Integration Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy.
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Transcript of Integration Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy.
Integration
Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy
Clinical ManagementPulmonology Module
2 years and 3 months prior to consult
Chronic cough – when did the coughing start? Productive or non-productive?
Loss of appetite and weight loss (weight at this time: 50 kg) – was the patient able to regain the weight after treatment?
Afternoon feverish sensation – sign of infection
Body malaise
Differential Diagnoses
PneumoniaBronchial AsthmaUpper Airway Cough SyndromeChronic Obstructive Pulmonary DiseaseGERDMalignancy
Personal Social History
Patient – laundrywoman while husband is a farmer
Family lives in a 1-room shanty house without windows or toilet
Nutrition: Drinking water from
peddlers Instant noodles and
occasionally rice and sardines
Consult in local health centerChest xray and sputum smear
diagnosed with pulmonary tuberculosis enrolled in DOTS program in Brgy San Roque, Cainta, Rizal
Claims to have undergone the program continuously for 6 months
1 year and 9 months prior to admissionRepeat chest xray cleared by the doctor to
have recovered from TB BUT THERE WAS NO DOCUMENTATION
Pathophysiology of Pulmonary TB
Interaction of bacilli with alveolar macrophage receptors endocytosis into macrophage inhibition of phagosome-lysosome fusion bacilli free to replicate
Cytokines induce Helper T-cell response activation of macrophages granuloma formulation Delayed type hypersensitivity caseous necrosis
Primary Pulmonary TBdistal airspaces of the lower part of the upper lobe or
the upper part of the lower lobeGhon Focus – initial site of parenchymal
involvement at the time of first infection which becomes an area of gray to white inflammation with consolidation measuring 1-1.5 cm (called the Ghon lesion or focus)
Ranke complex – Ghon focus + calcified lymph nodes
The primary lesion can then become latent or progressive.
Progressive Pulmonary TBprimary lesion increases in size and evolve in
different ways rapidly progressing to clinical illness.
resembles acute bacterial pneumonia with lower and middle lobe consolidation and hilar adenopathy
pleural effusion - result of penetration of bacilli into the pleural space from a subpleural focus
Ghon focus enlarges central necrosis irregular cavity poorly walled off by fibrous tissue
Secondary Pulmonary TB apical and posterior segments of the upper
lobes and superior segments of the lower lobe due to higher oxygen tension in these areas favoring mycobacterial growth
Tuberculous pneumonia - result from massive involvement of pulmonary segments or lobes with coalescence of lesions
Diagnosing TB
Sputum smear recommended mode of diagnosis for countries without lab capacities for culture sensitivity testing (WHO 2010)
Screening for TB: Mantoux Method Tuberculin Skin Test
To screen for LATENT tuberculosisIntradermal injection of 0.1 mL of tuberculin
purified protein derivative (PPD) into the inner surface of the forearm measure induration
(+) when ≥ 10 mm for residents of high-risk congregate settings and infants, children, and adolescents exposed to adults in high-risk categories
SN: 60%; SP: 78%; PLR: 2.28; NLR: 0.45
Screening for TB: Chest XrayTo identify persons with ACTIVE TB
Active disease - detection of any abnormality (parenchymal, nodal or pleural) with or without associated calcification
There is no single radiologic finding consistent with active TB.
Initial screening method of choice when skin test results are unreliable or high, or when risks of transmission of an undiagnosed case are high
Sn: 75.8%; Sp: 80%; PPR: 67% when combined with symptoms
Chest Xray for Primary TB
Can resemble pneumonia
Lymphadenopathy – radiologic hallmark; right paratracheal and hilar stations most common sites (Leung et al 1999)
Parenchymal opacities – area of homogenous consolidation
Chest Xray for Secondary TBParenchymal opacities
– heterogenous opacities most commonly in apical and posterior segmental upper lobes and the superior segment of the lower lobes
Cavitation and Air-fluid levels
Bronchogenic spreadSimon foci – apical
nodules that are often calcified resulting from hematogenous seeding from primary infection Chest xray of our patient at
the time of admission
Treatment of Tuberculosis
Anti-TB Treatment for the Patient
Category I Anti-TB Regimen for Adult weighing 50 kg:First 2 months daily:
Isoniazid – 300 mgRifampicin – 450 mgPyrazinamide – 1,200 mgEthambutol – 800 mg
Next 4 months daily: Isoniazid – 300 mgRifampicin – 450 mg
Gauging Response to Treatment
Radiographic evaluation is of less importance than sputum smear in assessing response to treatment (Leung 1999)
Sputum smears on the 2nd month and 6th month
Prognosis Tuberculosis is a very treatable disease good
prognosis if proper treatment is acquired. As of 2008, the mortality rate of tuberculosis in the
Philippines is 52 out of 100,000 tuberculosis has a relatively bad prognosis in the Philippines
The prevalence of TB in the Philippines is 550 out of 100,000
Incidence is 280 out of 100,000 As of 2007, case detection rate for new smear positive
cases in the Philippines is 67% Reasons:
poor compliance to the treatmentgaps in the implementation of DOTS in the country.
