has a total of 1,452 Agrarian Reform Communities (ARCs)and a grand total of 749,275 Agrarian Reform beneficiaries.

2-9. Department of Science and Technology (DOST)

DOST is the premier science and technology body in the country charged with thetwin mandate of providing central direction, leadership and coordination of all scientificand technological activities. In pursuit of its vision of a competent and competitivescience and technology community with a social conscience, DOST works with theS&T community.

DOST has five (5) Sectoral Planning Councils, seven (7) Research and DevelopmentInstitutes, seven (7) Service Institutes, two (2) Collegial bodies, fourteen (14) RegionalOffices and seventy three (73) Provincial S&T Centers.

2-10. National Economic and Development Authority (NEDA)

NEDA is the country’s independent social and economic development planning andpolicy coordinating body. NEDA’s task is to formulate development plans and ensurethat plan implementation achieves the goals of national development. Five governmentagencies are attached to the NEDA for purposes of administrative supervision. Theseare: Tariff Commission (TC), Philippine National Volunteer Service Coordinating Agency(PNVSCA), National Statistical Coordination Board (NSCB), National StatisticsOffice (NSO), and Statistical Research and Training Center (SRTC). Moreover, thePhilippine Institute for Development Studies (PIDS) is attached to the NEDA for policyand program coordination.

The following committees as well as sector staffs are tasked to look into the specificconcerns of the NTP: a) Social Development Staff (SDS) – evaluates program and


projects, facilitates the inclusion of program and projects in the Mid-Term PublicInvestment Program (MTPIP), including those in support of the NTP; b) ProjectMonitoring Staff (PMS) – monitors the progress of the implementation of ODA-assisted TB Control Program, identifies the bottlenecks and proposes solutions toproblems of implementation, prepares integrated reports on the status of approvedTB Control Project; c) Trade, Industry & Utilities Staff (TIUS) – provides technicaland legal advise and assistance in the formulation and implementation of developingpolicies, plans and programs particularly on request for inclusion in the National PriorityPlan to avail of full tax deductibility of donations on TB control Program and Projects;and d) Regional Development Coordination Staff (RDCS) & Regional Offices –monitors and evaluate regional policies, plans and programs related to the NTP.

2-11. National Commission on Indigenous Peoples (NCIP)

NCIP is an agency created under R.A. 8371, otherwise known as the IndigenousPeoples Rights Act. Its mandate is to protect and promote the interest and well beingof the indigenous peoples with due respect to their beliefs, customs, traditions andinstitutions. As such, it shall serve as the primary government agency responsible forthe formulation and implementation of pertinent and appropriate policies, plans andprograms to carry out the policies set forth in the new law.

It caters to more than 12 million indigenous peoples of 110 ethnic tribes spread out allover the country. It has 12 Regional Offices, 46 Provincial Offices, and 108 communityservice centers.

NCIP intends to support the NTP through TB health education and informationdissemination and referral of TB patients to the nearest health center/rural health unit/barangay station for case finding and treatment.

3. Policies and Guidelines

3-1. On Case Finding

Case finding is an essential component in the control of tuberculosis. Its objective is toidentify the sources of infection in the community, that is to find the persons dischargingthe tubercle bacilli and initiate treatment to render them non-infectious initially andultimately cure them (see Annexes 2-6, pages 84 to 88).

Among the agencies’ employees, identification of patients with TB disease may bedone during consultation at the agency clinic for those manifesting TB symptoms orduring the annual check-up. All those found with TB symptoms or those with Chest X-ray shadows consistent with active PTB during annual check up but are asymptomaticshall be made to undergo sputum microscopy at the agency clinic by a trained medicaltechnologist/microscopist. If the agency does not have the facility for sputumexamination, a referral may be made to the nearest microscopy center (Rural Health


Unit (RHU)/Health Center (HC)/Health Maintenance Organization (HMO)) or anyaccredited DOTS Center.

Other clienteles of the different agencies may be referred to the agency clinic or toother health facility nearest them.

a) Policies and Guidelines:

1) Direct Sputum Microscopy shall be the primary diagnostic tool in NTP casefinding.

· Employees consulting the agency clinic, e.g., DOJ, DepEd, DILG (PNP,BJMP, BF), DA, DAR, DND (AFP & VMMC) with signs and symptomsof TB shall be made to undergo sputum examination regardless of whetherthey have available chest x-ray results.

The employee shall be referred for sputum examination to the nearesthealth facility (Rural Health Unit (RHU)/Health Center (HC)/ HealthMaintenance Organization (HMO)) for agencies without a facility forsputum microscopy (e.g., DOST, DSWD, NEDA, and NCIP). Referralshall be made using the appropriate NTP form (see Annex 18-B: NTPLaboratory Request Form for Sputum Examination, page 108).

· Employees found to have chest x-ray findings compatible with TB duringtheir annual check-up whether symptomatic or asymptomatic shall also bereferred to the agency clinic e.g. DOJ, DepEd, DILG (PNP, BJMP, BF),DA, DAR, DND (AFP and VMMC) or the nearest health facility forsputum microscopy in the case of agencies with no facility of their owne.g. DOST, DSWD, NEDA, NCIP. For those without cough, inductionof the same shall be done.

· Employees of government agencies without a treatment facility or clinic,nor annual medical check-up benefit who develop TB symptoms, shall bereferred to the nearest health facility for diagnosis. Referral shall be madeusing the appropriate NTP form (see Annex 18-B: NTP LaboratoryRequest Form for Sputum Examination, page 108).

· Dependents of employees (e.g. DND) and clientele (persons served bythe other government agencies e.g. DSWD, DA, DAR) with symptoms ofTB shall be referred to the nearest health facility for diagnosis. Referralshall be made using the appropriate NTP form (see Annex 18-B: NTPLaboratory Request Form for Sputum Examination, page 108).

2) Only an adequately trained medical technologist or NTP microscopist shallperform sputum examination (smearing, fixing and staining of sputum specimens,reading the smear). The procedure for identification of TB symptomatics,collection and transport of sputum specimen, and smearing shall follow theNTP procedures (see Chapter IV. NTP Core Policies and Procedures, pages24-27).


· Training of medical technologist/microscopist shall be coordinated withthe TB Unit-Infectious Disease Office, Department of Health.

· Training of the agency medical technologist/microscopist shall beundertaken by the National TB Reference Laboratory, Research Instituteof Tropical Medicine, Department of Health at Alabang, Muntinlupa, MetroManila or any other laboratory designated by the Department of Health.

3-2. On Case Holding

Case holding does not only refer to treatment per se, but also means making sure thatthe TB patient religiously takes all his/her anti-TB drugs everyday without fail until he/she completes treatment. This would ensure cure of TB patients, prevent deaths dueto TB and most importantly prevent multi-drug resistance.

The DOTS strategy is a comprehensive strategy to ensure the correct diagnosis andcure of TB patients and treatment compliance. It has the following five elements:

· Political Commitment – funding and support from the local executives and othergovernment agencies and private sectors to execute.

· Microscopy – to confirm whether or not TB bacilli are present in the sputum.

· Drugs for TB – complete drug requirement for each patient should be availableat all times in the health facility.

· DOT (Directly Observed Treatment or Supervised Treatment) – a health workercalled a “Treatment Partner” is assigned to each patient to make sure that thepatient is swallowing all his/her drugs everyday until completion of treatment. DOTis just one of the components of the strategy.

· Reporting Books – part of the system that documents the progress of eachpatient until totally cured.


1) Treatment of TB cases shall consist of at least four anti-TB drugs during theintensive phase and two drugs in the maintenance phase. Treatment Regimenshall follow the recommendation of the NTP (see Annex 7: TreatmentRegimens, page 89, and Annex 8-A: Drug Dosage and Adjustment and Annex8-B: FDC Composition, page 90).

2) DOT (Directly observed treatment or supervised treatment) shall be adoptedin the treatment of TB patients. It shall be done at the agency clinic, supervisedby the clinic nurse/attendant. On Saturdays, Sundays and Holidays, anti-TBdrugs shall be taken at home by the patient himself/herself supervised by afamily member. For agencies without treatment facility (e.g. DOST, NEDA)patients shall be referred for DOT to the nearest DOTS center.

· Each participating government agency that will be treating their own patients(e.g., DepEd, DILG-PNP, DA, DAR, DSWD, DND, and DOJ) shallensure that all patients started on treatment are assured of a completecourse of anti-TB drugs.


Patients of agencies with no facility to do DOT treatment of their employeesshall be referred to the health facility nearest the patient.

For dependents of employees and clientele of the different agencies whoneed treatment shall likewise be referred to the health facility nearest him/her.

· No newly diagnosed patient shall be admitted for treatment if there isshortage of drugs in the clinic. Borrowing of drugs from the ongoing patientsshall not be allowed since the arrival of the next batch of drugs is not clear/ guaranteed.

· Daily intake of drugs shall be recorded in the treatment card andidentification card of the patient as proof of treatment.

· Health Education shall be done during initiation of treatment and oncontinuous basis during the daily supervision of treatment. Messages shallinclude the importance of daily intake of drugs and completing treatment.It should also include the schedule of sputum follow-up examination aswell as its importance. Information about the possible side effects (drugreaction) shall also be included (see Annex 12: Guide in Managing SCCDrugs Side Effects, page 96).

· Sputum follow-up examination shall be done to all TB cases as scheduledto monitor treatment response (see Annex 10-A: Schedule of SputumSmear Follow-Up Examination for Category I and Annex 10-B: Scheduleof Sputum Smear Follow-Up Examination for Categories II and III, page93 and 94).

· Patients who fail to come to the clinic for daily administration of treatmentshall be followed-up / reminded, for him/her to report back to the clinicwithin two (2) days during the intensive phase and within a week duringthe maintenance phase.

· Treatment outcome shall be determined and analyzed for each patient(see page 32 for the various treatment outcomes and definition).

3-3. On Recording and Reporting

a) Participating government agencies (e.g., DepEd, DILG, DA, DAR, DND, andDOJ) shall adopt the NTP records and reports in the implementation of the TBprogram (see Annexes 18-A to 18-M, pages 107 to 126).

b) Treatment Card shall be used for each TB patient for individual assessment oftreatment response of patient and as proof of treatment of TB patients (see Annex18-D: NTP Treatment Card, page 113).

c) Identification Card (ID) shall be provided each TB patients on treatment (seeAnnex 18-E: NTP Identification Card, page 116).

d) A register of TB symptomatic called the NTP Laboratory Register (see Annex 18-C: NTP Laboratory Register, page 111) and NTP TB Case Register (see Annex18-F: TB Register, page 118) for TB patients put to treatment shall be maintainedfor program assessment and individual’s treatment outcome.


e) The standard referral form shall be used in referring TB symptomatics for diagnosisand of TB patients for continuation of treatment in another facility wheneverapplicable. (Refer to Annex 18-G1: PPMD Referral Form / NTP, page 120).

f) Quarterly report on New Cases and Relapses (see Annex 18-J: Quarterly Reporton New Cases and Relapses of Tuberculosis and on Drug Inventory andRequirement, page 125) and Treatment Result (see Annex 18-L: NTP QuarterlyReport on the Treatment Outcome of Pulmonary TB Cases, page 127) shall besent to the respective Regional Health Office. For central office clinics, such reportsshall be sent to the TB Unit, Infectious Disease Office of the DOH as these shallbe the basis for drug allocation and inclusion in the case notification on tuberculosis.

3-4. On Training

Training of health personnel of all agencies participating in the implementation of theNTP is an important support component of the program. A good knowledge of thetuberculosis control program policies, guidelines and procedures is necessary toimplement an effective TB program. Health workers such as doctors, nurses andmidwives should have the knowledge and skills to identify TB symptomatics, give theappropriate treatment regimen, monitor treatment response, and maintain the necessaryNTP records and reports. Medical technologists and/or TB microscopists should beskilled in sputum microscopy and maintain its quality. Barangay Health workers shouldlikewise be trained on identification of TB symptomatics as well as on DOT. Withoutthese knowledge and skills, there will be a poor program implementation, which mayultimately lead to non-cure of TB patients and possible development of drug resistance.


1) Participating government agencies (DepEd, DILG-PNP, LGU, DA, DAR,DSWD, DND, and DOJ) shall conduct NTP orientation at their regional/provincial offices in coordination with the DOH Regional Health Office whenevernecessary.

2) Participating government agencies (DepEd, DILG-PNP, LGU, DA, DAR,DND, DOJ) shall conduct sputum microscopy training for medical technologistsand nurses (DepEd) in coordination with the Regional and TB Unit, CentralOffice of the DOH.

3) DepEd shall conduct orientation of school principal and administrators and allschool health personnel on DOTS Strategy.

4) DepEd shall conduct communication skills training on TB messages for healthpersonnel.

3-5. On Monitoring and Evaluation

Monitoring is a process of collecting and analyzing information about the programimplementation. It also involves dissemination of and providing feedback on findingsand recommendations to improve program implementation. Evaluation is the assessment


of the program focusing on its effectiveness and impact (see “Monitoring, Supervisionand Evaluation”, page 38).

a) Policies and Guidelines (DepEd, DOLE, DILG, DA, DAR, DND, DOJ):

The Technical Working Group Member of each agency shall:

1) Monitor and evaluate the NTP program in their respective agency.

2) Monitor implementation of policy and program on TB prevention and controlin the workplace (see Annex 22-A: TB Benefit Form (DOLE Guidelines),page 152).

3) Conduct physical inventory of drugs and other logistics necessary for theprogram implementation and issue requisition for the needed logistics quarterly,if applicable.

4) Ensure accomplishment and analysis of the quarterly reports (on casefindingand cohort analysis) by their respective regional offices, and routing of thesame to the corresponding Regional Health Office on the second month of thesucceeding quarter. Reports of the agencies at the central level shall be sentdirectly to the TB Unit, Infectious Disease Office of the DOH.

5) Conduct annual evaluation of the program implementation in collaboration withthe Regional Health Office (NTP Coordinators).

6) Participate in the monitoring of the ODA-assisted TB project implementation(NEDA).

3-6. Health Education and Advocacy

a) Develop modules for elementary and secondary students on the prevention andcontrol of tuberculosis. (DepEd)

b) Support information campaign of the programs. (all agencies)

c) Develop campaign materials (DepEd, DILG-LGU) and other agencies.

d) Conduct health education and information dissemination about tuberculosis disease,its prevention and control to their respective clientele. (all participating agencies)


Employees Clients Dependents

With shadows suggestive of TB With TB symptoms (Annual Checkup)

Sputum Examination

Agency Clinic Health Facility (DOTS Center) (DOTS Center)

Directly Observed Treatment

Agency Clinic Health Facility (DOTS Center) (DOTS Center)

TB Disease

DIAGRAM OF NTP IMPLEMENTATION GOVERNMENT AGENCIES

57CHAPTER VII : TB BENEFITS POLICY OF THE ECC, SSS AND GSIS

1. Introduction

T UBERCULOSIS is listed among the occupational diseases that may be compensable under the Employees’ Compensation (EC) Program of the Employees’ Compensation Commission (ECC), subject to applicable criteria for its diagnosis and

compensability.

The ECC program provides compensation package for public and private sector employeesand their dependents in the event of work-related contingencies. The primary aim of the ECprogram is to help workers and their dependents, in the event of work-related injury, sickness,or death, to promptly receive meaningful and adequate income benefits, medical or relatedservices, and rehabilitation services.

The ECC program is administered by the Social Security System (SSS) in the case of workersin the private sector, and by the Government Service Insurance System (GSIS) in the case ofworkers in the public sector.

In addition to the ECC program of ECC, the SSS also implements its Social Security Protectionprogram which, under RA 8282, or the Social Security Act of 1997, basically provides for thereplacement of income lost in times of sickness, disability, and death. SSS benefits for sickness,disability, and death applies to injuries or diseases that are work-related and those that are notwork-related. In the case of work-related injuries, SSS members may claim for both ECCprogram benefits and SSS program benefits.

The GSIS also provides for the replacement of income lost in times of sickness and disabilityas well as other benefits due to an illness as provided for under RA 8291, or the GSIS Act of1997. By virtue of its provision for mutual exclusiveness of benefits, however, GSIS membersmay not claim for both EC program benefits and GSIS program benefits for the same illness.Among the conditions to entitlement are the following: (a) has been duly reported to the System;

VII. TB Benefits Policyof the ECC, SSS, and GSIS


(b) sustains the disability as a result of the TB disease; and (c) the System has been dulynotified of the sickness which caused his disability.

2. Policies, Benefits and Procedures for Claims

2-1. Employees Compensation Program

a) Policy:

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

2) The ECC shall provide Permanent TB Disability Benefit to separated GSISand SSS members with work-connected TB disease who shall remain to besputum positive at the end of 120 days and/or with impairment classification ofclass 2 or higher (see Annexes 20-A to 20-C, pages 129 to 130). Those withimpairment classification of Class 1 and with at least mildly impaired respiratoryfunction by spirometry or peak flow determination shall also be entitled toPermanent Disability Benefit. Qualified members with TB of extrapulmonarysite may apply for Permanent TB Disability Benefit based on the severity offunctional impairment of the organ involved (Annex 21, page 131).

b) EC Program Benefits:

1) Temporary Total Disability Benefit. This is an income benefit paid to aneligible GSIS/SSS member who suffers work-connected TB starting on thevery first day. It shall not exceed 90% of the employee’s daily salary credit asdetermined by the System. Presently, this income benefit is set at not morethan Pesos 200 per day for private workers and Pesos 90 per day forgovernment employees to be paid beginning on the first day the worker isdiagnosed with TB but shall not be paid longer than 120 days. At the sametime, the member with a work-connected TB is entitled to reimbursement ofhis/her medical and related expenses.

· Requirement for Eligibility:

An eligible SSS member is qualified to avail of the EC benefit simultaneouslywith benefits under the regular social security program of SSS regardlessof whether he/she has or has not exhausted his/her sick leave credits if he/she satisfies the following conditions:

i. He/she has been duly reported to the System

ii. He/she has work–connected tuberculosis

iii. The system has been duly notified of his/her TB disease. His/heremployer shall be liable for the benefit if the illness occurred before

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the employee is duly reported to the System.

· Medical Requirements for Entitlement to EC-TTD:

i. Initial Temporary Total TB Disability (TB Sickness) BenefitRequirements:

- Pulmonary Tuberculosis:

• Attending physician report (initial portion of the TB BenefitForm

• Results of 3 separate sputum examinations for AFB or culture• Chest x-ray result with findings consistent with pulmonary TB

diagnosis

• Verification of TB diagnosis by GSIS/SSS physician

- Extrapulmonary Tuberculosis:

• Referral from attending physician with history and physicalexamination

• Positive TB culture result of fluid or tissue from involved siteor histological evidence from the site involved

• Certification from the attending physician attesting to thediagnosis of TB of the extrapulmonary site concerned

• Verification of the TB diagnosis by GSIS/SSS physician

Entension of Temporary Total TB Disability (TB Sickness) BenefitPackage. An extension of 30 days beyond the initial TTD benefitalready granted may be given to a member with TB who fulfills thefollowing requirements:

- Pulmonary TB:

Still sputum (+) or becomes sputum positive on the basis of threesputum follow–up examinations at least 3 weeks from the previousexamination or impairment classification of class 1 or higher.

- Extrapulmonary TB:

A certification from the attending physician that the patient hasextrapulmonary tuberculosis and still needs time off from workwhile continuing treatment.

2) Permanent Partial Disability Benefit. This is a cash benefit paid to an ECbeneficiary for his TB who at the end of 120 days TTD is found to be partiallydisabled due to his TB disease. It is given beginning the end of his TTD Benefitsand shall continue for a period as may be warranted by his/her medical conditionas determined by the ECC rating on compensation benefits. The benefits includereimbursement of his/her medical and related expenses which may be enjoyedsimultaneously with benefits under the social security program. The monthly

CHAPTER VII : TB BENEFITS POLICY OF THE ECC, SSS AND GSIS


income benefit that is given for the PPD will be suspended if the employeerecovers from his/her partial disability or fails to submit quarterly medicalprogress report certified by his/her attending physician. Failure to submit thequarterly report will mean suspension/forfeiture of the said benefit based onthe policy on non-submission of medical progress report.


A GSIS/SSS member is qualified to avail of this benefit from the ECC ifhe/she satisfies the following conditions:

i. He/she has been duly reported to the System;

ii. He/she sustained the permanent partial disability as a result of a work– connected TB disease; and,

iii. The system has been duly notified of his/her TB disease. His/heremployer shall be liable for the benefit if the illness occurred beforethe employee is duly reported to the System.

· Medical Requirements for Entitlement to EC - PPD:

i. Pulmonary Tuberculosis:

- He/she met the criteria for PTB and has proof of at least 100 daysof documented treatment

- He/she is still sputum positive at the end of the Temporary TotalDisability

- He/she has an impairment classification of Class 1 to 3 (Annexes20-A to 20-C, pages 129 to 130) and Functional IndependenceMeasure (FIM) classification for permanent partial disability(Annex 21, page131).

ii. Extrapulmonary Tuberculosis:

- He/she met the criteria for extrapulmonary TB and has proof ofat least 100 days of documented treatment

- He/she satisfies functional impairment classification for PermanentPartial Disability of organ System involved and FunctionalIndependence Measure (FIM)

3) Permanent Total Disability Benefit. The Permanent Total Disability is acash benefit in monthly pension paid to a qualified GSIS/SSS member foundwith Permanent Total Disability due to TB disease. The benefit includesreimbursement for medical, rehabilitation and related expenses and a monthlypension plus 10 percent for each of the five dependent children beginning withthe youngest and without substitution, which may be enjoyed simultaneouslywith benefits under the social security program. A permanent total disabilitypensioner is also given a monthly supplemental allowance for his/her extraneeds depending on his physical condition arising from his/her TB. The monthlypension will be suspended if the employee is gainfully employed, recoversfrom his/her permanent disability, or fails to present himself/herself for

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examination at least once a year upon notice by the GSIS/SSS or fails tosubmit a quarterly report certified by his/her attending physician. The suspension/forfeiture of the said benefit will be based on the policy on non–submission ofmedical progress report.


i. He/she has been duly reported to the System;

ii. He/she sustained the permanent total disability as a result of a work-connected TB disease;

iii. The system has been duly notified of his/her TB disease. His/heremployer shall be liable for the benefit if the illness occurred beforethe employee is duly reported to the System.

· Medical Requirements for Entitlement to EC – PTD:

i. Pulmonary Tuberculosis:

- He/she met the criteria for PTB and has proof of at least 100 daysof documented treatment

- He/she is still sputum positive at the end of the Temporary TotalDisability

- He/she has an impairment classification of Class 4 (Annexes 20-A to 20-C, pages 129 to 130) and Functional IndependenceMeasure (FIM) classification of permanent total disability (Annex21, page131).

ii. Extrapulmonary Tuberculosis:

- He/she met the criteria for extrapulmonary TB and has proof of atleast 100 days of documented treatment

- He/she satisfies functional impairment classification for PermanentTotal Disability of organ System involved and FunctionalIndependence Measure (FIM) of total disability

c) Procedure for Claims:

1) All claims for work-connected TB shall be filed using the prescribed formfurnished by either the GSIS or SSS and endorsed by the employer or hisduly authorized representative together with the following supporting documents:

· Completed TB Benefits Form initial portion with the following asattachments:

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

- Pulmonary TB:



Official results of 3 AFB sputum examination, x-ray films and officialresults of mycobacterial or TB culture examination if available.


History and physical examination of attending physician,histopathology examination result of involved tissue or results ofculture of fluid or tissue from involved site and certification fromthe attending physician attesting to the diagnosis of TB of theextrapulmonary site concerned.

ii. For extension of Temporary Total TB Disability:

- Pulmonary TB:

Results of sputum examination or culture taken three weeks fromthe previous sputum examination or culture, evidence of at leastmild respiratory impairment by spirometry or peak flow andcertification by the attending physician that he/she has at least Class1 respiratory impairment.


History and physical examination of attending physician,histophathology examination results of involved tissue or results ofculture of fluid or tissue from involved site and certification fromthe attending physician attesting to the diagnosis of TB of theextrapulmonary site concerned.

iii. For Permanent Total or Partial TB Disability:

- Pulmonary TB:

Results of sputum examination or culture taken at the end of thetemporary total disability, respiratory impairment result byspirometry or peak flow and proof of at least 100 days ofdocumented treatment.


History and physical examination of attending physician,histopathology examination result of involved tissue or results ofculture of fluid or tissue from involved site, certification from theattending physician attesting to the diagnosis of TB of theextrapulmonary site concerned and proof of at least 100 days ofdocumented treatment.

· Supporting documents:

i. Updated service record

ii. Statement of duties and responsibilities

iii. Pre-employment x-ray

iv. Official receipts in payment of laboratory bills

v. Professional fees and medicines purchased from the drugstore

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· Proof of treatment or treatment record where the daily dose of the patient’santi-TB drugs taken under supervised treatment is recorded.

2) The GSIS/SSS physician shall evaluate the application within twenty (20)calendar days from the submission of all required documents and shall rendera decision denying or awarding compensation benefits.

3) The claimant shall be notified in writing by the GSIS or SSS of its award ordecision on the action taken on his claim. The claimant shall be informed of hisright to appeal and that the decision shall become final and executory if noappeal or motion for reconsideration is filed within the prescribed period.

4) The claimant shall file with the GSIS or SSS, as the case may be, only onemotion for reconsideration within ten (10) calendar days from receipt of thedecision. When a motion for reconsideration is denied by the GSIS or theSSS, the claimant may appeal to the Commission within (30) calendar daysfrom receipt of the decision or the notice of denial of the motion forreconsideration.

5) The claimant shall file with the GSIS or the SSS, a notice of appeal withinthirty (30) calendar days from receipt of the decision.

2-2. Social Security System

a) Policy:

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

2) The SSS shall provide Permanent TB Disability Benefit to members withtuberculosis whose sputum acid-fast stain remains positive at the end of 120days and/or with impairment classification (Annexes 20-A to 20-C, pages129 to 130) of class 2 or higher. Those with impairment classification of Class1 and with at least mildly impaired respiratory function shall also be entitled toPermanent Disability Benefit. Qualified members with extrapulmonary TB mayapply for Permanent TB Disability Benefit based on the severity of functionalimpairment of the organ system involved (Annex 21, page 131).

3) SSS shall report members who applied for Temporary Total Disability (TBSickness) Benefit to the body designated to manage the National TB DataBase.

b) Benefits:

The SSS administers two programs: the Social Security Protection and theEmployees Compensation (EC) Program of the Employees’ CompensationCommission to workers in the private sector. Basically, the SSS provides for the



replacement of income lost in times of sickness, disability, and death under RA8282, the Social Security Act of 1997.

1) TB Sickness Benefit:

It is a daily cash allowance paid to an eligible SSS member for the number ofdays he is unable to work due to TB sickness. Such allowance shall begin onlyafter all company sick leaves of absence with full pay to the credit of theemployee for the current year have been exhausted. The member is alsoentitled to EC TB sickness under the EC Program if he suffers a work-relatedTB and the period of compensability shall be counted from the first day ofsuch sickness.

The member may enjoy simultaneously both SS and EC sickness benefitprovided he meets all the qualifying conditions in the availment of such benefitas required by both Agencies.

· Packages:

i. SSS - The sickness benefit is given in the form of a daily cash allowance.The amount of benefit is computed as: the daily sickness allowancetimes the approved number of days (the daily sickness allowance is90 per cent of the average daily salary credit).

ii. EC - The sickness benefit is an income cash benefit equivalent to 90per cent of the employee’s average daily salary credit with a minimumof P90.00 and a maximum of P200.00. The TB sickness can be paidfor a continuous period of 120 days and may go beyond up to 240days if sickness requires more treatment. If it persists after this period,the sickness can be considered a disability.

· System Requirements for Eligibility:

i. SSS -- A member is qualified to avail of sickness benefit if he/she:

- Is unable to work for more than 3 days due to TB sickness;

- Has paid at least three monthly contributions within the 12-monthperiod immediately preceding the semester of sickness;

- Has used up all current company sick leaves with pay for thecurrent year; and,

- Has notified the employer or SSS if separated, voluntary or self-employed member of his confinement within 5 calendar days afterthe start of such confinement unless such confinement is in ahospital.

ii. EC -- A member is qualified to avail of sickness benefit if he/she:

- Has been duly reported to the SSS;

- Has work-connected tuberculosis; and,

65

- SSS has been duly notified of his TB disease.

His/her employer shall be liable for the benefit if such TB illnessoccurred before the employee is duly reported for coverage to thesystem.

· Medical Requirements:

i. Initial TB Sickness Benefit Package:

- Pulmonary TB:

• Attending physician’s report (initial portion of the TB BenefitForm (refer to Annexes 22-A and 22-B, pages 152-153).

• Results of three separate sputum examinations for AFB orculture.

• Chest x-ray film and result with findings consistent withpulmonary TB.

• Verification of TB diagnosis by SSS physicians.


• Referral from attending physician with history and physicalexamination report.

• Positive TB culture result of fluid or tissue from involved siteor histological evidence from the site involved.

• Certification from the attending physician attesting to thediagnosis of TB of the extrapulmonary site concerned.

• Verification of TB diagnosis by SSS physician.

ii. Extension of TB Sickness Benefit Package:

An extension of 30 days or more (until maximum of 120 days) beyondthe initial benefit maybe given to a member with TB disease who fulfillsthe following requirements:

- Pulmonary TB:

• Still sputum (+) or becomes sputum (+) on the basis of threesputum follow-up examinations at least 3 weeks from theprevious examination or impairment classification of class 1or higher.

• Certification from the Attending Physician attesting thepresence of the above-mentioned signs and symptoms. Thecertification shall be written in the Sickness Notification Form.




• Certification from the attending physician that the patient hasextrapulmonary tuberculosis and still needs time off from workwhile continuing treatment.

• Verification of TB diagnosis by SSS physician.

· Procedure for Claim

i. Initial TB Sickness Benefit Package:

- Members diagnosed with TB disease are required to submit thefollowing:

• TB Sickness Notification Form for employed members orSickness Benefit Claim for separated, self-employed, orvoluntary members.

• Sickness Benefit Reimbursement Application Form (for theemployer)

• Completed TB Benefit Form (refer to Annexes 22-A and 22-B, pages 152-153) with the following as attachments:

(a) Pulmonary TB:

Official result of three (3) AFB sputum examinations,x-ray films and official result showing PTB,mycobacterial or TB culture examination if available.

(b) Certification from attending physician attesting to thediagnosis of pulmonary TB.

(c) Extrapulmonary TB:

History and physical examination of attending physician,histopathology examination result of involved tissue orresults of culture of fluid or tissue from involved site andcertification from the attending attesting to the diagnosisof TB of the extrapulmonary site concerned.

- The application shall be evaluated by the SSS physician who shallreturn the basic TB Sickness Notification form with the appropriaterecommendation to the employee/employer except in the case ofvoluntary, self-employed or separated SSS members who shallreceive direct payment of benefit.

• The TB Sickness Benefit Form shall be collected by SSS andsubmitted to the Philippine Coalition Against Tuberculosis orother body designated to manage the National TB Data Baseon a monthly basis.

• The employer shall advance the approved benefits and havethis reimbursed by SSS.

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ii. Extension of TB Sickness Benefit Package:

- Members diagnosed with TB disease who shall remain sputumpositive after thirty (30) days are required to submit the following:

• TB Sickness Notification Form for employed members orSickness Benefit Claim for separated, self-employed, orvoluntary members.

• Sickness Reimbursement Application Form (for the employer).

• Completed TB Benefit (Extension Portion) Form with thefollowing as attachments:

(a) Pulmonary TB

(1) Results of sputum examination or culture or evidence of at least mild respiratory impairment by spirometry or peak flow and certification by a physician that he/she has at least Class 1 respiratory impairment.

(2) Certification by the attending physician attesting to the diagnosis of Pulmonary Tuberculosis.

(3) Verification by SSS physician of member’s health condition to warrant granting of extension.

(b) Extrapulmonary TB

(1) History and physical examination of attending physician, histopathology examination result of involved tissue or results of culture of fluid or tissue from involved site.

(2) Certification from the attending physician attesting to the diagnosis of TB of the extrapulmonary site concerned.

- The application shall be evaluated by the SSS physician who shallreturn the basic TB Sickness Benefit form with the appropriaterecommendation back to the employee/employer except in thecase of voluntary, self-employed or separated SSS members whoshall receive direct payment of benefit.

- The employer shall advance payment of the approved benefits toemployees and have advances reimbursed by SSS.

2) TB Disability Benefit

SSS pays cash benefit in monthly pension or lump sum to eligible memberswith permanent partial or total disability due to TB disease. In addition to the



monthly pension, a supplemental allowance of P500.00 is paid to provideadditional financial assistance to meet his/her extra needs arising from thedisability.

For permanent total disability, each dependent child of the pensioner, (notexceeding five and without substitution starting from the youngest), will receivea dependent’s pension equivalent to 10 per cent of the member’ s monthlypension or Pesos 250 whichever is higher. The dependent pension stops whenthe child reaches 21 years old, gets married, gets employed or dies.

For work-connected TB disability, the ECC pays cash benefit in monthlypension to eligible members. Also, it provides a supplemental allowance ofP575.00 (15% higher than SSS) and a dependent’ s allowance equivalent to10 per cent of the member’ s monthly pension. In addition, the eligible memberis also entitled to medical and related services and rehabilitation services anddependent pension for each of his dependent child (not exceeding five andwithout substitution starting from the youngest).

The EC disability benefit may be enjoyed simultaneously with SS disabilitybenefit.

· Packages:

i. SSS -- It is a cash benefit paid to a member who becomes permanentlydisabled due to TB, either partially or totally. The disability benefitmay either be in lump sum or monthly pension and the amount andduration of benefit is based on the current policy of the System, whichare subject to change.

ii. EC -- It is a monthly cash income benefit paid to a member whobecomes permanently disabled due to a work-connected TB disease,either partially or totally. The amount and duration of the benefit isbased on the policy of the System.

· System Requirement for Eligibility:

i. SSS -- A member who suffers partial or total permanent disability,with at least one monthly contribution paid to the SSS prior to thesemester of contingency, is qualified.

ii. EC -- A member is qualified to disability benefit if he satisfies thefollowing conditions:

- He has been duly reported to the System; and,

- He has sustained the permanent partial or total disability as a resultof work-connected TB disease.

· Medical Requirements:

i. Pulmonary TB

- He/she met the criteria for PTB and has proof of at least 100 daysof documented treatment.

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- He/she is still sputum positive at the end of the Temporary TotalDisability.

- He/she has an impairment classification of Class 1 to 3 (Annexes20-A, 20-B, and 20-C on pages 129-130 and FunctionalIndependence Measure (FIM) classification for permanent partialdisability (Annex 2, page 84).

ii. Extrapulmonary

- He/she met the criteria for extra pulmonary TB and has proof of atleast 100 days of documented treatment.

- He/she satisfies functional impairment classification for PermanentPartial Disability of organ system involved and FunctionalIndependence Measure (FIM).

· Procedure for Claim:

i. SSS members with TB disease should submit the following:

- Claim for Disability Benefit Form

- Medical certificate form

- Other documents that might be required to support the disabilityclaim:

* Pulmonary TB

Chest x-ray result indicating PTB and results of sputumexamination or culture taken at the end of the temporary totaldisability, respiratory impairment result by spirometry or peakflow and proof of at least 100 days of documented treatment.

* Extrapulmonary TB

History and physical examination of attending physician,histopathological examination result of involved tissue or resultsof culture of fluid or tissue from involved site, certification fromthe attending physician attesting to the diagnosis of TB of theextrapulmonary site concerned and proof of at least 100 daysof documented treatment.

The application shall be evaluated by the SSS physician whoshall give the appropriate recommendation.


71CHAPTER VIII : PHILHEALTH’S OUTPATIENT ANTI-TB DOTS BENEFIT PACKAGE

1. Introduction

T he outpatient TB DOTS benefit package is the response of the Philippine Health Insurance Corporation (PhilHealth) to the need to provide accessible and quality health care services to its members and their qualified dependents who are suffering

from TB. This package was included in PhilHealth’s Benefits Package pursuant to BoardResolution Nos. 485 and 490, Series of 2002, as embodied in Circular No. 19, Series of2003. The DOTS (Directly Observed Treatment, Short-course) strategy, which is reported tohave an 85% or higher cure rate, is highly recommended to effectively deliver this benefitpackage.