According to the WHO as well, the
Preventive MeasuresTransmission of TB is through droplet nuclei.Four factors that determine the likelihood of
transmission of tuberculosis: (1) number of organisms expelled into the air (degree
of infectiousness of the case)(2) concentration of organisms in the air determined
by volume of space and ventilation (shared environment in which contact takes place)
(3) length of time the case breathes the contaminated air (proximity and duration of the contact)
(4) immune status of the exposed individual
Preventive MeasuresEducating the patient about coughing etiquette
and importance of handwashing.minimize stigma and the exposure of non-
infected patients to those who are infected CONTACT Investigation: Get the family
screened! encouraged but not mandatoryCostly to get sputum smears for the whole family Family dynamics when one member is already sickEnvironmental and sanitation conditions
Preventive MeasuresAdequate ventilation of the house, particularly the
room where the patient with infectious TB would spend considerable time
Anyone in the family who coughs should be educated on cough etiquette and respiratory hygiene, and should follow such practices at all times
The smear-positive TB patients should also be advised to spend as much time as possible outdoors sleep alone in a separate, adequately ventilated
room, if possible spend as little time as possible in congregate settings
or in public transport.
Preventive Measures for the Patient
Wear a surgical mask. HandwashingFind ways to get
proper ventilation in the house or spend more time outdoors.
Gastrointestinal
HPITimeline Signs and Symptoms Implication
2 years, 3.5 mo PTC (Mar 2008)
chronic cough TBloss of appetite TB
weight loss TBafternoon fever TB
body malaise TBlocal HC in Cainta: CXR,
sputum examTB
1 year, 8.5 mo PTCrepeat CXR, claimed cleared,
no records availableResolution of TB?
HPI
Timeline Signs and Symptoms Implication
8 months PTC (Feb 2010)
tolerable colicky abdominal pain
Involvement of a hollow organ
bloatedness
Involvement of more distal segments of intestines
abdominal distention
Hallmark of intestinal obstruction;
Involvement of more distal segments of intestines
relieved by passage of flatus or stool
Not obstipated, partial obstruction
HPITimeline Signs and Symptoms Implication
4 weeks PTC
vomiting of ingested food ~1-2x/week
Obstruction
increased frequency and severity of abdominal
distention
Progressive cause of obstruction
colicky pain localized @ RLQ
Possible locations Chronicity rules out
appendicitis
anorexia Malabsorption,
malnutrition
lost 20-30% weight Malabsorption,
malnutrition
HPITimeline Signs and Symptoms Implication
18 days PTC menses
Rules out pregnancy as cause of vomiting, colicky pain
(Ruptured ectopic pregnancy can present as intestinal obstruction)
HPITimeline Signs and Symptoms Implication
On admission
stable vitals
BP, HR and RR important indicators of compensatory responses to a hypovolemic status.
37.8 degrees Celsius is the cut-off point for normal expected temperature in cases of obstruction
ambulatory
evidence of muscle wasting Malabsorption, malnutrition
hyposthenia Malabsorption, malnutrition
minimally worked up and diagnosed but cannot be cleared for intervention due to pulmonary complications
Primary Impression: GI Tuberculosis
History of pulmonary tuberculosis with undocumented resolution
Abdominal pain localized at the right lower quadrant
Signs and symptoms of obstruction Bloatedness Abdominal disentention relieved by passage of
flatus or stoolVomiting AnorexiaProgressive
Gastrointestinal TuberculosisGastrointestinal Tuberculosis is the 6th most
common extrapulmonary manifestation of tuberculosis (Chong and Lim 2009)
Any site of the GI tract may be involved although studies show a predilection to the ileocecal segments (Fauci et al, 2008).increased density of lymphoid tissueincreased stasis neutral luminal pH absorptive transport mechanisms
route of infection penetration of the bowel wallhematogenous dissemination
Gastrointestinal Tuberculosis and its Correlation with Pulmonary
Tuberculosis25% of gastrointestinal TB cases have
evidence of pulmonary TBthere is a direct correlation between the
severity of pulmonary infection with the presence of GI infectionWith minimally advanced pulmonary disease, 1%
of patients have a concomitant GI infectionmoderately advanced cases of pulmonary TB,
4.5% have evidence of GI TB25% of patients with severely advanced PTB
cases have concomitant GI TB while 55% to 90% of fatal cases have GI involvement.