2. Definitions

2-1. Tuberculosis (TB)

TB is an infectious disease caused by the microorganism called Mycobacteriumtuberculosis or the TB bacillus. The microorganism enters the body by inhalationthrough the lungs. They spread from the initial location in the lungs to other parts of thebody via the blood stream, the lymphatic system, via the airways or by direct extensionto other organs.

2-2. Pulmonary TB

A pulmonary TB case refers to disease involving the lung parenchyma. It is the mostfrequent form of the disease, occurring in over 80 percent of cases. This form oftuberculosis may be infectious. A “case” of TB is a patient in whom the diagnosis hasbeen confirmed bacteriologically or a patient in whom a presumptive diagnosis ofactive TB is made on the basis of radiological evidence and a decision by the TBDiagnostic Committee to treat with a full course of anti-TB therapy.

VIII. PhilHealth’s Outpatient TBDOTS Benefit Package


2-3. Symptomatic pulmonary TB

Symptomatic pulmonary TB case refers to an individual with symptoms ofpulmonary TB and is found to have one of the following:

a) At least two sputum specimens positive for AFB, with or without radiographicabnormalities consistent with active PTB; or

b) One sputum specimen positive for AFB and with radiographic abnormalitiesconsistent with active PTB as determined by the TB Diagnostic Committee; or

c) One sputum specimen positive for AFB with sputum culture positive for M.tuberculosis; or

d) All three sputum specimens negative for AFB with radiographic abnormalitiesconsistent with active PTB as determined by the TB Diagnostic Committee, withno history of anti-TB treatment and with a normal previous chest x-ray.

Signs and symptoms of pulmonary TB include cough for two weeks duration ormore with one or more of the following:

· Fever

· Sputum expectoration

· Significant weight loss

· Hemoptysis or recurrent blood streaked sputum

· Chest and/or back pains not referable to any musculo-skeletal disorders

· Other symptoms such as chills, fatigue, body malaise, shortness of breath

2-4. Asymptomatic pulmonary TB

An asymptomatic pulmonary TB case refers to an individual without symptoms ofpulmonary TB and is found to have one of the following:

a) Radiographic abnormalities consistent with active PTB and at least one sputumspecimen positive for AFB, OR

b) Previous chest x-ray normal and current chest x-ray show abnormalities consistentwith active PTB as determined by the TB Diagnostic Committee and three sputumAFB smears are negative, OR

c) Previous chest x-ray showed abnormality consistent with active PTB, three sputumAFB smears previously negative, current chest x-ray shows progression ofradiographic abnormality.

N.B. If current CXR shows abnormality consistent with TB and 3 sputum specimensare negative for AFB, but no previous CXR is available and the patient does not fulfillthe criteria for PTB, follow-up CXR and sputum examination should be done at leasta month after.


2-5. Extrapulmonary TB

Extrapulmonary TB (EPTB) affects organs other than the lungs, more frequently thepleura, lymph nodes, spine, joints, genitourinary tract, nervous system or abdomen.Tuberculosis, moreover, may affect any part of the body.

N.B. Diagnosis for extra-pulmonary tuberculosis should be based on one culture positivespecimen, or histological or strong clinical evidence consistent with active extra-pulmonary tuberculosis, followed by a decision by a clinician to treat with a full courseof tuberculosis chemotherapy.

2-6. Qualified TB Patient

A qualified TB patient is any of the following:

a) A new case of smear positive pulmonary TB;

b) A new smear negative pulmonary TB as recommended for treatment by the TBDiagnostic Committee;

c) A new extrapulmonary TB;

d) Children diseased with TB.

In order to qualify, the abovementioned patients shall have been seen and worked upby a qualified TB/DOTS Provider. Once this requirement has been met, a qualified TBpatient shall be eligible to avail of the outpatient anti-TB DOTS benefit package.

2-7. Qualified Provider

A qualified provider is an outpatient clinic duly accredited by PhilHealth.

2-8. Defaulter

Qualified TB patient who starts the treatment but who for any reason discontinuestreatment and could no longer be retrieved is considered a defaulter.

3. Policy

3-1. NTP Manual of Procedures

Implementation of the DOTS Strategy shall be based on the Manual of Procedures ofthe National Tuberculosis Control Program, 2004. The PhilHealth outpatient TB DOTSbenefit package shall cover follow-up diagnostic work-up, follow-up consultationservices and anti-TB drugs in an out-patient set-up.


3-2. Cases covered

The DOTS Benefit Package shall cover new cases of pulmonary and extra-pulmonarytuberculosis only. It shall not cover the following types of tuberculosis cases: relapse,failure and return after default (RAD).

3-3. Standards for accreditation

Accreditation of DOTS Centers as providers of DOTS services shall be based onstandards developed by the Corporation in consultation with other stakeholders. QualityAssurance Standards shall be based on the PhilHealth Benchbook.

3-4. Payment scheme

The accredited DOTS Center shall be paid on a case-based reimbursement paymentscheme. Two payments shall be released to the accredited DOTS Center as determinedby the Corporation.

3-5. Monitoring

The Health Finance Policy and Services Sector, specifically, the Utilization ReviewUnit of the Quality Assurance Research and Policy Development Group shall spearheadthe monitoring of the implementation and impact of the outpatient anti-TB DOTS benefitpackage.

4. Outpatient Anti-TB DOTS Benefit Package

4-1. Coverage

a) All PhilHealth members and their qualified dependents may avail of the outpatientTB DOTS benefit package if they satisfy the “Criteria for Eligibility” and are notexcluded by the “Criteria for Exclusion.”

Criteria for Eligibility:

· New cases of smear positive or smear negative pulmonarytuberculosis.

· New cases of extra pulmonary tuberculosis

· TB disease in children

Criteria for Exclusion:

The PhilHealth outpatient TB DOTS benefit package shall not cover the followingtypes of TB cases:· Failure cases (On previous treatment)

· Relapse cases

· Return After Default cases (RAD)


All members and dependents who are qualified to avail of the outpatient TB DOTSbenefit package may avail of services in the DOTS center where he/she is registered.Transfer to another accredited DOTS center during the course of treatment shallbe referred to a PhilHealth Committee for appropriate action.

b) In accordance with Section 46 of the Implementing Rules and Regulations of R.A.7875, qualified PhilHealth members and their dependents shall be entitled to theoutpatient TB DOTS benefit package if:

· The member has paid at least three monthly premium contributions within theimmediate six months prior to enrollment at the DOTS Center for employedand individually paying members.

· The member is covered within the date of effectivity of membership as statedin the ID Card/Eligibility Certificate in the case of sponsored (indigents),pensioners and overseas Filipino workers.

c) Qualified dependents of a PhilHealth member may be one of the following:

· Spouse who is not a PhilHealth member;

· Children under 21 years old, not married and unemployed;

· Parents > 60 years of age, who is not a member, and wholly dependent on themember

The DOTS Provider shall render services to a qualified PhilHealth memberand its dependents based on the Manual of Procedures of the NationalTuberculosis Control Program 2004.

d) PhilHealth shall provide a comprehensive package that will cover follow-updiagnostic work-up, follow-up consultations and anti-TB drugs for all membersdiagnosed with TB as defined above.

4-2. Providers

a) Providers of the DOTS Benefit Package shall be out-patient DOTS centers dulyaccredited by PhilHealth. Accreditation will be based on standards developed bythe Corporation in consultations with stakeholders. Quality Assurance standardsare based on the PhilHealth Benchbook. Likewise, PhilHealth shall accreditphysicians rendering DOTS services.

b) DOTS centers such as those but not limited to a hospital, HMO, LGU healthunits, factory clinic, church-based clinics, school clinics are qualified to becomeproviders after being duly certified by the Center for Health Development (CHD)Sentrong Sigla Assessment Team (Public Sector) or the Philippine Coalition AgainstTuberculosis or PhilCAT (Private Sector).

4-3. Certification and Accreditation

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


b) Standards for accreditation of providers shall be based on the new PhilHealthBenchbook on Performance of Improvement of Health Services and all othernecessary claims processing requirements.

4-4. Payment

a) Drugs, consultation fees and laboratory fees will be covered by a flat rate of Pesos4,000 per case payable in two separate payments.

b) The first payment of Pesos 2,500 shall be made after completion of the intensivephase and the final payment of Pesos 1,500 shall be made after the end of themaintenance phase.

c) Reimbursement requirements shall be in accordance with PhilHealth claimsreimbursement guidelines.

d) PhilHealth shall not reimburse a qualified TB patient who is considered a defaulterif he/she decides to go back to the program. This is to ensure that all DOTScenters will take full responsibility of patient compliance and at the same timeensure the program’s success rate.

4-5. Reimbursement Process

The reimbursement process shall have three phases: registration of qualified TB patient,release of first payment and release of final payment (second payment).

a) For registration purposes, a photocopy of the NTP Treatment Card of a qualifiedTB patient shall be submitted to PhilHealth within 60 days upon enrollment at theDOTS Center. Other supporting documents may be required, which may includethe following:

· Proof of contribution for the self-employed

· Proof of dependency which may include marriage certificate for spouse andbirth certificate for children, as the case may be

b) For release of first payment, the DOTS Center shall submit to the PhilHealth ClaimsDepartment the following: (1) PhilHealth Claim Form 1, (2) Photocopy of theNTP Treatment Card and (3) TB–DOTS Package Claim Form 5 within 60 daysafter the completion of intensive phase.

c) For release of final payment (second payment), the DOTS Center shall submit tothe PhilHealth Claims Department the following: (1) PhilHealth Claim Form 1, (2)Photocopy of the NTP Treatment Card and (3) TB–DOTS Package Claim Form5 within 60 days after the completion of maintenance phase.

d) All claims applications are covered by the rule on ICD–10 requirement of theCorporation.

e) Claims with incomplete requirements shall be returned to the DOTS Center andmust be complied with the 60 days prescription.


f) Non-compliance shall cause denial of a claim.

4-6. National TB Registry

All DOTS Centers shall be linked to the National TB Registry. This registry shallprovide all the information and utilization of the benefit package. Likewise, the NationalTB Registry shall collect and process the basic information on the patient’s treatment,provider update and referral status.

4-7. Monitoring

The Health Finance Policy and Services Sector shall spearhead monitoring of thisprogram.

A committee composed of Quality Assurance Research and Policy Development Group,Accreditation Department and Fraud Unit shall develop the monitoring tool incollaboration with DOH and PhilCAT.

79

ANNEXES

ANNEXES

81ANNEXES

TREATMENT UNIT

MICROSCOPY CENTER

MICROSCOPY CENTER

Collection and examination of 3 sputumspecimens for diagnosis

Collection and examination of 1 sputum specimenfor follow up based on specified schedule

COMMUNITYIdentification of TB symptomatics

Symptoms of TB• Cough for 2 weeks or more• Sputum expectoration• Fever• Significant weight loss• Hemoptysis• Chest and/or back pains

Case Finding

Diagnosis

Initiation of Treatment

Case Holding with DOTS

Treatment Completion

Sputum specimens (3 Specimens) with Request Form for Sputum Examination

Results of the sputum smear examination (SputumSmear Examination for Diagnosis)

Sputum specimen (1 specimen per once) with Request Form for Sputum Examination

Results(Sputum Smear Examination for Follow-up)

Report Treatment Outcome/Request SuppliesMonitoring and Supervision

ANNEX 1: FLOW OF NTP ACTIVITIES


TB Symptomatic(cough for 2 weeks or more)

Three (3)sputum collection

2 or 3smear positive

Only one (1)smear positive (*1)

Allsmear negative

Refer to Physician(Observe and give

symptomatic treatmentfor 2-3 weeks)

Collect another 3sputum specimen

Classify as smearpositive TB

If symptoms persist,collect another three

(3) sputum specimensand refer to Physician(refer to flow chart in

Annex 3)

If all smearnegative

If at least one (1)smear positive

Requestfor CXR

Classify as smear-positive TB

If not consistent withactive TB

If consistent withactive TB

Observe/FurtherExam, if necessary

Classify as smear-positive TB

ANNEX 2: FLOWCHART FOR THEDIAGNOSIS OF PULMONARY TUBERCULOSIS

83

ANNEX 3: FLOWCHART FOR THE DIAGNOSIS OFSMEAR-NEGATIVE PULMONARY TUBERCULOSIS

This flow chart is a sample for making decision of the physician. Arrangement may berequired in accordance with the patient condition as well as the available resources onTB control.

ANNEXES

all 3 smearNEGATIVE

Refer to Physician(sympt. Tx for 2-3 weeks)

If symptoms persist,collect another three

(3) sputum specimens

2 or 3 smear POSITIVE only one (1) smearpositive all 3 smear NEGATIVE

Refer to Annex 2 (*1) Request for CXRClassify as Smear-Positive TB

No abnormal findings onCXRAbnormal findings on CXR

Observe/furtherexaminationTB Diagnostic Committee

Not consistent with activeTBConsistent with active TB

Observe/furtherexamination

Classify as Smear-Negative TB


ANNEX 4: APPROACH TO TB ASYMPTOMATIC

May repeatCXR (after 6months) ortreat with

Reg 3

Treat withReg 1

Lesionstable

Lesionworse/new

Lesionstable

Lesion worse/new

Advise patient.May be

cleared foremployment.

Furtherinvestigation

required

Sputuminduction

Furtherinvestigation

required

Sputum (+)AFB

Sputum (-)AFB)

Treat with Reg1

Treat with Reg3

Sputum (+)AFB

Sputum (-)AFB)

Previous treatment for PTBcompleted and verified

Induce sputumproduction

Previous CXR available

Patient asymptomaticCXR available

(with lesions suggestive of TB

YES

YES NO

NO

85

ANNEX 5: GUIDE TO CASE FINDING

SPUTUM COLLECTION UNIT(to be accomplished by the Midwife/Nurse/Physician)

1. Register the client in NTP Client List (or Target Client List).2. Label each sputum containers (name and serial no. 1, 2, 3).3. Collect 3 sputum specimens (spot, early morning, spot).4. Fill-out the Laboratory Request Form for Sputum Examination.5. Pack and send the specimen/s to the Microscopy Center with the

Laboratory Request Form for Sputum Examination.

MICROSCOPY CENTER(to be accomplished by the Medical Technologist/Microscopist)

1. Register the client in NTP Laboratory Register.2. Record the date received and the Laboratory Serial No. in the

Laboratory Request Form for Sputum Examination.3. Sputum Smear Examination: smearing, fixing, staining and reading

slides4. Record the results in the Laboratory Request Form for Sputum

Examination and in the NTP Laboratory Register.5. Send back accomplished Laboratory Request Form for Sputum

Examination the collection unit..

DIAGNOSIS ANDINITIATION OFTREATMENT

SPUTUM COLLECTION UNIT(to be accomplished by the Midwife/Nurse/Physician)

1. Record the results in the NTP Client List/Target Client List (TCL)2. Inform and explain the result to the patient (If doubtful, immediately

collect another 3 specimens for confirmation).3. Refer to Nurse/Physician

ANNEXES

TB Symptomatics withsymptoms as:

> Cough for 2 weeks or more> Fever> Significant weight loss> Chest and/or back pains> Hemoptysis


ANNEX 6: GUIDE TO DIAGNOSIS AND INITIATION OF TREATMENT

INITIATION OF TREATMENTTo be done by thePhysician

1. Physical assessment and prescription of appropriate regimen forthe TB patient (according to the patient type and the classification)

2. Registration• Fill-in the NTP Treatment Card• Fill-in two NTP ID Cards, one for the treatment partner and one

for the patient• Register in the TB Register

3. Health education with emphasis on key messages such as:• TB is infectious. It can affect anybody.• TB can be cured but requires regular drug intake.• Results of irregular drug intake.• Side effects of anti-TB drugs.• Importance of follow-up sputum smear examinations.• Importance of family/treatment partner support.

4. Intake of first dose• Record the date when treatment started.• Record the due date of the 1st follow-up sputum examination in

the NTP Treatment Card and NTP ID Cards.5. DOT

• Assign a treatment partner.• Do DOT for both intensive and maintenance phases of

treatment.• Conduct weekly consultation meeting at the health facility

during the whole course of treatment.6. Record keeping

1) Maintain and update the TB Register2) Maintain and update the NTP Treatment Card at the health

facility.3) Maintain and update the NTP ID Cards.4) Keep the NTP ID Card.

To be done by the Nurse(initially)

To be done by all healthworkers

To be done by the Nurse

To be done by the Nurseand treatment partners

To be done by the nurse/midwife/treatment partner/patient

CLINICAL DIAGNOSIS(Determination of patient type and classification is done by the Physician/Nurse/Midwife)

1. Verify information gathered on case finding• Symptoms/condition of patient• Result of sputum examination• Result of further examination (i.e. CXR, Culture, etc.)• Source of infection

2. Verify sputum smear examination results3. Review history of previous treatment

87

ANNEX 7: TREATMENT REGIMENS

TB Patients To Be GivenTreatment

Category I

• New pulmonary smear(+) cases

• New pulmonary smear (-)cases with extensiveparenchymal involvementand as assessed by theTBDC

• Extra-pulmonary TBcases

2HRZE / 4HR :HRZE for two monthsduring the intensive phase.

HR for 4 months during themaintenance phase.

2HRZE / 5HRE :HRZES for the first twomonths, then HRZE for thethird month during theintensive phase.

HRE for the next fivemonths during themaintenance phase.

• Failure cases• Relapse cases• RAD• Other (smear +)• Other (smear -)

2HRZE* / 4HR :HRZE for 2 months duringthe intensive phase.

HR for 4 months during themaintenance phase.

Category II

Category III

TB DiagnosticCategory

Tuberculosis TreatmentRegimen & Duration of

Treatment

ANNEXES

• New smear(-) but withminimal pulmonary TB onradiography and asassessed by the TBDC

*Ethambutol may be omitted for patients with non-cavitary, smear-negative pulmonary TB who are known to be HIV-negative, patients who are known to be infected with fully drug susceptible bacilli. Young children with primary TB should be given 3 drugs combination only (without ethambutol).

Source: “Operational Guide for National Tuberculosis Control Program on the Introduction andUse of Fixed Dose Combination.” WHO 2002


DRUG Dose per kg body weigh and maximum dose

ISONIAZID 5 (4-6) mg/kg, and not to exceed 400mg daily

RIFAMPICIN 10 (8-12) mg/kg, and not to exceed 600mg daily

PYRAZINAMIDE 25 (20-30) mg/kg, and not to exceed 2g daily

ETHAMBUTOL 15 (15-20) mg/kg, and not to exceed 1.2g daily

STREPTOMYCIN 15 (12-18) mg/kg, and not to exceed 1g daily

DRUG FDC - A4-Drug (HRZE)

FDC - B2-Drug (HR)

ISONIAZID (H) 75mg 75mg

RIFAMPICIN (R) 150mg 150mg

PYRAZINAMIDE (Z) 400mg

ETHAMBUTOL (E) 275mg

DOSAGE PER TREATMENT REGIMENThe number of tablets of FDCs per patient will depend on the body weight. Hence,all patients must be weighted in kilogram before treatment is started.

ANNEX 8A: DRUG DOSAGE AND ADJUSTMENT

ANNEX 8B: FDC COMPOSITION

Dose per kg body weight and maximum dose

ed

89

ANNEX 8C: FDC DOSAGING

ANNEXES

REGIMEN I: 2 HRZE / 4HR

Body Weight (kg)

No. of tablets per dayIntensive Phase

(2 months)FDC - A (HRZE)

No. of tablets per dayMaintenance Phase

(4 months)FDC - B (HR)

30 - 37 2 2

38 - 54 3 3

55 - 70 4 4

> 71 5 5

REGIMEN III: 2 HRZE / 4HR

Body Weight (kg)

No. of tablets per dayIntensive Phase

(2 months)FDC - A (HRZE)

No. of tablets per dayMaintenance Phase

(4 months)FDC - B (HR)

30 - 37 2 2

38 - 54 3 3

55 - 70 4 4

> 71 5 5

REGIMEN II: 2 HRZES / HRZE / 4HRE

Body Weight(kg)

INTENSIVE PHASE MAINTENANCE PHASE

First two months Third month

FDC - B(HR)

E400 mg

FDC - A(HRZE) STREPTOMYCIN FDC - A

(HRZE)

30 - 37 2 0.75 g 2 2 1

38 - 54 3 0.75 g 3 3 2

55 - 70 4 0.75 g 4 4 3

> 71 5 0.75 g 5 5 3

>

>

>

CATEGORY I: 2 HRZE / 4HR

CATEGORY II: 2 HRZES / HRZE / 4HRE

CATEGORY III: 2 HRZE / 4HR


ANNEX 9: FDC DRUG SAMPLES

FDC A Blister Pack

FDC B Blister Pack

Pyrazinamide Blister Pack

Ethambutol Blister Pack

91

ANNEX 10A: SCHEDULE OF SPUTUM SMEARFOLLOW-UP EXAMINATION

ANNEXES

REGIMEN I

Schedule of SputumSmear Follow-up

Examination

Regimen I (2HRZE/4HR)

Regular Treatment with One Month Extension(HRZE)

Towards the end of the2nd month YES

Towards the end of the3rd month YES

Towards the end of the4th month YES


Towards the end of the6th month YES (* 1)


* 1 Check the follow-up sputum smear examination at the end of the treatment (during the last week oftreatment) for the patient who has smear positive in the last follow-up smear examination and shows smearnegative in the repeated smear examination.

(if positive)(ifnegative)

CATEGORY I

Treatment Regimen for Category I (2hrze/4hr)


ANNEX 10B: SCHEDULE OF SPUTUM SMEARFOLLOW-UP EXAMINATION

REGIMEN II and REGIMEN III

Schedule of SputumSmear Follow-up

Examination

Regimen II (2HRZES/1HRZE/5HRE)Regimen III

(2HRZE/4HR)Regular Treatment with One MonthExtension (HRZE)

Towards the end of the2nd month YES

Towards the end of the3rd month YES (If positive)

Towards the end of the4th month (If negative) YES



Towards the end of the7th month



* 2 Check the follow-up sputum smear examination at the end of the treatment (during the last week oftreatment) for the patient who has smear positive in the last follow-up smear examination and showssmear negative in the repeated smear examination.

Treatment Regimen for Category II(2HRZES/1HRZE/5HRE)

TREATMENT REGIMENS FOR CATEGORY II AND CATEGORY III

Category III Treatment Regimen

(2HRZE/4HR)

93

ANNEX 11: SUMMARY OF TREATMENT REGIMEN MODIFICATIONBASED ON THE SPUTUM FOLLOW-UP

ANNEXES

Examination Results

Regimen - 1

1st mo. 2nd mo. 3rd mo. 4th mo. 5th mo. 6th mo. 7th mo.

H R Z E H R

If negative,

If positive H R Z E H R

With Extension

Regimen - 3

1st mo. 2nd mo. 3rd mo. 4th mo. 5th mo. 6th mo.

H R Z E H R

* Check the follow-up sputum smear examination at the end of the treatment for the patient who has smear positive in the last follow-upsmear examination and shows smear negative in the repeated smear examination.

*

*With Extension

Regimen - 2

1st mo. 2nd mo. 3rd mo. 4th mo. 5th mo. 6th mo. 7th mo. 8th mo. 9th mo.

H R Z E S HRZE H R E

If negative,

If positive, HRZE H R E

*

*

If positive

If positive

Treatment Regimen for Category II

Treatment Regimen for Category I

Treatment Regimen for Category III


ANNEX 12: GUIDE IN MANAGING SCC DRUGS SIDE EFFECTS

Side effects Drug(s) responsible What to do?

MINOR SIDE EFFECTS - Patient should be encouraged to continue taking medicines.

1. Gastro-intestinal intolerance Rifampicin Give medication at bedtime.2. Mild skin reactions Any kind of drugs Give anti-histamines.

3. Orange/red colored unine Rifampicin Reassure the patient.

4. Pain at the injection site Streptomycin Apply warm compress. Rotate sitesof injection.

5. Burning sensation in the feetdue to peripheral neuropathy Isoniazid

Give Pyridoxine (Vitamin B6):100 - 200mg daily for treatment10mg daily for prevention.

6. Arthralgia due tohyperuricemia Pyrazinamide

Give aspirin or NSAID.If symptoms persist, consider goutand give allopurinol. *

7. Flu-like symptoms (fever,muscle pains, inflammation ofthe respiratory tract)

Rifampicin Give antipyretics.

MAJOR SIDE EFFECTS: Discontinue taking medicines and refer to the Physician immediately.

1. Severe skin rash due tohypersensitivity

Any kind of drugs (especiallyStreptomycin)

Discontinue anti-TB drugs and referto the Physician.

2. Jaundice due to hepatitisAny kind of drugs (especially

Isoniazid, Rifampicin andPyrazinamide)

Discontinue anti-TB drugs and referto the Physician.If symptoms subside, resumetreatment and monitor clinically.

3. Impairment of visual acuityand color vision due to opticneuritis

Ethambutol Discontinue Ethambutol and referto an ophthalmologist.

4. Hearing impairment, ringingof the ear and dizziness due tothe damage of the eighthcranial nerve

Streptomycin Discontinue Streptomycin and referto the Physician.

5. Oliguria or albuminuria dueto renal disorder

StreptomycinRifampicin

Discontinue anti-TB drugs and referto the Physician.

6. Psychosis and convulsion Isoniazid Discontinue all TB drugs d andrefer to the Physician.

7. Thrombocytopenia, anemia,shock Rifampicin Discontinue anti-TB drugs and refer

to the Physician.

95

ANNEX 13A: TREATMENT REGIMEN MODIFICATIONS BASED ON THE RESULTS OF SPUTUM FOLLOW-UP EXAMINATIONS (without extension)

ANNEXES

Follow-up ExaminationsTREATMENT REGIMEN FOR CATEGORY I

• Do sputum smear examinations for follow-up towards the end of the 2nd month of treatment.• If the sputum examination result is NEGATIVE, start Maintenance Phase (HR) and follow Annex 13A.• If the sputum examination result is POSITIVE, extend intensive Phase (HRZE) for another one month

and follow Annex 13B.

Treatment Modification Based on the Results of the Sputum Follow-up Examinations for Regimen - IWithout Extension

Towards the end ofthe 4th month In the beginning of the 6th month Towards the end of the

6th month (* 1)If smear negative, continuethe maintenance phase(HR).

If smear negative, complete the maintenance phase until the end ofthe treatment course and declare as "Cure".

If smear positive, repeat smearexamination immediately forconfirmation and consult withProvincial/City/CHD TBCoordinators throughMHO/CHO/PPMD Physician.

If smear negative in therepeated smear examination,continue the maintenance phase(HR) and do the smearexamination towards the end ofthe 6th month of treatment.

If smear negative, declare as"Cure."

If smear positive, declare as"Treatment Failure," then re-register as "Failure" and startRegimen-II.

If smear positive again in therepeated smear examination,declare as "Treatment Failure,"then re-register as "Failure" andstart Regimen II.

If smear positive, continuethe maintenance phase(HR).

If smear negative, continue the maintenance phase (HR) and dothe smear examination towards the end of the 6th month oftreatment.


If smear positive, declare as"Treatment Failure," then re-register as "Failure" and startRegimen- II.

If smear positive, declare as "Treatment Failure," then re-registeras "Failure" and start Regimen II.

* 1 Check the follow-up sputum smear examination towards the end of the 6th month of the treatment only for the patient who hassmear positive in the beginning of the 6th month and shows smear negative in the repeated smear examination; and for the patientwho has smear positive towards the end of the 4th month turns out to be negative in the beginning of the 6th month.

/PPMD Physician


ANNEX 13B: TREATMENT REGIMEN MODIFICATIONSBASED ON SPUTUM FOLLOW-UP EXAMINATIONS (with Extension)

Follow-up Examinations for Regimen-1 with ExtensionTowards the

end of the3rd mo.

Towards theend of the 5th

mo.In the beginning of the 7th month

Towards the endof the 7th month (*

2)If smear negative,start themaintenancephase (HR).

If smear negative,continue themaintenance phase(HR).

If smear negative, complete the maintenance phase until theend of the treatment course and declare as "Cure".

If smear positive, repeatsmear examinationimmediately for confirmationand consult withProvincial/City/CHD TBCoordinators throughMHO/CHO/ PPMDPhysician.

If smear negative in therepeated examination,continue the maintenancePhase (HR) and do thesmear examination towardsthe end of the 7th month oftreatment.

If smear negative, declareas "Cure."

If smear positive, declareas "Treatment Failure,"then re-register as"Failure" and startRegimen-II.

If smear positive in therepeated examination,declare as "TreatmentFailure," then re-register as"Failure" and start RegimenII.

If smear positive,continue themaintenance phase(HR) anyway.

If smear negative, continue the maintenance phase (HR)and do the smear examination towards the end of the 7thmonth of treatment.



If still smear positive, declare as "Treatment Failure," thenre-register as "Failure" and start Regimen-II.

If smear positive,start themaintenancephase (HR)anyway.

If smear negative,continue themaintenance phase(HR).

If smear negative, complete the maintenance phase until theend of the treatment course and declare as "Cure."

If smear positive, repeatsmear examinationimmediately for confirmationand consultProvincial/City/CHD TBCoordinators throughMHO/CHO/ PPMDPhysician.

If smear negative in therepeated examination,continue the maintenancephase (HR) and do thesmear examination towardsthe end of the 7th month oftreatment.



If smear positive in therepeated examination,declare as "TreatmentFailure," then re-register as"Failure" and start Regimen-II.

If still smear positive,declare as"Treatment Failure,"then re-register as"Failure" and startRegimen-II.

* 2 Check the follow-up sputum smear examination towards the end of the 7th month of treatment only for the patient who has smearpositive in the beginning of the 7th month and shows smear negative in the repeated smear examination; and for the patient who hassmear positive towards the end of the 5th month and turns out to be negative in the beginning of the 7th month.

Follow-up Examinations for Treatment Regimen Category I with Extension

MHO/CHO/PPMD Physician.


97

ANNEX 13C: TREATMENT REGIMEN MODIFICATIONSBASED ON SPUTUM RESULTS

ANNEXES

TREATMENT REGIMEN FOR CATEGORY II

• Do sputum smear examination for follow-up towards the end of the 3rd mo. of treatment.• If sputum examination result is NEGATIVE, START Maintenance Phase (HRE) and follow Annex 13C.• If sputum examination result is Positive, extend Intensive Phase (HRZE) for another one (1) month

and follow Annex 13D.

Follow-up Examinations for Regimen-II without ExtensionTowards the end of

the 5th mo. In the beginning of the 8th mo. Towards the end of the8th mo. (* 3)

If smear negative, continuethe maintenance phase(HRE).

If smear negative, complete the maintenance phase until the end ofthe treatment course and declare as "Cure."If smear positive, repeat smearexamination immediately forconfirmation and consult withProvincial/City/CHD TBCoordinators through MHO/CHO/PPMD Physician.

If smear negative in the repeatedsmear examination, continue themaintenance phase (HRE) anddo the smear examinationtowards the end of the 8thmonth.


If smear positive, declare as"Treatment Failure."

If smear positive again in therepeated smear examinationcomplete the maintenance phase(HRE) until the end of thetreatment course and declare as"Treatment Failure."

If smear positive, continuethe maintenance phase(HRE) anyway.

If smear negative, continue the maintenance phase (HRE) and dothe sputum smear examination towards the end of the 8th month.

If smear negative, declare as"Cure."If smear positive, declare as"Treatment Failure."

If smear positive, complete the maintenance phase (HRE) until theend of the treatment course and declare as "Treatment Failure."

* 3 Check the follow-up sputum smear examination towards the end of the 8th month of treatment only for the patient who has smearpositive in the beginning of the 8th month and shows smear negative in the repeated smear examination; and for the patient who hassmear positive towards the end of the 5th month and turns out to be negative in the beginning of the 8th month.

Follow-up Examinations for Treatment Regimen Category II without Extension

/CHO/PPMD Physician.


ANNEX 13D: TREATMENT REGIMEN MODIFICATIONSBASED ON SPUTUM RESULTS

Follow-up Examinations for Regimen-II with Extension

Towards the endof the 4th mo.

Towards the endof the 6th mo. In the beginning of the 9th mo. Towards the end

of the 9th mo. (* 4)If smear positive orsmear negative, startthe maintenance phase(HRE) anyway.

If smear negative,continue themaintenance phase(HRE).

If smear negative, complete the maintenance phaseuntil the end of the treatment course and declare as"Cure."If smear positive, repeatsmear examinationimmediately forconfirmation and consultwith Provincial/City/CHDTB Coordinators throughMHO/CHO/ PPMDPhysician.

If smear negative in therepeated smearexamination, continue themaintenance phase(HRE) and do the smearexamination towards theend of the 9th month oftreatment.


If smear positive, declareas "Treatment Failure."

If smear positive again inthe repeated smearexamination, complete themaintenance phase(HRE) until the end anddeclare as "TreatmentFailure."

If smear positive,continue themaintenance phase(HRE) anyway.

If smear negative, continue the maintenance phase(HRE) and do the smear examination towards theend of the 9th month of treatment.

If smear negative, declareas "Cure."If smear positive,complete the maintenancephase (HRE) until the endof the treatment courseand declare as"Treatment Failure."

If still smear positive, complete the maintenancephase (HRE) until the end of the treatment course anddeclare as "Treatment Failure."

* 4 Check the follow-up sputum smear examination towards the end of the 9th month of treatment only for the patient who has smearpositive in the beginning of the 9th month and shows smear negative in the repeated smear examination; and for the patient who hassmear positive at the end of the 6th month and turns out to be negative in the beginning of the 9th month.

Follow-up Examinations for Treatment Regimen Category II with Extension


99

ANNEX 14A: TREATMENT REGIMEN MODIFICATIONS FOR NEW SMEAR-POSITIVE CASES WHO INTERRUPTED TREATMENTS

ANNEXES

Who Interrupted Treatment

Length oftreatment

Length ofinterruption

Do asmear?

Result ofsmear Register again? Treatment

modificationLess thanone month

Less than 2weeks No No, use the same treatment

card. Continue Regimen-I

2 weeks ormore Yes

PositiveNo, open a new treatmentcard and use same casenumber.

Start again on Regimen- I

Negative No, use the same treatmentcard. Continue Regimen-I

One to twomonths


card. Continue Regimen - I

2 to 8 weeks YesPositive No, use the same treatment

card.

Complete the remainingIntensive Phase, add oneextra month of IntensivePhase.

Negative No, use the same treatmentcard. Continue Regimen - I

More than 8weeks butwithin the 6month regimen

YesPositive

Close the previousregistration as "Defaulter",then re-register as "RAD",open a new treatment card.

Start on Regimen - II


More than 2months

Less than 2weeks No No, use the same

treatment card. Continue Regimen - I

2 to 8 weeks YesPositive

Close the previousregistration as "Defaulter"(*1), then re-register as"RAD", open a newtreatment card.

Start on Regimen - II



YesPositive


Start on Regimen- II

Negative No, use the sametreatment card. Continue Regimen - I

Continue Regimen for Category I








Start on Regimen for Category II



Start again on Regimenfor Category I


ANNEX 14B: TREATMENT REGIMEN MODIFICATION FORRELAPSE & FAILURE CASES WHO INTERRUPTED TREATMENT

Who Interrupted Treatment

Length oftreatment

Length ofinterruption

Do asmear?

Result ofsmear Register again? Treatment

modificationLess thanone month


card. Continue Regimen-II

2 weeks ormore Yes

PositiveNo, open a new treatmentcard and use same casenumber.

Start again on Regimen- II

Negative No, use the same treatmentcard. Continue Regimen-II

One to twomonths


card. Continue Regimen - II

2 to 8 weeks YesPositive No, use the same treatment

card.

Complete the remainingIntensive Phase, add oneextra month of IntensivePhase.

Negative No, use the same treatmentcard. Continue Regimen - II


Yes

Positive


Start on Regimen-II

Negative


Continue Regimen-II

More than 2months


card. Continue Regimen-II

2 to 8 weeks YesPositive

Close the previousregistration as "Defaulter"(*2), then re-register as"RAD", open a newtreatment card.

Start on Regimen-II

Negative No, use the same treatmentcard. Continue Regimen-II


Yes

Positive


Start on Regimen-II

Negative

Close the previousregistration as "Defaulter",then re-register as "RAD",open using a newtreatment card.

Continue Regimen-II

* 2 This is the exceptional case to define as "Defaulter" for a patient who interrupted treatment of less than 8 weeks.