Hamer et al 1998
Gastrointestinal Tuberculosis Manifestations
Ulcerative form major form associated with increased pathogenicity and mortality appears as superficial ulcerative lesions on the epithelial surface.
Hypertrophic form scarring, fibrosis and mass formation resembling carcinomatous
lesions.
Ulcerohypertrophic form combination of the first two with both ulcerations and scar formation
The host’s immune system plays a major role in determining the presentation. Those with depressed immune responses are likely to develop the
ulcerative form while those with competent immunologic responses would present with a hypertrophic form of the disease (Chong and Lim. 2009).
Hamer et al 1998
Pathophysiology of the Disease
Imaging Studies
Differential Diagnoses
Mechanical causes of obstructionherniations, volvulus and intussusceptions
are ruled out on physical exam and barium studies performed on the patient
adhesions secondary to previous surgery are unlikely as there is no mention of it in the patient’s history
Adynamic ileus and colonic pseudo-obstruction are ruled out as colicky pain is absent in both conditions
Fauci 2008
Differential DiagnosesCauses of RLQ pain
Appendicitis, ruled out by the duration of illness.Right-sided diverticulitis
less prevalent form of diverticulitis. clinical manifestation includes abdominal tenderness,
nausea, emesis, anorexia and GI bleeding (Nirula and Greaney, 1997)
Obstruction secondary to scarring from an infectious process can be a complication of this disease
Examinations for ruling out this disease include a complete blood cell count, urinalysis, and flat and upright abdominal radiography.
Further examinations include CT imaging studies, abdominal radiography with contrast and endoscopy (Roberts et al 1995).
Differential Diagnoses
Causes of RLQ painGastroenteritis and inflammatory bowel
disease both do not present with obstructive symptoms lack of diarrhea in the patient lack of cobblestoning on radiographic studies
rules out inflammatory bowel disease, particularly Crohn’s disease.
Differential Diagnoses
Causes of RLQ painGynecologic causes of right lower
quadrant pain such as ovarian tumor or torsion, and pelvic inflammatory disease as well as
Renal causes such as pyelonephritis, perinephritic abscess and nephrolithiasis are ruled out as they do not present with obstructive symptoms.
Differential Diagnoses
TB peritonitisuncommon extrapulmonary manifestationa consideration in patients presenting with several
weeks of abdominal pain, fever, and weight loss. Ruled out because of the lack of ascites, a major
feature arising from the exudation of proteinaceous fluid from the tubercles
Ruptured tubal pregnancy presenting as intestinal obstruction is unlikely as the patient reports recent menstruation
Management
1. Alleviation of symptoms of distention via nasogastric decompression
2. Correction of nutritional status3. Resection of the involved tissue4. Demonstration of organism via culture of
resected segment followed by sensitivity testing
5. Anti-mycobacterial treatment using appropriate medications
Management
1. Alleviation of symptoms of distention via nasogastric decompression
2. Correction of nutritional status serves to prepare the patient for
surgical intervention monitoring of serum albumin
Management
3. Resection of the involved tissue obstruction is a leading indication for
surgery in intestinal tuberculosis other indications for surgery include
ulcerative complications such as free perforation, perforation with abscess, or massive
Preoperative drug therapy is still controversial
Townsend et al 2008Sharma and Bhatia 2004
Management
3. Resection of the involved tissue right hemicolectomy with a 5 cm
margin with anastomosis an ileostomy and a mucous fistula with
subsequent anastomosis
Townsend et al 2008Sharma and Bhatia 2004
Management
4. Demonstration of organism via culture of resected segment followed by sensitivity testing