Continue Regimen for Category II











Start again on Regimen for Category II

101

ANNEX 15: GUIDE TO CASE HOLDING

ANNEXES

AT THE TREATMENT UNITTo be accomplished bythe Nurse/Midwife

Record the sputum-smear examination results and due date of next sputumsmear follow-up examination in the NTP Treatment Card. Any follow-upexamination with smear positive results must be referred to the physician.

To be accomplished bythe Nurse

Record the results in the NTP TB Register.

To be accomplished byNurse/Midwife

Inform the treatment partner of the sputum-smear examination results so thatshe can update the NTP ID Card.

To be accomplished bythe Physician, Nurseand Midwife

Upon Treatment Completion1. Evaluate and record the treatment outcome in the NTP TB Register and

NTP Treatment Card.2. Prepare the Quarterly Report on Treatment Outcome and submit it.

AT THE MICROSCOPY CENTER(To be accomplished by the Medical Technologist or Microscopist)

1. Register in the NTP Laboratory Register (date received and serial number)2. Smearing, fixing, staining, and microscopic examination.3. Record the results in the Laboratory Request Form for Sputum Examination and in the NTP

Laboratory Register4. Send the Laboratory Request Form for Sputum Examination to the treatment unit.

AT THE TREATMENT UNITTo be accomplished bythe health workers

1. Conduct health education to patient and his/her family on the following keymessages:• Importance of regular drug intake• Results of irregular drug intake• Side effects of anti-TB drugs• Necessity of follow-up sputum smear examinations• Importance of family and treatment partner support

2. Conduct regular consultation meeting with patient and treatmentpartner during the course of treatment.

To be accomplished bythe Nurse/Midwife andtreatment partner

3. Monitor and record treatment regularly.• TB Register (Nurse)• NTP Treatment Card (Midwife)• NTP ID Card (Treatment Partner and TB patient)

To be accomplished bythe Nurse/Midwife

4. Do follow-up sputum smear examinations on time.• Label container with the name of the patient and serial No.1, 2, 3.• Collect 1 sputum specimen (preferably early morning specimen).• Fill up the NTP Laboratory Request Form for Sputum Examination• Pack the specimens securely and send together with the properly

accomplished Laboratory Request Form for Sputum Examination tomicroscopy center.


ANNEX 16: GUIDE TO ENSURE TREATMENT

Recorded Information should be checked to ensure individual treatment.

NTP TREATMENT CARD

Laboratory Register

NTP TB Register

(to be accomplished by the Nurse or Midwife)Record of Individual Patients

• TB Case Number• Classification, Type and Regimen• Sputum examination results on diagnosis, for follow-up• Drug collection• Defaulter action• Treatment outcome

The nurse should check the followinginformation weekly. These are:

• Is the diagnosis correct?• Is the treatment regimen appropriate?• Are all smear-positive cases registered

and treated properly with DOT?• Are drugs collected on time?• Are follow-up exams done on time?• Are treatments regular and effective?• Are actions taken to retrieve defaulters?

(to be accomplished by the Medicaltechnologist/microscopist)

Record of laboratory examination results• 3 sputum collection• Sputum-smear examination results

on diagnosis/for follow-up

(to be accomplished by the Nurse)Record of Treatment Activity in the Treatment Unit

• TB Case Number• Classification, Type and Regimen• Sputum examination results on diagnosis and for follow-up• Defaulter action• Treatment outcome

103

ANNEX 17: PERSONS RESPONSIBLE FORTHE RECORDING FORMS

ANNEXES

Recording Responsible for InitialRecording

Responsible for RECORDSMaintenance and Updating

NTP Client List/Target ClientList Midwife/Nurse Midwife/Nurse

NTP Laboratory RequestForm for SputumExamination

Midwife/Nurse

NTP Laboratory Register Medical Technologist andMicroscopist

Medical Technologist andMicroscopist

NTP Treatment Card Nurse Midwife/Nurse

NTP Identification Card NurseTreatment partner

(kept by the treatment partner andthe patient)

NTP TB Register Nurse Nurse

NTP Referral/Transfer Form Physician/Nurse

Records

Midwife/Nurse Midwife/Nurse


ANNEX 18: RECORDING & REPORTING FORMS

RECORDING FORMS

TB SYMPTOMATICS MASTERLISTNTP LABORATORY REQUEST FORM FOR SPUTUM EXAMINATIONNTP LABORATORY REGISTERNTP TREATMENT CARDNTP IDENTIFICATION CARDTB REGISTERNTP REFERRAL/TRANSFER FORMTB DIAGNOSTIC COMMITTEE (TBDC) REFERRAL FORMTTB DIAGNOSTIC COMMITTEE MASTERLISTNTP MONITORING CHECKLIST

REPORTING FORMS AND COUNTING SHEETS

QUARTERLY REPORT ON NTP LABORATORY ACTIVITIESCOUNTING SHEET FOR LABORATORY ACTIVITIES REPORTQUARTERLY REPORT ON NEW CASES AND RELAPSES OF TUBERCULOSIS AND ONDRUG INVENTORY AND REQUIREMENTCOUNTING SHEET FOR CASE FINDING BY TYPES/DRUG INVENTORYQUARTERLY REPORT ON THE TREATMENT OUTCOME OF PULMONARY TB CASESREGISTERED 13 – 15 MONTHS EARLIERCOUNTING SHEET FOR QUARTERLY REPORT ON THE TREATMENT OUTCOME OFPULMONARY TB CASESQUARTERLY TB DIAGNOSTIC COMMITTEE ACCOMPLISHMENT REPORT

105

ANNEX 18A: NTP CLIENT LIST / TARGET CLIENT LIST (TCL)

ANNEXES

The following are the instructions on how to record information in the NTP Client List.

(1) Write the family serial number based on the family consultation record or annual serial number for TBsymptomatics in the clinic.

(2) Write the date (mo/dd/yr) when the TB symptomatics were discovered.

(3) Write the patient’s full name, with the family name written first in capital letters followed by the firstname.

(4) Write the patient’s full address including landmarks/telephone or celfone number (if possible) so thatthe patient can be traced in case he/she does not return to get his/her examination results.

(5) Write the exact age of the patient in years.

(6) Indicate the sex of the patient, write M for male and F for female.

(7) Write the date when each sputum specimen is collected and its corresponding results written below.

(8) Write the date and results of sputum collection in TB Sx with doubtful smear results on the firstexamination.

(9) Write the date (mo/dd/yr) when the patient was referred for an X-ray examination.

(10) Write the date when the X-ray finding was received by the health worker and its results written below.

(11) Write the TB Case Number for patients who have been diagnosed with TB and registered.

(12) Write any significant information pertaining to symptomology, referral or diagnostic findings, such aspatient with massive hemoptysis, referred to hospital, etc.

Note: Target Client List (TCL) may be used as TB Symptomatic Masterlist in Public Health facilities.


ANNEX 18B: NTP LABORATORY REQUEST FORMFOR SPUTUM EXAMINATION

TO BE FILLED OUT BY NURSE OR MIDWIFE

Name of Collection Unit: ____________________ Date of Submission: _________________

Name of Patient:___________________________ Age: ______ Sex: M F

Address (in full): ______________________________________________________________

Disease Classification: Pulmonary Extra-pulmonary

Site: _________________________

Reason for Examination Diagnosis Follow-up Others

TB Case No.:__________________

Signature of Specimen Collector:__________________________ Remarks: ______________

Specimen Date of Collection1233

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

(Be sure to enter the patient’s TB Case No. for follow-up of patient’s Chemotherapy)

TO BE FILLED UP BY MICROSCOPY UNIT/LABORATORY PERSONNEL

Date Received: ____________________Laboratory Serial No._______________________

* Specimen #2 & 3 = not applicable if sputum follow-up** Muco-purrulent, bloodstained, saliva, etc.

Date of Examination:____________________ Examined by (Signature):________________

Specimen 1 2* 3*Visual Appearance**ReadingLaboratory Diagnosis

The completed form (with results) should be sent to the treatment unit to record the results in thelaboratory register.

107

ANNEX 18B: NTP LABORATORY REQUEST FORMFOR SPUTUM EXAMINATION (UPPER PORTION)

ANNEXES

The following are the instructions on how to record information in the upper portion of the LaboratoryRequest Form for Sputum Examination. (To be accomplished by the midwife/nurse).

(1) Write the name of the health facility (BHS/RHU/PPMD Unit) where sputum specimen was collected.

(2) Write the date (mo/dd/yr) when the sputum specimens were sent to the laboratory/microscopy unit.

(3) Write the patient’s full name with his/her family name first followed by his/her first name.


(5) Indicate the sex of the patient, write M for male and F for female.

(6) Write the patient’s full address including landmarks/telephone or celfone number (if possible) so thepatient can be traced in case he/she does not return to get his examination results.

(7) Check the Pulmonary box if the patient is a pulmonary TB suspect. Check the Extra-pulmonary box forTB of organs other than the Lung, i.e. pleura (TB pleurisy), bones, genito-urinary tract etc., and the site(name of the organ or body part is written).

(8) Check the diagnosis box for sputum specimens collected for diagnosis (three specimen). The follow-upbox is checked for sputum specimen collected to follow-up sputum smear status of patients undertreatment (one specimen). Check the box on Others for reasons other than the two.

(9) Write the TB Case Number from treatment card/TB registry of patients for follow-up.

(10) Write the date of collection of each sputum specimen and should correspond to the number labeled onthe sputum container; for diagnosis (three specimen), for follow-up (one specimen).

(11) Place the signature of the sputum collector or head of the referring treatment unit.


ANNEX 18B: NTP LABORATORY REQUEST FORMFOR SPUTUM EXAMINATION (LOWER PORTION)

The completed form (with results) should be sent to the treatment unit to record theresults on the Tuberculosis Treatment Card.

The following are the instructions on how to record information in the lower portion of theLaboratory Request Form for Sputum Examination (to be accomplished by the Medical Tech-nologist or Microscopist).

(1) Write the date when the sputum specimen was received with this form at the laboratory ormicroscopy center.

(2) Indicate the laboratory serial number designated for each specific sputum microscopyexamination in the laboratory or microscopy center.

(3) Write the observed visual appearance of each specimen submitted.(4) Write the readings of each specimen examined for sputum microscopy. This is either negative

or positive. If negative, indicate “O.” if positive, indicate the positivity grading as follows:“+n” = 1– 9 AFB / 100 visual fields“1+” = 10 – 99 AFB / 100 visual fields“2+” = 1– 10 AFB / OIF in at least 50 visual fields“3+” = More than 10 AFB / OIF in at least 20 visual fields

(5) Record the overall evaluation of the specimens submitted for sputum microscopy. A POSITIVEresult should have at least two specimens positive. A NEGATIVE result should have at leastthree specimens negative. A DOUBTFUL result has only one specimen positive.

(6) Write the date when the specimens were examined.(7) The Medical Technologist or Microscopist who actually examined the sputum specimen

must sign in the space provided in the form.

109

ANNEX 18C: NTP LABORATORY REGISTER (FORM)

ANNEXES

(1)

Sab.

Serial

No.

(2)

Dat

e of

Reg

istr

atio

n

(3)

Nam

e(4

)Age

(5)

Sex

(6)

Nam

e of

Col

lect

ion

/Tre

atm

ent

Uni

t

(7)

Nam

e/T

ype

ofRef

erring

Phys

icia

n

(8)

Add

ress

(9)

Exam

ined

for

(10)

Dat

e of

Exa

min

atio

n/R

esul

t

(11)

Rem

arks

(12)

Sign

atur

eof

MT

Dx

Ff-u

p(T

BCas

eN

o.)

1st

2nd

Lo

fN

ame

/P

hilC

AT C

ertif

icat

ion

No.


ANNEX 18C: NTP LABORATORY REGISTER(RECORDING INSTRUCTIONS)

The following are the instructions on how to record information in the Laboratory Register(to be accomplished by the Medical Technologist or Microscopist).(1) Write the laboratory serial number assigned for every examination made, whether for diagnosis

or for follow-up.

(2) Write the date when the 1st sputum specimen was received by the microscopy center.

(3) Write the patient’s full name with his family name first in capital letters followed by the firstname.


(5) Indicate patient’s sex with the letter M for male and the letter F for female.

(6) Write the name of the health facility where sputum for diagnosis was collected or name oftreatment unit for patients on follow-up.

(7) Indicate the name and the PhilCAT certification number of the referring physician.

(8) Write the patient’s full address should include landmarks or telephone number/celfone number(if available).

(9) Check Dx when sputum examination was requested for diagnosis. The TB case number isindicated in the column on follow-up examination.

(10) Write the date and the results of each sputum specimen examined in the correspondingcolumns provided.

(11) Write in the remarks column, significant information pertaining to the examination, i.e., Positive,Negative, Doubtful. For visual appearance of the specimens, use the abbreviation M for muco-purulent, S for salivary or QNS for inadequate specimen.

(12) Signature of medical technologist or microscopist who actually examined the sputumspecimens.

111

ANNEX 18D: NTP TREATMENT CARD

DRUG INTAKE (INTENSIVE PHASE)

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

DRUG INTAKE (MAINTENANCE PHASE)

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

REMARKS:

ANNEXES

(Back page of NTP Treatment Card)

Remarks:

1

34

6 7 89 10

1312

11

14

15

16

17

18

19

20

21

22

25

24

23

a b c d

e

5

2

26


ANNEX 18D: NTP TREATMENT CARD (CONTINUATION)

The following are the instructions on how to record information in the treatment card.(1) Write the TB Case Number assigned to a TB case from the TB register.(2) PhilHealth ID Card Number(3) Write the date when this NTP Treatment Card was opened.(4) Write the name of the region and province where the treatment facility is located.(5) Write the name of the health facility/treatment unit where the patient is receiving TB

treatment.(6) Write the patient’s full name with his family name written first in capital letters followed by

the first name.(7) Write the patient’s occupation and place of work.(8) Write the exact age of the patient.(9) To indicate patient’s sex, encircle the letter M for male and the letter F for female.(10) Number of Household contact.(11) Write the patient’s full address including landmarks/telephone number (if available) to

easily trace him/her.(12) Write the name/relationships/address of a person who can assist the patient for a regular

treatment during the entire treatment course. Indicate the number of persons living withthe patient.

(13) Mark/check the appropriate box whether patient has BCG scar or not.(14) Indicate the exact history of patient’s previous TB treatment should be carefully recorded.

If the patient has previous TB treatment history, mark Yes and mark whether it is less thana month or more than a month and specify the drug administered to the him/her; recordthe year and the place the patient received TB medicines.

(15) Check/mark the appropriate box indicating the classification of the patient (Pulmonary orExtra-pulmonary TB). Mark/check the space that indicates the type of patient based onthe previous TB treatment history and results of sputum examination before treatment(New, Relapse, Transferred In, Return After Default, Failure, Other).

(16) Name of referring health worker and type of referral.(17) Record sputum examination results and weight in kilograms of patient.(a-e) Month 0 pertains to the sputum examination result before treatment. Fill up the date

examined and the result of the sputum examination before treatment in the columnsdesignated. The Due Date when follow-up sputum examination is scheduled, the Date

1

34

6 7 8 9 1013

1211

14

15

16

18

19

5

2

113

ANNEX 18D: NTP TREATMENT CARD (CONTINUATION)

(20) Mark one of the Treatment Outcome Cured Treatment Completed, Died, Treatment Failure, Defaulter,Transfer Out. The date is when the patient stopped taking medicines.

(21) Write any pertinent information concerning the diagnosis and treatment process of the patient.(22) Write the name of treatment partner assigned to the patient.(23) Write the designation of the treatment partner, PHN RHM, or BHW.

(24-25) Mark the date the treatment partner collects the medicines for the following one week at BHS anddraw line between marks. If the midwife at the BHS as treatment utilizes this TB Treatment Card as aTB Identification Card, each box should be marked, to indicate the day and month, when the patienttook his/her anti-TB drugs in front of the midwife (treatment partner).

(26) Record pertinent information that occur during the treatment course, i.e. adverse reactions and reasonsfor failure to follow-up/ tracing action.


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


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

Remarks:

ANNEXES

Examined when the sputum examination is actually made and the Result of the follow-upsputum examination should be filled up carefully in the columns of Month 2 to Month >7according to the schedule of following-up sputum examination.

(18) Write the patient’s treatment regimen by the category, I, II or III.(19) Write the date when the first dose is actually taken by the patient.

(Back page of NTP Treatment Card)

17 a b c d

20

21

22

25

24

23

e

26


ANNEX 18E: NTP IDENTIFICATION CARD (FRONT)

CERTIFICATION

This certifies that the patient,

_____________________________,

bearer of this NTP ID Card, hasbeen CURED (completed the

required treatment, dailysupervised by the health

personnel/BHW of_____________________________

RHU/ Health Center and, withNegative smear follow-up result at

the end of the treatment).

Issued this __________ day of_______________, 20___.

_____________________________MHO/RHP

(SIGNATURE OVER PRINTED NAME)

NTPIDENTIFICATION CARD

Case No. (1)

MGA PAALALA1. Ang TB ay nakakahawa pero

nagagamot.2. Ang mga gamot ay kailangan araw-

araw na inumin upang tuluyanggumaling.

3. Kailangang magpasuri ng plema saitinakdang araw ng health workerupang malaman kung gumagaling na.

4. Kapag magaling ka na higit kangmakakatulong sa iyong pamilya atkabarangay.

HEALTH UNIT (2):____________________

NAME OF PATIENT (3):_______________

ADDRESS (in full) (4):

TREATMENT PARTNER/S (5):

(1) The case number designated to a TB casefrom the TB Register after initiation oftreatment/registration is completed.

(2) The name of the health facility/treatmentunit where the patient is receiving TBtreatment.

(3) The full name of the patient (family namewritten first followed by the given name).

(4) The exact address of the patient. Indicate thelandmarks and telephone number (if any) toeasily trace for necessary action.

(5) The name of the treatment partner (aresponsible person supervising the patient’s dailydrug intake).

NTPIDENTIFICATION CARD

115

ANNEX 18E: NTP IDENTIFICATION CARD (BACK)

(6) Disease Classification: Tick one.(7) Indicate the prescribed treatment regimen. Indicate the exact date when treatment started.(8) Type of Patient. Tick one.(9) All sputum examinations done to the patient. Before Tx, indicate examination results before

treatment. In the succeeding months, indicate the follow up examination results and weight inkilograms.

(10) DRUG INTAKE WITH DOT. Indicate the month and tick or sign the corresponding day whentreatment was started. Tick each box, indicating the day and the month, when the patient tookhis/her anti-TB drugs in front of the treatment partner. Indicate a missed day with a blank.

(10)

DISEASE CLASSIFICATION(6) TYPE OF PATIENT (8)

[ ] Pulmonary [ ] New [ ] Treatment Failure

[ ] Extra-Pulmonary [ ] Relapse [ ] Return after default

Site: ________________________ [ ] Transfer In [ ] Others

REGIMEN (7) _____________ SPUTUM EXAMINATION RESULT (9)

Treatment started: BeforeTx 2 mos 3 mos 4 mos 5 mos 6 mos > 7

mos

Mo. _____ Day: _____ Yr.: _______


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


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

Remarks:

ANNEXES

(6)

Date

ResultWeight (kg)

Remarks:


ANNEX 18F: TB REGISTER

Year: _____________________(1)

Date ofRegistrati-

on

(2)TB Case

No.

(3)Name

(4)Age

(5)Sex

(6)Address

(7)HealthFacility

(8)Name /Type of Referring Physician

(9)CLASSOF TBDIAG.(P/EP)

(10)TYPE OF PATIENT

(11)REGIMEN

New Relapse Trans. inReturnafter

defaultFailure Other

The following are the descriptions of the items to be recorded in the form.(1) The exact date when the patient was registered in the TB Register.(2) The case number assigned to a TB case after registration.(3) Name of patient (surname first)(4) Age of the patient in years.(5) Indicate the patient’s sex with the letter M for male and the letter F for female.(6) The exact address of the patient including phone number, if available and the nearest

landmark to easily locate the patient.(7) The health facility or treatment unit where the patient is receiving treatment for TB.(8) Name and PhilCAT Certification No. of Referring Physician / Health Worker, and

type of referral (Public, PPMD, PDI, Walk-in)(9) “P” for Pulmonary TB, “EP” for Extra-pulmonary TB.(10) Check or mark the TYPE of patient under the appropriate column provided.(11) Indicate the prescribed SCC treatment regimen as Category: I, II, III.

Referring Health Worker

Type of ReferralName Type of Referral

117

ANNEX 18F: TB REGISTER (CONTINUATION)

The following are instructions on how to record information on the form.(12) Write the date when the patient first started treatment.(13) Indicate all sputum examinations done to the patient. Indicate the date of examination done

in the upper row and the examination results in the middle row and weight in kilograms in thelower row.

(14) Check the appropriate treatment outcome and indicate the exact date (mm/dd/yr) when thepatient stopped or completed treatment or his last day of drug intake.

(15) Treatment Partner: PHN/RHM/BHW/FM/Others.(16) Remarks – Result of CXR and any information about the patient’s status or any action taken

on his behalf.

Name of Health Facility(12)

DATE STARTED TX.(13)

SPUTUM EXAMINATION RESULTS/WEIGHT RECORD(upper space: date of exam; middle space: results; lower space: weight)

(14)TREATMENT OUTCOME

(15)Tr. Part.

(16)Remarks

(CXRresult, etc.)

Before TX. 2nd mon. 3rd mon. 4th mon. 5th mon. 6th mon. > 7th mon. CureTreat.Compl. Died

Treat.Failure Default Transf. Out

ANNEXES


ANNEX 18G1: PPMD REFERRAL FORM / NTP (Sample PPMD Form)

TO BE FILLED-UP BY RHU/HC/PPMD UNIT STAFF

TO BE FILLED-UP BY DOTS REFERRING PHYSICIAN

119

ANNEX 18G2: PPMD FOLLOW-UP FORM / NTP (Sample PPMD Form)

ANNEXES

TO BE FILLED-UP BY MEDICAL TECHNOLOGIST OR MICROSCOPIST

TO BE FILLED-UP BY RHU/HC/PPMD UNIT STAFF


ANNEX 18H: QUARTERLY REPORT ON NTP LABORATORY / ACTIVITIES

QUARTERLY REPORT ON NTP LABORATORY ACTIVITESName of Province/City: TB Symptomatics/Patients examined

during the ____ Quarter of _____

Name of Health Facility: Date Reported:

Prepared by:

Designation

CASE FINDING

Laboratory Activities Public PPMD

1. No. of TB Symptomatics examined:

2. No. of TB Symptomatics with 3 sputum specimens:

3. No. of TB Symptomatics diagnosed as smear-positive with 2 or more positive results: (including the number of doubtful cases in the 1st collection with at least one positive result in the 2nd collection set)

4. No. of TB Symptomatics with Doubtful result:

TREATMENT FOLLOW-UP

5. No. of Follow-up examination done: Number of smear positive

Type of Facility:Public PPMD - Public-initiated

- Private-initiated

Walk-in Referral

121

ANNEX 18I: COUNTING SHEET FOR LABORATORY ACTIVITIES REPORT

PageStart Lab.

No.Total

PersonsNo. of TB Symptomatics

Examined

No. of TB Symptomaticswith 3 sputum

specimens

No. of TB Symptomaticswith 2 or more positive

No. of TB Symptomaticswith doubtful result

No. of Follow-upexamination done

1

2

3

4

5

6

7

8

9

10

ANNEX 12: GUIDE IN MANAGING SCC DRUGS SIDE EFFECTS

ANNEXES


DRUG INVENTORY AND REQUIREMENT REPORT:

Regimen Est. No. ofCases

FDC A(HRZE)

(BP)

FDC B(HR)(BP)

PZA tab(BP)

Ethambutol(BP)

SM(vial)

INHsrp(100mg /tsp

120ml)

RFPsrp(100mg /tsp

60ml)I (x 6) (x 12)

II (x 9) (x 15) (x 10) (x 56)

III (x 6) (x 12)

Childhood TB

Total for Reg. I, II,and IIITotal + Buffer (Totalmultiplied by 2)

Available on hand

Re-order for Reg. I,II and III

ANNEX 18J: QUARTERLY REPORT ON CASE FINDING & DRUGS INVENTORY

Quarterly Report on New Cases and Relapses of Tubercolosis and onDrug Inventory and Requirement

Name of Province/City: TB Patients registered during

the ____ Quarter of _____

Name of Health Facility: Date Reported:

Prepared by:

Designation

CASE HOLDING REPORT:

Type of Patient Age Group

Health Facility Total

Public PPMDPublic PPMD

M F M F

A. Pulomonary Tubercolosis 1. Smear-positive cases 1.1. New

0 - 14

15 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 & above

SUB-TOTAL

1.1. Relapses

2. New Smear-negative cases

B. New Extra-pulmonary TB

TOTAL

Quarterly Report on Case Finding and Drug Inventory Requirement

Type of Facility:Public PPMD - Public-initiated

- Private-initiated

ReferralReferral

Walk-inWalk-in

CASE FINDING REPORT:

A. Pulmonary Tuberculosis

123

ANNEX 18K: COUNTING SHEET FOR CASE FINDING BY TYPE /DRUG INVENTORY

Page Start TBCase No.

TotalPersons

New Smear Positive

Rel.New

SmearNeg.

NewEP

Progre-ssivePTB

PrimaryPTB

Failure,Transfer In,

Others(*)

Cat. -I Cat. -II Cat. -III0-14 15-24 25-34 35-44 45-54 55-64 65- Total

M F M F M F M F M F M F M F M F

* This column is not for reporting but only for counting validation

+

ANNEXES


ANNEX 18L: NTP QUARTERLY REPORT ON THE TREATMENTOUTCOME OF PULMONARY TB CASES

REGISTERED 13 - 16 EARLIER

Name of Province/City: Patients registered during the Date Reported:

Name of Health Facility: ________ Quarter of _________ Prepared by:

Designation:

Name of Province/City: Patients registered during the

__________ Quarter of __________

Date Reported:

Name of Health Facility Prepared by:

Designation:

TOTAL NUMBER OFREPORTED PULMONARY TB

CASES*

TYPE (1)CURE

(2)TREATMENTCOMPLETED

(3)DIED

(4)TREATMENT

FAILURE

(5)DEFAULTER

(6)TRANSFER

OUT

(1 - 6)TOTAL NO.EVALUATED

(Copy the total number you reported in theCase-Finding Report during the same

quarter)

1. NEW CASES

1.1. Smear-positive

1.2. Smear-negative

2. RE=TREATMENT

2.1. Relapse

2.2 Failure

TOTAL NUMBER EVALUATED* Of those, ________ (number) were excluded from evaluation of chemotherapy for the following reasons: Trans-in, Other and Extra-pulmonary.

__________ Quarter of __________

TYPE CURED TREATMENTCOMPLETED DIED TREATMENT

FAILUREDEFAULTER TRANSFER

OUTTOTAL

New Smear-Positive

New Smear-Negative

Relapse

Failure

TOTAL NUMBEREVALUATED

ANNEX 18M: COUNTING SHEET FOR QUARTERLY REPORT ON THETREATMENT OUTCOME OF PULMONARY TB CASES

5

Type of Facility:Public PPMD

- Public-initiated- Private-initiated

125

ANNEX 19: PROGRAM INDICATORS

INDICATORS CALCULATION DATA SOURCECASE FINDING1. Three- sputum

Collection Rate (%)Number of TB symptomatics who submitted 3sputum specimens

x 100Total number of TB symptomatics examined

Quarterly Report onLaboratory Activities;Laboratory Register

2. Positivity Rate (%) Total number of sputum smear-positive casesdiscovered

x 100Total number of TB symptomatics examined

4. Case Notification Rateof new smear-positivecases per 100,000population

Quarterly Report onLaboratory Activities;Laboratory Register

3. Case DetectionRate (CDR) ofnew smear-positive cases

Number of New smear-positive cases detectedx 100

Number of estimated new smear-positive TBcases(The denominator is a WHO estimation for eachcountry based on available data including casenotifications, mortality and studies on diseaseprevalence and risk of infection, and adjusted forcountries with high incidence. These estimationsare reported every year by WHO in the annual“Global Tuberculosis Control” report.)

Quarterly Report on TBRegister Case finding

Quarterly Report onCasefinding TBRegister

TB DIAGNOSTIC COMMITTEE5. Proportion of new

smear-negative, CXRpositive TB casesdiagnosed as activeTB for treatment

Number of new smear-negative, CXR positive TBcases diagnosed as active TB

x 100Total number of smear-negative, CXR positive TBcases evaluated by TBDC

TBDC Register

OLD

Number of new smear-negative, CXR positive TBcases initiated to treatment

x 100Total number of smear-negative, CXR positive TBcases evaluated by TBDC

(TBDC Register)(NTP TB Register)

6. Proportion of newsmear-negative, CXRpositive TB cases forre-treatment

8. Proportion ofpulmonary smearpositive cases out ofall pulmonary cases(%)

# Number of Pulmonary smear-positive cases(New and Relapse) registered

x 100Total number of pulmonary (New smear-positive,New smear-negative and Relapse) casesregistered

Quarterly Report onCases Initiated toTreatment (TB register)

Number of New smear-positive cases notifiedx 100,000

Total number of population in the specified area

Proportion of pulmonary smear positive cases out of total pulmonary cases (%)

# of TB symptomatics w/ 3 sputum specimensTotal # of TB symptomatics examined X 100

Total # of sputum smear (+) casesTotal # of TB symptomatics examined X 100

# of new smear (+) cases detected # of estimated new smear (+) TB cases X 100

# of pulmonary smear (+) cases registered Total # of pulmonary cases registered X 100

# of new smear (-), CXR (+) active TB Total # of smear (-), CXR (+) TBDC cases X 100

# of new smear (-), CXR (+) TB cases for re-treatment Total # of smear (-), CXR (+) TBDC cases X 100

ANNEXES


ANNEX 19: PROGRAM INDICATORS (CONTINUATION)

INDICATORS CALCULATION DATA SOURCECASE HOLDING7. Sputum conversion

rate at the end of 2months of treatmentfor new smear positivecases (%)

Number of New sputum smear-positive caseswhich are smear negative at the end of 2months of treatment

x 100Total number of New sputum smear-positivecases registered during some period of time

TB register

8. Treatment outcomesfor New smear-positive cases, Newsmear-negative cases,Relapse cases andFailure cases (%).

(Reminder: There is nocure rate applied tosmear negative cases.)

• Cure rate:Number of cases who were cured

x 100Total number of cases registered

• Completion rate:Number of cases who completed treatment


• Death rate:Number of cases who died during thetreatment


• Treatment Failure rate:Number of smear positive cases who stillsmear positive at five months or more oftreatment


• Defaulter rate:Number of cases who were defaulted


• Transfer-out rate:Number of cases who transferred to anotherHealth facility with a proper referral/transferslip


Quarterly Report on theTreatment Outcome ofPulmonary TB cases ;TB register

# of new smear (+) cases who are smear (-) after 2 mos treatment

Total # of new sputum smear (+) cases registered during same period

X 100

# of cases who were cured Total # of cases registered

X 100

# of cases who completed treatment Total # of cases registered

X 100

# of cases who died during treatment Total # of cases registered

X 100

# of cases who defaulted Total # of cases registered

X 100

# of cases who transferred to another Health facility with proper referral/transfer slip

Total # of cases registeredX 100

# of cases of smear (+) cases that remain smear (+) after 5 or more months of treatment

Total # of cases registeredX 100

127

ANNEX 20A: IMPAIRMENT CLASSIFICATION FOR RESPIRATORYDISEASE INJURIES (Modified from American Thoracic Society Criteria)

CRITERIA Class I20% OB

Class 230% OB

Class 350% OB

Class 4100% OB

I. History andP.E. Findings

FunctionalClassification(DYSPNEA)

Grade 1 Grade 2 Grade 3 Grade 4

and and and and

PertinentSigns andSymptoms

SlightConstitutional

symptoms

ModerateConstitutional

symptoms

MarkedConstitutionalsymptoms with

cardio-pulmonaryembarrassment

In Injuries SlightConstitutional

symptoms, alsoPain, discomfort

on exertion;slight limitation

of chestexpansion/excur-

sion, and/orchest deformity

Slight limitationof Chest

expansion and/orchest deformity

Moderaterestriction of

chest expansion,deformities of

chest

Markedrestriction of

chest expansionand/or

deformities ofchest, e.g.,

markedadhesions ofdiaphragm orpericardium

If present

Anemia (Hgb) 81 to 100 g/l 70 to 80 g/l <70 g/l

Weight loss 10% of IBW* 15% of IBW* >15% of IBW*

Respiratoryimpairment byspirometry

Mildly impaired Moderatelyimpaired

Severelyimpaired

Modified Tanhauser's formula for IBW for Filipinos = (height in cm - 100) x 10%

ANNEXES


ANNEX 20B: ATS FUNCTIONAL CLASSIFICATION (of Dyspnea)

DESCRIPTION GRADE DEGREENot troubled by shortness of breath when hurrying on thelevel or walking up a slight hill

0 None

Walks more slowly than people of same age on the levelbecause of shortness of breath

1 Mild

Has to stop for breath when walking at own pace on the level 2 Moderate

Stops for breath when walking about 100 yards or after a fewminutes on the level

3 Severe

Too breathless to leave house, or breathless on dressing orundressing

4 Very severe

RATING PULMONARY FUNCTIONPARAMETERS

FUNCTIONALIMPLICATION

NORMAL FVC > 80% predicted, andFEV1 > 80% of predicted

No functional limitations

MILDLYIMPAIRED

FVC 60-79% of predicted or FEV160-79% of predicted

Usually not correlated withdiminished ability to performmost jobs

MODERATELYIMPAIRED

FVC 51-59% of predicted, orFEV1 41-59% of predicted

Progressively lower level of lungfunction correlated withdiminishing ability to meet thephysical demands of many jobs

SEVERELYIMPAIRED

FVC < 50% of predicted, orFEV1 < 40% of predicted

Unable to meet the physicaldemands of most jobs includingtravel to work

ANNEX 20C: ATS RATINGS OF RESPIRATORY IMPAIRMENTBY SPIROMETRY

_

FEV1 60-79% of predicted

129

ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT

SSS GUIDE to FUNCTIONAL ASSESSMENT

I. Procedures for Scoring the Functional Independence Measure (FIM)

II. Table: Relationship of Raw FIM Score to Impairment of the Whole-Person

III. Description of the Levels of Function and their Scores

A. SELF CARE1. Eating2. Grooming3. Bathing4. Dressing – Upper Body5. Dressing – Lower Body6. Toileting

B. SPHINCTER CONTROL1. Bladder Management2. Bowel Management

C. MOBILITY1. Transfers – Bed, Chair, Wheelchair2. Transfers – Toilet3. Transfers – Tub Shower

D. LOCOMOTION1. Walk/Wheelchair2. Stairs

E. COMMUNICATION1. Comprehension2. Expression

F. SPECIAL COGNITION1. Social Interaction2. Problem Solving3. Memory

ANNEXES


ANNEX 21: SSS GUIDE TO FUNCTIONAL ASSESSMENT (Continuation)

Procedure for Scoringthe Functional Independence Measure (FIM) *

Each of the 18 items comprising the FIM has a maximum score of 7, and thelowest score on each item is 1. The highest total score is 126 and the lowest totalscore is 18. The clinicians in the field have been adamant in their conviction that aseven-level scale is necessary for showing claimant function change with sufficientsensitivity. The original four-level scale was superseded in 1987 and the seven-level scale is recommended for all items.

Comment:

The social cognition items: social interaction, problem solving, and memoryare estimates of function in three important areas of a person’s daily activity. Un-like the other areas of function assessed with the FIM, which have been in clinicaluse for years, consensus is not yet clear among behaviorists and rehabilitationclinicians about how to quantify these activities at the level of disability. The socialcognition items in the FIM have very acceptable reliability. They have been refinedas a result of comments made by users during the trial and implementation phasesand will continue to be refined as more clinical and research experience is gainedby the field.

Step 1. Record the number which best describes the subject’s level of func-tion for every FIM item on the coding sheet.

If the subject would be put at risk for injury if tested, then enter 1.Leave no FIM item blank.

When two helpers are required in order for the patient to perform thebehaviors described in an item, enter level 1. Set-up is uniformlyscored a level 5 for all items.

Step 2. Convert the raw FIM score to the equivalent whole-person impair-ment estimate (% OB). Refer to ‘Table – Relationship of Raw FIMScore to Impairment of the Whole – Person’ on the following page.