definitive diagnosis of mycobacterial infection by acid-fast stain or culture
PCR methods culture and sensitivity to determine
which drugs are still effective
Management
5. Anti-mycobacterial treatment using appropriate
HRZES RCT: standard 6 month course vs
prolonged courses of conventional TB medication shows no significant difference in cure rates
Sharma and Bhatia 2004
Nutrition
Nutrition
SUBJECTIVE FINDINGS
1 month prior to consult, patient claimed to have lost 20-30% of her weight (can be classified as severe weight loss), anorexic
Markedly decreased oral intake (short starvation) due to vomiting after each oral intake
Patient lived on water, coffee, and diluted Bear Brand (intolerance of both solid and soft diet becoming almost daily)
Weak, able to stand up with support and poor hand grip Evidence of muscle wasting
NutritionOBJECTIVE FINDINGS
Weight is 35 kg; height is 1.5m; BMI (kg/m2) is 15.6. Based on the Asia-Pacific BMI classification, the patient is underweight. Normal BMI= 18.5-22.9 Severe weight loss (>5-10%) Ideal body weight computation = 45kg Patient is less than 10 kg of his Ideal Body weight %IBW= 35kg/45kg = 78%, meaning that current weight is 78% of ideal body weight, patient is classified under moderate malnutrition
ASSESSMENT ABC’s of Nutritional Assessment 1. Anthropometric Measurements (Height, Weight, BMI, Triceps Skin Fold, Mid-Arm Circumference, Mid Arm Mass Circumference) BMI=15.6 (Underweight); IBW (Tanhausser’s)= 45kg; %IBW= 78%- moderate malnutrition %wt loss= severe (>5% in 1 month) 2. Biochemical Parameters (Common: Serum albumin <3.0g%; Total Lymphocyte <1500) 3. Clinical Parameters or Manifestations (Nutritional Risk Screening, 2002, First and Second Screening) Impaired Nutritional Status= Wt loss >5% in 1 mos or >15% in 3 mos, or BMI <18.5 + impaired general condition or food intake
PLAN
Appropriate nutritional assessment. Institute a nutritional care plan for the patient. (Patient is nutritionally at- risk, NRS score of >=3) Calculate for total energy allowance and protein, carbohydrates, and fats requirement Method of delivery: IV route then oral upon improvement (Pt has been vomiting, pt has poor hand grip)
Nutrition: NRS, 2002 ESPEN Guideline
Table 1 Initial Screening Yes No
1 Is BMI<20.5
2 Has the patient lost weight within the last 3 months?
3 Has the patient had a reduced dietary intake in the last week
4 Is the patient severely ill? (e.g intensive therapy)
Yes: If the answer is “Yes” to any of the question, the screening in Table 2 is performed.No: If the answer is “No” to all questions, the patient is re-screened at weekly intervals. If the patient e.g is
schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.
Nutrition: NRS, 2002 ESPEN Guideline
Table 2 Final Screening
Impaired Nutritional Status
Severity of disease (increase in requirements)
Absent Score 0 Normal nutritional Status Absent Score 0 Normal nutritional requirements
Mild Score 1 Wt loss >5% in 3 mos or Food intake below 50-75% of normal requirement in preceding week
Mild Score 1 Hip fracture, Chronic patients in particular with acute complications: cirrhosis, COPD, chronic hemodialysis, diabetes, oncology
Moderate Score 2 Wt loss >5% in 2 mos or BMI 18.5-20.5+ impaired general condition or food intake 25-60% of normal requirement in preceding week
Moderate Score 2 Major abdominal surgery, Stroke, Severe Pneumonia, hematologic malignancy
Severe Score 3 Wt loss >5% in 1 mo or BMI <18.5 +impaired general condition or food intake 0-25% of normal requirement in preceding week
Severe Score 3 Head injury, Bone marrow transplantation, Intensive care patients (APACHE >10)
Score + Score Total Score
Age If >=70 years old, add 1 to total score = age adjusted total score
Score >=3: the patient is nutritionally at risk and a nutritional care plan is initiated
Score <3: weekly re-screening of the patient. If the patient e.g is schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.