* UNIFORM DATA SET FOR MEDICAL REHABILITATION. The Uniform Data System for MedicalRehabilitation was developed with support from the US Department of Education, NationalInstitute on Disability and Rehabilitation Research (NIDRR ), grant number G008435062, andwas conducted by the State University of New York at Buffalo, School of Medicine, Departmentof Rehabilitation Medicine, 1990

131


Relationship of Raw FIM Score to Impairment of the Whole–person(OB)

FIMScore

OBImpairment

(%)

FIMScore

OBImpairment

(%)

FIMScore

OBImpairment

(%)

FIMScore

OBImpairment

(%)126 0 98 26 70 52 42 78

125 1 97 27 69 53 41 79

124 2 96 28 68 54 40 80

123 3 95 29 67 55 39 81

122 4 94 30 66 56 38 81

121 5 93 31 65 56 37 82

120 6 92 31 64 57 36 83

119 6 91 32 63 58 35 84

118 7 90 33 62 59 34 85

117 8 89 34 61 60 33 86

116 9 88 35 60 61 32 87

115 10 87 36 59 62 31 88

114 11 86 37 58 63 30 89

113 12 85 38 57 64 29 90

112 13 84 39 56 65 28 91

111 14 83 40 55 66 27 92

110 15 82 41 54 67 26 93

109 16 81 42 53 68 25 94

108 17 80 43 52 69 24 94

107 18 79 44 51 69 23 95

106 19 78 44 50 70 22 96

105 19 77 45 49 71 21 97

104 20 76 46 48 72 20 98

103 21 75 47 47 73 19 99

102 22 74 48 46 74 18 100

101 23 73 49 45 75

100 24 72 50 44 76

99 25 71 51 43 77

ANNEXES



Description of the Levels of Function and Their Scores

A. SELF-CARE1. EATING

Includes use of suitable utensils to bring food to the mouth, chewing andswallowing, once the meal is appropriately prepared.

NO HELPER

7 CompleteIndependence

Eats from a dish, while managing all consistencies of food, anddrinks from a cup or glass with the meal presented in the customarymanner on a table or tray. The subject uses a spoon of fork tobring food to the mouth: food is chewed and swallowed.

6 ModifiedIndependence

Requires an adaptive or assistive devise such as a straw, spork,rocking knife, requires more than a reasonable time to eat, orrequires modified food consistency or blenderized food, or thereare safety considerations. If the individual relies in part on othermeans of alimentation, such as parenteral of gastrostomy feedings,then he/she administers the feedings him/herself.

HELPER

5 Supervision orSet-up

Requires supervision (e.g. standing by, cuing, or coaxing) or setup(application of orthoses); or another person is required to opencontainers, cut meat, butter bread or pour liquids.

4 Minimal ContactAssistance

Subject performs 75% or more of feeding tasks.

3 Moderate Assistance Performs 50% to 74% of feeding tasks

2 Maximal Allowance Performs 25% to 49% of feeding tasks

1 Total Assistance Performs <25% of feeding tasks. Or, the individual does not eat ordrink full meals by mouth but must rely in part on other means ofalimentation, such as parenteral or gastrostomy feedings, and doesnot administer the findings him/herself.

133


2. GROOMINGIndicates oral care, hair grooming, washing hands and face, and eithershaving or applying make-up. If there is no preference for shaving or

applying make-up, then disregard.

NO HELPER


Cleans teeth or dentures, combs or brushes hair, washes handsand face, shaves or applies make-up, including all preparations.


Requires specialized equipment (including prosthesis, or orthosis)or takes more than a reasonable time, or there are safetyconsiderations.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (application of orthoses, setting out grooming equipment, andinitial preparation such as applying toothpaste to brush, openingmake-up containers).


Subject performs 75% or more of grooming tasks

3 Moderate Assistance Performs 50% to 74% of grooming tasks

2 Maximal Assistance Performs 25% to 49% of grooming tasks

1 Total Assistance Performs <25% of grooming tasks

ANNEXES



3. BATHING

Indicates bathing the body from the neck down (excluding the back),either tub, shower or sponge/bed bath. Performs safely.

NO HELPER


Baths and dries the body.


Requires specialized equipment (including prosthesis, or orthosis)or takes more than a reasonable time, or there are safetyconsiderations.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (setting out bathing equipment, and initial preparation such aspreparing the water or washing materials).


Subject performs 75% or more of bathing tasks

3 Moderate Assistance Performs 50% to 74% of bathing tasks

2 Maximal Assistance Performs 25% to 49% of bathing tasks

1 Total Assistance Performs <25% of bathing tasks

135


4. DRESSING – UPPER BODY

Indicates dressing above the waist as well as donning and removingprosthesis or orthosis when applicable.

NO HELPER


Dresses and undresses including obtaining clothes from theircustomary places such as drawers and closets; manages zippers,buttons, and snaps; dons and removes prosthesis or orthosis whenapplicable.


Requires special adaptive closure such as Velcro, or assistivedevice (including prosthesis or orthosis) or takes more than areasonable time.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (application of orthosis, setting out clothes or dressingequipment).

4Minimal Contact

AssistanceSubject performs 75% or more of dressing tasks

3 Moderate Assistance Performs 50% to 74% of dressing tasks

2 Maximal Assistance Performs 25% to 49% of dressing tasks

1 Total Assistance Performs <25% of dressing tasks

ANNEXES



5. DRESSING – LOWER BODY

Indicates dressing from the waist down as well as donning and removingprosthesis or orthosis when applicable.

NO HELPER


Dresses and undresses including obtaining clothes from theircustomary places such as drawers and closets; managesunderpants, slacks, skirt, belt, stockings, and shoes; manageszippers, buttons, and snaps; dons and removes prosthesis ororthosis when applicable.


Requires special adaptive closure such as Velcro, or assistivedevice (including prosthesis or orthosis) or takes more than areasonable time.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (application of orthosis, setting out clothes or dressingequipment).


Subject performs 75% or more of dressing tasks

3 Moderate Assistance Performs 50% to 74% of dressing tasks

2 Maximal Assistance Performs 25% to 49% of dressing tasks

1 Total Assistance Performs <25% of dressing tasks

137


6. TOILETING

Includes maintaining perineal hygiene and adjusting clothing before andafter toilet or bedpan use. Performs safely.

NO HELPER


Cleanses self after voiding and bowel movement; puts on sanitarynapkins/inserts tampons; adjusts clothing before and after usingtoilet.


Requires specialized equipment (including prosthesis or orthosis)or takes more than a reasonable time, or there are safetyconsiderations.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (application of adaptive devices or opening packages).


Subject performs 75% or more of toileting tasks

3 Moderate Assistance Performs 50% to 74% of toileting tasks

2 Maximal Assistance Performs 25% to 49% of toileting tasks

1 Total Assistance Performs <25% of toileting tasks

ANNEXES



2


Controls bladder completely and intentionally and is never incontinent.

6 Modified Independence Requires a urinal, bedpan, commode, catheter, absorbent pad, diaper,urinary collecting device or urinary diversion or uses medication for control;if catheter is used, the individual instills or irrigates catheter withoutassistance; cleans, sterilizes, and sets up the equipment for irrigationwithout assistance. If the individual uses a devise, he/she assembles andapplies condom drainage or al ileal appliance without assistance of anotherperson; empties, puts on, removes, and cleans leg bag or empties andcleans ileal appliance bag. No accidents.

HELPER

5 Supervision or Set-up Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (placingor emptying ) of equipment to maintain a satisfactory voiding pattern or tomaintain an external device; or because of the lapse of time to get tobedpan or the toilet the individual may have occasional bladder accidents,or bedpan or urinal spills, but less often than monthly.


Requires minimal contact assistance to maintain an external devise; theindividual performs 75% or more of bladder management tasks; or mayhave occasional bladder accidents, but less often than weekly.

3 Moderate Assistance Requires moderate contact assistance to maintain an external devise; theindividual performs 50% to 74% of bladder management tasks, or mayhave occasional bladder accidents, but less often daily.

Maximal Assistance Despite assistance the individual is wet on a frequent or almost daily basis,necessitating wearing diapers or other absorbent pads, whether or not acatheter or ostomy devise is in place. The individual performs 25% to 49%of bladder management tasks.

1 Total Assistance Despite assistance the individual is wet on a frequent or almost dailybasis, necessitating wearing diapers or other absorbent pads, whether ornot a catheter or ostomy devise is in place. The individual performs <25%of bladder management tasks.

Comment: The functional goal of bladder management is to open the bladder sphincter only when that isneeded and to keep it closed the rest of the time. This may require devices, drugs or assistance in someindividuals. This item, therefore, deals with two variables: 1) level of success in bladder management and2) level of assistance required. Usually the two follow each other, e.g. when there are more accidents usuallymore assistance is required. However, should the two levels not be exactly the same, always record thelower level.

B. SPHINCTER CONTROL1. BLADDER MANAGEMENT

Includes complete intentional control of urinary bladder anduse ofequipment or agents necessary for bladder control.

NO HELPER

139


2. BOWEL MANAGEMENTIncludes complete intentional control of bowel movementand use of

equipment or agents necessary for bowel control.NO HELPER


Controls bowels completely and intentionally and is neverincontinent


Requires bedpan or commode, digital stimulation or stool softeners,suppositories, laxatives, or enemas on a regular basis, or usesother medication for control. If the individual has a colostomy, he/she maintains it. No accidents.

HELPER5 Supervision or

Set-upRequires supervision (e.g. standing by, cuing, or coaxing) or set-up of equipment necessary for the individual to maintain asatisfactory excretory pattern or to maintain an ostomy device; orthe individual may have occasional bowel accidents, but less oftenthan monthly.


Requires minimal contact assistance to maintain a satisfactoryexcretory pattern by using suppositories or enemas or an externaldevise; the individual performs 75% or more of bowel managementtasks; or may have occasional bowel accidents, but less oftenthan weekly.

3 Moderate Assistance Requires moderate contact assistance to maintain a satisfactoryexcretory pattern by using suppositories or enemas or an externaldevise; the individual performs 50% to 74% of bowel managementtasks, or may have occasional bowel accidents, but less oftenthan daily.

2 Maximal Assistance Despite assistance the individual is soiled on a frequent or almostdaily basis, necessitating wearing diapers or other absorbent pads,whether or not an ostomy devise is in place. The individualperforms 25% to 49% of bowel management tasks.

1 Total Assistance Despite assistance the individual is soiled on a frequent or almostdaily basis, necessitating wearing diapers or other absorbent pads,whether or not an ostomy devise is in place. The individualperforms <25% of bowel management tasks

Comment: The functional goal of bowel movement is to open the anal sphincter only when that is neededand to keep it closed the rest of the time. This may require devices, drugs or assistance in some individuals.This item, therefore, deals with two variables: 1) level of success in bowel management and 2) level ofassistance required. Usually the two follow each other, e.g. when there are more accidents usually moreassistance is required. However, should the two levels not be exactly the same, always record the lowerlevel.

ANNEXES



C. MOBILITY

1. TRANSFERS – BED, CHAIR, WHEELCHAIR

Includes all aspects of transferring to and from bed, chair, and wheelchair,and coming to a standing position, if walking is the typical mode of

locomotion.

NO HELPER


… If walking. Approaches, sits down and gets up to a standingposition from a regular chair; transfers from bed to chair. Performssafely.

… If in a wheelchair. Approaches a bed or chair, locks brakes, liftsfoot rests, removes arm rest if necessary, and performs either astanding pivot or sliding transfer and returns. Performs safely.


Requires adaptive or assistive devise (including prosthesis ororthosis) such as a sliding board, a lift, grab bars, or special seator chaor or brace or crutches; takes more than a reasonable time,or there are safety considerations.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (positioning sliding board, moving foot rests, etc.).


Subjects performs 75% or more of transferring tasks

3 Moderate Assistance Performs 50% to 74% of transferring tasks.

2 Maximal Assistance Performs 25% to 49% of transferring tasks.

1 Total Assistance Performs <25% of transferring tasks.

Comment: When assessing bed to chair transfer, the subject begins and ends in the supine position.

141


2. TRANSFERS - TOILET

Includes getting on and off a toilet.

NO HELPER


… If walking. Approaches, sits down and gets up from a standardtoilet. Performs safely.

… If in a wheelchair. Approaches toilet, locks brakes, lifts footrests, removes arm rests if necessary, and does either a standingpivot or sliding transfer and returns. Performs safely.


Requires adaptive or assistive devise (including prosthesis ororthosis) such as a sliding board, a lift, grab bars, or special seat;takes more than a reasonable time, or there are safetyconsiderations.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (positioning sliding board, moving foot rests, etc.).





1 Total Assistance Performs less than 25% of transferring tasks.

ANNEXES



3. TRANSFERS - TUB OR SHOWER

Includes getting into and out of a tub or shower stall.

NO HELPER


… If walking. Approaches, enters and leaves a tub or shower stall.Performs safely

.… If in a wheelchair. Approaches tub or shower, locks brakes,lifts footrests, removes armrests if necessary, and does either astanding pivot or sliding transfer and returns. Performs safely.


Requires adaptive or assistive devise (including prosthesis ororthosis) such as a sliding board, a lift, grab bars, or special seat;takes more than a reasonable time, or there are safetyconsiderations.

HELPER


Requires supervision (e.g. standing by, cuing, or coaxing) or set-up (positioning sliding board, moving foot rests, etc.)





1 Total Assistance Performs < 25% of transferring tasks.

143


1. WALK/WHEELCHAIR

Includes walking, once in a standing position, or using a wheelchair, oncein a seated position, on a level surface. Check most frequent mode of

locomotion. If both are about equal, check both W and C.W = walking C = wheelchair

NO HELPER

Performs < 25% of effort, or requires assistance of two people, ordoes not walk or wheel a minimum of 50 feet.


… Walks a minimum of 150 feet without assistive devise. Doesnot use a wheelchair. Performs safely.


Walks a minimum of 150 feet but uses a brace (orthosis) orprosthesis on leg, special adaptive shoes, cane, crutches, orwalkarette: takes more than a reasonable time, or there are safetyconsiderations.

If not walking, operates manual or electric wheelchair independentlyfor a minimum of 150 feet; turns around; maneuvers the chair to atable, bed, toilet; negotiates at least a 3% grade; maneuvers onrugs and over doorsills.

5 Exception(HouseholdAmbulation)

Walks only short distances (a minimum of 50 feet) with or withouta devise. Could take more than reasonable time, or there aresafety considerations, or operates a manual or electric wheelchairindependently only short distances (a minimum of 50 feet)

HELPER5 Supervision or

Set-upIf walking, requires standing by supervision, cuing, or coaxing togo a minimum of 150 feet.

If not walking, requires standing by supervision, cuing, or coaxingto go a minimum of 150 feet in wheelchair.


Subject performs 75% or more of locomotion effort to go aminimum of 150 feet.

3 Moderate Assistance Performs 50% to 74% of locomotion effort to go a minimum of 150feet.

2 Maximal Assistance Performs 25% to 49% of locomotion effort to go a minimum of 50feet. Requires assistance of one person only.

1 Total Assistance

D. LOCOMOTION

ANNEXES



2. STAIRS

Goes up and down 12 to 14 stairs (one flight) indoors.

NO HELPER


Goes up and down at least one flight of stairs without any type ofhandrail or support. Performs safely.


Goes up and down at least one flight of stairs requiring side supportor handrail, cane or portable supports; takes more than areasonable time, or there are safety considerations.

5 Exception(HouseholdAmbulation)

Goes up and down 4 to 6 stairs independently, with or without adevise. Could take more than reasonable time or there are safetyconsiderations.

HELPER


Requires standing by supervision, cuing, or coaxing to go up anddown one flight.


Subject performs 75% or more of effort to go up and down oneflight.

3 Moderate Assistance Performs 50% to 74% of the effort to go up and down one flight.

2 Maximal Assistance Performs 25% to 49% of stair climbing effort to go up and down 4to 6 stairs. Requires assistance of one person only.

1 Total Assistance Performs < 25% of the effort, or requires assistance of two people,or does not go up and down 4 – 6 stairs, or is carried.

145


1. COMPREHENSION

Includes understanding of either auditory or visual communication (e.g.writing, sign language, gestures). Check and evaluate the most usualmode of comprehension. If both are equally used, check both A and V.

A = Auditory V = VisualNO HELPER

Comment: Comprehension of complex or abstract information includes, but is not limited to understanding:group conversation, current events appearing in television programs or newspaper articles, or abstractinformation such as religion, humor, math, or finances used in daily living. Information about basic dailyneeds refers to conversation, directions, question or statements related to the subject’s need for nutrition,fluids, elimination, hygiene, sleep (physiological needs).


Understands directions and conversation that are complex orabstract; understands either spoken or written native language.


Understands directions and conversations that are complex orabstract in most situations or with mild difficulty. No prompting isneeded. May require a hearing or visual aid, other assistive device,or extra time to understand the information.

HELPER

5 Standby Prompting Understands directions and conversation about basic daily needsmore than 90% of the time. Requires prompting (slowed speechrate, use of repetition, stressing particular words or phrases,pauses; visual or gestural cues) less than 10% of the time.

4 Minimal Prompting Understands directions and conversation about basic daily needs75% to 90% of the time.

3 Moderate Prompting Understands directions and conversation about basic daily needs50% to 74% of the time.

2 Maximal Prompting Understands directions and conversation about basic daily needs25% to 49% of the time. May understand only simple questions orstatements. Requires prompting more than half the time.

1 Total Assistance Understands directions and conversation about basic daily needs< 25% of the time, or does not understand simple questions orstatements or may not respond appropriately or consistently despiteprompting.

E. COMMUNICATION

ANNEXES



2. EXPRESSIONIncludes clear vocal or non-vocal expression of language. This itemincludes both intelligible speech and expression of language using

writing or a communication device. Check and evaluate the most usualmode of expression. If both are about equally used, check both V and N.

V = Vocal N = Non-vocalNO HELPER

Comment: Examples of complex or abstract ideas include, but is not limited to, discussing current events,religion, or relationships with others. Expression of basic needs and ideas refers to the subject’s ability tocommunicate about necessary daily activities such as nutrition, fluids, elimination, hygiene, and sleep(physiological needs).


Expresses complex or abstract ideas clearly and fluently.


Expresses complex or abstract ideas in most situations, or withmild difficulty. No prompting is needed. May require anaugmentative communication device or system.

HELPER

5 Standby Prompting Expresses basic daily needs and ideas more than 90% of the time.Requires prompting (e.g. frequent repetition) less than 10% of thetime to be understood.

4 Minimal Prompting Expresses basic daily needs and ideas 75% to 90% of the time.

3 Moderate Prompting

Expresses basic daily

needs and ideas 50% to 74% of the time.

2 Maximal Prompting Expresses basic daily needs and ideas 25% to 49% of the time.May use only single words or gestures. Needs prompting morethan half the time.

1 Total Assistance Expresses basic daily needs and ideas < 25% of the time, or doesnot express basic needs appropriately or consistently despiteprompting.

147


1. SOCIAL INTERACTION

Includes skills related to getting along and participating with others intherapeutic and social situations. It represents how one deals with one’s

own needs together with the needs of others.

NO HELPER


Interacts appropriately with staff, other patients, and familymembers (e.g. controls temper, accepts criticism, is aware thatwords and actions have an impact on others).


Interacts appropriately with staff, other patients, and familymembers in most situations or with mild difficulty. No supervisionis required. May require more than a reasonable time to adjust insocial situations or may require medication for control.

HELPER

5 Supervision Requires supervision (e.g. monitoring; verbal control; cuing, orcoaxing) only under stressful or unfamiliar conditions, but no morethan 10% of the time. May require encouragement to initiateparticipation.

4 Minimal Direction Subject interacts appropriately 75% to 90% of the time.

3 Moderate Direction Interacts appropriately 50% to 74% of the time.

2 Maximal Direction Interacts appropriately 25% to 49% of the time. May need restraint.

1 Total Assistance Interacts appropriately less than 25% of the time, or not at all. Mayneed restraint.

Examples of socially inappropriate behaviors: temper tantrums; loud, foul or abusive language; excessivelaughing, crying; physical attack; or very withdrawn or non-interactive.

F. SPECIAL COGNITION

ANNEXES



2. PROBLEM SOLVINGIncludes skills related to solving problems of daily living. This means making

reasonable, safe, and timely decisions regarding financial, social and personal affairsand initiating, sequencing and self-correcting tasks and activities to solve the

problems.NO HELPER

Examples of problems: Complex problem solving includes activities such as: managing a checking account,participating in discharge plans, self-administration of medications, confronting impersonal problems, andmaking employment decisions. Routine problems include successfully completing daily tasks or dealingwith unplanned events or hazards that occur during daily activities.


Consistently recognizes a problem, makes appropriate decisions,initiates and caries out a sequence of steps to solve complexproblems until the task is completed, and self-corrects if errorsare made.


Recognizes a problem, makes appropriate decisions, initiates andcarries out a sequence of steps to solve complex problems inmost situations, or with mild difficulty, or requires more than areasonable time to make decisions about or solve complexproblems.

HELPER

5 Supervision Requires supervision (e.g. cuing, or coaxing) to solve routineproblems only under stressful or unfamiliar conditions, no morethan 10% of the time.

4 Minimal Direction Subject solves routine problems 75% to 90% of the time.

3 Moderate Direction Solves routine problems 50% to 74% of the time.

2 Maximal Direction Solves routine problems 25% to 49% of the time. Needs directionmore than half the time to initiate, plan or complete simple dailyactivities. May need restraint for safety.

1 Total Assistance Solves routine problems < 25% of the time. Needs direction nearlyall the time, or does not effectively solve problems. May requireconstant 1:1 direction to complete simple daily activities. May needa restraint for safety.

149


3. MEMORY

Includes skills related to recognizing and remembering while performingdaily activities inan institutional or community setting. It includes ability tostore and retrieve information, particularly verbal and visual. A deficit in

memory impairs learning as well asperformance of tasks.

NO HELPER


Recognizes people frequently encountered and remembers dailyroutines: executes requests of others without need for repetition.


Recognizes people frequently encountered, remembers dailyroutines and requests of others with mild difficulty. May use self-initiated or environmental cues, prompts or aids.

HELPER

5 Standby Prompting Requires prompting (e.g. cuing, repetition, reminders) only understressful or unfamiliar conditions, but no more than 10% of thetime.

4 Minimal Prompting Subject recognizes and remembers 75% to 90% of the time.

3 Moderate Prompting Recognizes and remembers 50% to 74% of the time.

2 Maximal Prompting Recognizes and remembers 25% to 49% of the time. Needsprompting more than half the time.

1 Total Assistance Recognizes and remembers < 25% of the time, or does noteffectively recognize and remember.

ANNEXES


ANNEX 22A: TB BENEFIT FORM (DOLE Guidelines - Front)

TB BENEFIT FORMName ________________________ Age _____ Sex _____ Date of Referral _________________________

Occupation ________________________ Home Tel. No. _________________________

Company ________________________ Work Phone No. _________________________

Company Address ________________________ Home Address _________________________________________

________________________ _________________________________________

ATTENDING PHYSICIAN'S REPORTSymptomatic? Yes No

Chronic Cough

Afternoon Fever

Hemoptysis

Weight Loss

Chest and/or Back Pain

Prior TB Diagnosis or Treatment (attach clinical abstract, if present)

Others: _______________________________________________

P.E. Findings Suggestive of TB? Yes No

Weight:

% of Ideal Body Weight

Pulomonary signs of TB:

Extra-Pulmonary signs of TB:

Sputum AFB Smears done Three Times? Yes No

Sputum 1: Positive Negative Date:



Sputum AFB Culture Positive? Yes No

Chest X-Ray Suggestive of TB? Yes No

Histopath. Suggestive of TB or Fluid Culture Positive? Yes No

Signature M.D.

License No.

SSS/GSIS/PHIC Accre. No.

PTR No.

EMPLOYER'S CERTIFICATION (For EC Claims)Status Employee Dependent

Employment History attached Job Description attached

Pre-Employment Chest X-Ray Normal

Abnormal; plese specify ______________________________________________

Pre-Employment P.E. Normal

Abnormal; plese specify ______________________________________________

Signature

Name

Position

Company

SSS/GSIS/PhilHealth VerificationNot qualified for benefits. Reason:

Complete requirements; approved for processing

Incomplete requirements. Please submit the following before processing could proceed:

Signature

Name

Official Designation

Date

151

ANNEX 22B: TB BENEFIT FORM (DOLE Guidelines - Back)

EXTENSION OF TEMPORARY TOTAL DISABILITY (TB Sickness) BENEFITSSputum AFB Smears done Three Times? Yes No





Impairment classification of class 1 or higher? Yes No

Certification from attending physician for extra-pulmonary TB? Yes No

Signature

License No.


PTR No.

PERMANENT TOTAL DISABILITY

Pulmonary TBMet Criteria for PTB? Yes No

Sputum AFB Smears done Three Times? Yes No





Impairment classificationof class 1-3 for partial Yes No

Class 4 for total? Yes No

Proof of 100 days of documented treatment? Yes No

Extra-Pulmonary TBMet Criteria for extra-pulmonary TB? Yes No

Satisfied functional impairment classification and functional independence measure oforgan involved Yes No

Proof of 100 days of documented treatment Yes No

Signature M.D.

License No.


PTR No.

M.D.

ANNEXES


ANNEX 23A: TB DIAGNOSTIC COMMITTEE

The TB Diagnostic Committee (TBDC)

BACKGROUND AND RATIONALE

The D.O.T.S. strategy was pilot-tested in the Philippines’ NTP in 1996, and was subse-quently expanded throughout the country. However, the smear (+) cases represented onlyabout 35% of the pulmonary TB cases,1 and among the smear negative but X-ray positiveTB cases, about 30%-50% were thought to be inactive TB cases. Most of these cases werereferrals from the private sector.

A 1997 study conducted in the NTP D.O.T.S. pilot sites showed that among cases diag-nosed by chest X-ray, only 25% have radiographic findings suggestive of active PTB, 36%have “suspicious shadows” only (or with doubtful TB activity), and 39% had either, normal X-rays or, radiographic lesions secondary to other diseases (Chaulet, P; WHO). There was ahigh level of over-reading and over-diagnosis that led to the unnecessary anti-TB treatmentof many patients. These patients were subjected to the psychological burden of being la-beled as a TB patient, and were exposed to the potential adverse effects of the anti-TBdrugs. Moreover, the situation resulted in the waste of limited resources particularly anti-TBdrugs.

These observations demonstrate the inherent problems, and the relatively low accu-racy, of the X-ray based diagnosis of TB. To improve the quality of diagnosis among thesmear negative/X-ray positive TB suspects in DOTS areas, the NTP created TB DiagnosticCommittees (TBDC) at the provincial or city level. These committees were tasked to evalu-ate the clinical data and X-ray films of the smear negative/X-ray positive TB suspects, andto come up with the diagnosis and the corresponding therapeutic recommendations (byconsensus) for these patients. The TBDC was subsequently integrated into the NTP frame-work for TB case finding.

OBJECTIVES

General Objective

The TBDC was created to improve the quality of diagnosis among smear negativePTB cases.

Specific Objectives

1. Reduce the level of over-diagnosis and over-treatment among smear negative PTB cases,2. Ensure that the active cases of smear negative PTB are detected, and are provided with

the appropriate anti-TB treatment.

1 Ahn, DI. Mission Report; TB Prevention and Control. World Health Organization. 1998.

153

ANNEX 23A: TB DIAGNOSTIC COMMITTEE (Continuation)

TBDC COMPOSITION AND ROLES OF COMMITTEE MEMBERS

The TBDC is chaired by the public sector (NTP Medical Coordinator) whose mem-bers come from the public and private sectors representing various disciplines. TheTBDC is established at the province or city level, or as an added option, at the districtlevel. The composition of the TBDC is as follows:

Provincial/City TB Diagnostic Committee:

1. Provincial/City NTP Medical Coordinator1.1 Acts as the Chairperson of the TBDC (Note: another TBDC member may be designated

as co-chairperson).1.2 Organizes the Committee.1.3 Convenes the Committee regularly.1.4 Moderates the discussions of the committee.1.5 Prepares the quarterly reports of the TBDC.1.6 Monitors and supervises the outputs of the TBDC activities

2. Radiologist2.1 Reviews the referred x-ray films together with the other Committee members.2.2 Provides a description and interpretation of the X-ray findings that will serve as one of

the bases for diagnosis and treatment.

3. Clinician/Internist/Pulmonologist3.1 Provides an analysis of the clinical data of each case for correlation with the radiographic

findings.3.2 Recommends the appropriate intervention(s) for the referred patients.

4. Provincial/City NTP Nurse Coordinator4.1 Consolidates the necessary documents of the referred cases prior to each meeting.4.2 Acts as the committee Secretariat.4.3 Monitors and supervises the outputs of the TBDC activities under the direction of the

Chairperson.

ORGANIZING THE TB DIAGNOSTIC COMMITTEE

1. The NTP Coordinators (Provincial or City level) will initiate a preliminary discussion with the PHO/CHO regarding the prospective members of the Committee.

2. An initial meeting with the potential members will be convened by the Province/City NTPCoordinators, in consultation with the PHO/CHO, to discuss the creation of theCommittee. The CHD NTP Coordinators may be invited to provide the technical inputs.The participants will also be given an orientation on the NTP, and on the TBDC.

3. The solicitation of membership will be formalized by the PHO/CHO. The operating detailssuch as the venue, and schedule of the TBDC sessions will also be finalized.

ANNEXES


4. A copy of the final list of members will be provided to the Provincial / City health officeand CHD.

Note: A district level TB Diagnostic Committee may also be established as an option, to make theTBDC services more accessible to the peripheral health units and to reduce the volume ofreferrals to the Provincial TBDC. The district level TBDC reports to the Provincial/City Medicalcoordinator. Monitoring of the district TBDC is the responsibility of the Provincial/City NTPcoordinators.

RECORDING/REPORTING

The TBDC shall make use of the prescribed TBDC referral, recording, and reporting forms(see table for descriptions, and Annexes 23B, 23C, 23D, and 24). The quarterly TBDC report shallbe prepared by the NTP coordinators and submitted to the CHD together with the other NTPquarterly reports.

FORM GENERAL DESCRIPTION RESPONSIBLE PERSON

TBDC ReferralForm

Used for referring smear negative TBsuspects to the TBDC. The form hastwo parts:

Upper Portion contains the clinicalinformation of the patient.

Upper portion to be filled-up by thePhysician or PHN referring unit: RHU,MHC, PPMD unit.

Lower Portion contains the TBDCfindings/decisions and therapeuticrecommendations.

Lower portion to be filled-up by theTBDC Secretariat, and duly signed bythe TBDC Chairperson andSecretariat.

TBDC Masterlist This is the listing of all Smearnegative TB suspects referred to theTBDC.

TBDC Secretariat

Quarterly TBDCReport form

This is the accomplishment report ofthe TBDC submitted to the CHD on aquarterly basis.

Provincial/City Medical or Nurse NTPCoordinators

MONITORING AND EVALUATION

Monitoring and evaluation of the TBDC shall be done in conjunction with the regular NTPmonitoring and program review. The IDO and other TB partners can join the CHD in the monitor-ing and evaluation of the TBDC. The TBDC Chairperson/NTP Coordinators should ensure thatthe TBDC recommendations are implemented by the RHU/MHC/PPMD unit accordingly.


155

REFERRAL PROCEDURES (Referring Unit Level)

1. The RHU/Main HC/PPMD unit shall refer to the TBDC all smear negative / X-ray positive TBsuspects using the TBDC Referral Form. The referring unit’s physician or PHN shall fill upcompletely the upper portion of the TBDC Referral Form.

2. The referring unit should follow the “Sample Flowchart for the Diagnosis of Smear NegativePTB” (MOP, page 18. 2001) in Annex 3.

3. The referring unit shall ensure that all the available chest x-ray films (including old films) andproperly filled-up TBDC Referral Form of each referred patient are submitted to the TBDC.

TB DIAGNOSTIC COMMITTEE OPERATING PROCEDURES

1. The Secretariat will consolidate all documents (including X-ray films) pertaining to each referredcase, and register all of the referred cases on the TBDC Masterlist.

2. The Committee will review all the documents and deliberate on each referred case duringtheir regular sessions.

3. The Committee will come-up with a consensus regarding the diagnosis and recommendationson patient management based on the recommended Diagnostic Flowchart (TechnicalGuide). If the Committee feels the need to see the patient, then the patient will be invited tothe next Committee session.

4. The Secretariat will write the TBDC diagnosis and recommendations on the Lower Portion ofthe TBDC Referral Form in accordance with the discussions during the TBDC session. Boththe Chairperson and the Secretariat should affix their signatures on the completed form.

5. The completed TBDC Referral Forms will be sent back to the referring units (RHU/Main HC/PPMD unit) for implementation of the TBDC recommendations. For patients who arerecommended for anti-TB treatment, their TBDC Referral Forms should be attached to theirrespective NTP Treatment Cards. All other completed TBDC referral forms should be filedfor future reference.

6. TBDC sessions shall be held at least two times a month.


ANNEXES


ANNEX 23B: TB DIAGNOSTIC COMMITTEE (TBDC) Referral Form

157

ANNEX 23B: TB DIAGNOSTIC COMMITTEE (TBDC) Referral Form

Important data to obtain from the referral form:

1. Patient’s age and sex, and other relevant personal data.2. Number of sputum examinations prior to TBDC referral, and compliance to MOP guidelines.3. Laboratory results: for verification of sputum AFB results, and dates of examinations.4. Details of medical history:past TB, associated illnesses (pulmonary or extra-pulmonary),

HIV status, etc. Provides a description of the characteristics of smear negative TB cases inthe locality (together with no.1).

5. Relevant physical findings: aids the TBDC in the inclusion or exclusion of other diseases.6. History of previous treatment: aid for diagnosis.

a. Anti-TB treatmentb. Symptomatic treatment

7. Number of referred cases diagnosed asa. active TBb. inactive TBc. other lung diseased. non-pulmonary disease

Provides an epidemiologic profile of lung diseases among TB symptomatics.8. Correlation of referring unit’s diagnosis with that of the TBDC: indicates the level of knowledge

at the health unit level on respiratory health; may be used as an aid in the assessment oftraining needs.

Information expected from a review of RF:1. Demographic description of smear negative cases.2. Associated illnesses among smear neg cases.3. Quality of history taking at the health unit level.4. Accuracy of TBDC diagnosis5. Effectiveness of TBDC recommendationsa. based on a follow up of the patients.6. Limitations of the TBDC’s ability to improve the quality of diagnosis.7. Compliance rate of HUs to TBDC recommendations and reasons for level of compliance

Information to be gathered from stakeholders:1. Results of theTBDC recommendations: were they implemented? What were the outcomes

in clinical terms (for the patient)? How does this affect the health unit staff in terms of servicedelivery?

2. What are the perceptions of TBDC members? Do they receive any feedback regarding theresults of their recommendations?

3. About the Program managers: What is the impact of the TBDC on the program, particularlyon the quality of diagnosis? Drug use? Data and information regarding TB epidemiology intheir locality?

4. From other stakeholders: PPM?, NGOs?

ANNEXES


ANNEX 23C: QUARTERLY TBDC ACCOMPLISHMENT REPORT FORM

Province/City: CHD:

Date for the Quarter: Year:

Prepared by: Date Submitted:

1. Total no. of (smear neg./X-ray pos.) TB suspects referred to TBDC

1.1. Classification of referred TB suspects TB, New

TB, Retreatment

Total

TBDC DIAGNOSIS

2. Total number of active TB cases diagnosed by TBDC

2.1. Classification of active TB cases diagnosed by TBDC TB, New

TB, Retreatment

Total

3. Total number of inactive TB patients

4. Total number of patients diagnosed as "other lung disease"

5. Total number of patients evaluated by TBDC for this quarter

6. Total number of patients recommended by the TBDC for anti-TB treatment in this quarter

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ANNEX 23D: TBDC MASTERLIST FORM

TBDC MASTERLIST

No. ReferringUnit Patient's Name

PatientType(N/R)

Age Sex CivilStatus Address Date of

Referral

Date ofTBDC

Meeting

TBDC DiagnosisTx. Cat.(1,2 or

3)

Act.TB

(N/R)

Inact.TB

OtherLD

ANNEXES


ANNEX 24: NTP MONITORING CHECKLIST

161

ANNEX 24: NTP MONITORING CHECKLIST (Page 2)

ANNEXES

163


ANNEXES

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