Nutrition Calculating total energy allowance and
protein, carbohydrates, and fats requirement
Total energy allowance = Weight (kg) x Caloric requirementTotal energy allowance = 35 x 45(kcal/kg/d) = 1575 kcal
Protein ( 1.0 – 1.5 g/kg/d) = (35 x 1.5) x 4; Protein = 210 kcal
Carbs= [(Total energy allowance – Calories from protein) x 0.7] / 4 Carbs = (1575 – 210) x (0.7) = 955 / 4 = 239 g CHO
Fats (30-40% of non-CHON calories) = [(Total energy allowance – Calories from protein) x 0.3] / 9
Fats = (1575 – 210) x (0.3) = 409.5 / 9 = 45.5 g Fats
Rapid Estimation of adult total daily calorie and protein requirement
Severity of Illness
Caloric Require
ment (kcal/kg/
d)
Protein Requireme
nt(g/kg/d)
None 25 0.8
Mild to Moderate
35 1.0
Moderate to Severe
45 1.5
Nutrition
Monitoring: Laboratory parameters, Body weight improvement, Functional status
Laboratory parameters (serum albumin, lymphocyte,
cholesterol, transferrin, iron-binding capacity)
General goal: Restore the patient’s nutritional, metabolic and
functional status.
Specific goals: 1. Provide the needed total caloric need to the patient following the macronutrient requirements of protein 15-20%, fats-30-35%, carbohydrates 50-60% of total calories. 2. Prevent complications of electrolyte and metabolic derangement that could lead to potentially life-threatening situations. 3. Prevent further complications of malnutrition such as muscle wasting
Surgical operation Relief from obstructive symptoms Prevention of malabsorption
caused by ileocecal TB Nutritional delivery must prepare
the patient for the surgical operation (monitoring of serum albumin)
VitB12 supplementation given post-surgery (since Vit B12 absorption is impaired in the terminal ileum)
PUBLIC HEALTH
3 E’s: Evidence, Economics, Ethics
EVIDENCECity A Philippines
Literacy Rate 98.32% 93%
Unemployment Rate
14.3% 7.3%
of City A’s total population is composed of migrants, most of which end up as informal settlers in the city.
Informal settlers have ,e.g. small living spaces, poor hygiene and sanitation
55%
poor living conditions
transmission of infectious diseases like TB
EVIDENCEHealth Indicator City A (2007)
Per 1,000Philippines
(FHSIS, 2005)Per 1,000
Crude Death Rate 4 4.2
Crude Birth Rate 15.7
Maternal Mortality Rate
0.7 0.71
Infant Mortality Rate
9.72
Stillbirths 2.5
21.5
4.7
EVIDENCEHealth Indicator City A (2007)
n= 2,861,090 Philippines
(FHSIS, 2005)
BHS 2 per 10,000
Doctors 0.4 per 10,000
Nurses and Midwives
2.6 per 10,000
0.22 per 10,000
0.27 per 10,000
0.83 per 10,000
Lack of Manpower
One of the factors associated with low cure rates (WHO):“Directly observed therapy is not
functioning or does not work well” due to UNDERSTAFFINGDefaulters are NOT TRACED
(Defaulter rate= 11%)
Proposed Solution
Addition of more public health workers (doctors,
BHWs, midwives and nurses) and/or BHS
Tap family members as therapeutic partners
ECONOMICS
More funds needed to:BUILD more
BHSHIRE more
health care workers
ETHICS
Macroallocation of fundsOther leading causes of mortality and morbidity
may be prioritized
Improvement of IMR, stillbirth rate or unemployment rate may be prioritized instead
Ethical dilemma may be resolved by adding more health care providers to address all health problems
Management
McKinsey’s 7S Framework
For TB DOTS
Strategy
TB DOTS program is part of WHO’s overall Stop TB Strategyaim: “a world free of TB”
ObjectivesTo achieve universal access to high-quality
diagnosis and treatment for people with TBTo reduce suffering and socioeconomic
burden associated with TB
Strategy
To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB
To support the development of new tools and enable their timely and effective use.
Component of the strategy that pertains to TB DOTS: pursue high-quality DOTS expansion and enhancementPolitical commitment with increased and
sustained financing
Strategy
Case detection through quality-assured bacteriology
Standardized treatment, with supervision and patient support
An effective drug supply and management system
Monitoring and evaluating system, and impact measurement
Structure
DOTS UNIT Head
Medical Technologist/Microscopist
Nurse in Charge TB Diagnostic
Committee (TBDC)
Structure
TB DOTS unit associated with a hospital may have more entities above itChairman of the Infection Control Committee Chairman of the Pulmonary Diagnostics and
Therapeutic Center Senior Vice President of the Patient Services
Group Assistant Vice President of the Special
Services Division
SystemNational Tuberculosis Program (NTP) is used
as the core policyDepartment of Health (DOH) and Center for
Health Development (CHD)Local Government Units (LGUs)PhilHealthExternal systems
Global Fund through Philippine Business for Social Progress (PBSP)
USAIDWHO
Shared Values
High-quality serviceSustainabilityEfficiencyPatient-centeredness
Staff
TB DOTS unit Unit head, head nurse, medical technician,
BHW, midwife
hospital based NTP coordinatorsmunicipal/city health officersCHD NTP Coordinators at the regional
and provincial levels
Skills
All TB DOTS health care workers are trained and certified by DOH before being allowed to work in a DOTS unit
trained according to the Manual of Procedures for the National TB Control Program, 2001
Gap Identification & Analysis
Interview with TB-DOTS personnel in The Medical City TB-DOTS FacilityTB-DOTS is not entirely freeEnrollment in TB-DOTS becomes the
burden of the health care personnelHuman resource issuesRecording and Reporting are not updated
Gaps between goals, targets and actual performance (Balanced Score Card)
Gaps in financing
Financial Analysis
cost of treatment for PTB greatly differs from treatment for extra-pulmonary TB requiring surgery
complete treatment of a New Case of Pulmonary TB: Php 2660.73 to Php 7584.90
complete treatment of a GI TB has an additional cost of ~ Php86250 to Php 228750
additional costs are mainly from cost of surgery (GI surgeon Professional fee, 45% of which is the Anesthesiologist Professional Fee and hospital costs
Differences in pharmacotherapy regimen, the choice of drugs and manufacturer affects the total cost of medication
cost of diagnostic modalities may also differ depending on the hospital or facility
Implicationsimportance of control of new cases of PTB
and prevention of development of extrapulmonary complications
need for accurate identification of Extra-PTB and complicated TB cases
provision for resource allocation for these cases
Balanced Scorecard
Vision – “a world free of TB”Goal
(G1)To achieve universal access to high-quality diagnosis and patient-centred treatment
(G2)To reduce the suffering and socioeconomic burden associated with TB
(G3) To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB
(G4) To support development of new tools and enable their timely and effective use
Strategy(S1) Sustained political commitment(S2) Access to quality-assured sputum
microscopy(S3) Standardized short-course chemotherapy for
all cases of TB under proper case management conditions, including direct observation of treatment
(S4) Uninterrupted supply of quality-assured drugs.
(S5) Recording and reporting system enabling outcome assessment of all patients and assessment of overall program performance.
Internal Business ProcessesGoal area/Perspective
Objectives Baseline Measure
Measures Targets
Actual Initiatives
G1 unversal access
to provide universal coverage
100% number or percentage of areas covered by TB-DOTS
100% 100% nationwide coverage of TB-DOTS, all Local health units have access to the TB-DOTS program
to provide quality assured bacteriology
number of new cases detected by sputum testing
255084/86,960,000 (0.29%)
2009
78,352/107,734
(73%) 2004
DOTS case detection rate
85% 75%
to effectively monitor and evaluate patients
number of cases enrolled and receiving treatment
*recording *reporting
Internal Business ProcessesGoal area/Perspective
Objectives Baseline Measure
Measures Targets
Actual Initiatives
G2 reduce suffering
to effectively coordinate and manage drug supply
inventory of drugs received
inventory of drugs consumed by patients
G3 protect groups
to prevent and control MDR-TB
number of MDR cases among new TB cases
FinancingGoal area/Perspective
Objectives Baseline Measure
Measures Targets
Actual Initiatives
G2 reduce suffering
To coordinate resources
total cost of drugs purchased
To account for expenses
total cost of non-drugs purchased
total current assets
total current liabilities
CustomerGoal area/Perspective
Objectives Baseline Measure
Measures Targets
Actual Initiatives
G1 universal access
To identify and treat cases successfully
78,352/107,734
(73%) 2004
DOTS case detection rate
85% (GTC WHO 2009)
75% (2007)
52,319/59,453 (88%) 2003
DOTS treatment success rate
80% (GTC WHO 2009)
88% (2006)
` patient education and public awareness campaigns by LGUs
G2 reduce suffering
To provide cheap services
new enrollees are given discounted sputum and xray services after being diagnosed
To provide free drugs
drugs provided for free after enrolling in TB DOTS
CustomerGoal area/Perspective
Objectives Baseline Measure
Measures Targets
Actual Initiatives
G3 protect groups
To prevent MDR and complications of TB/HIV
0.30% New Adult TB Cases
95% GF: # of MDR-TB patients whose sputum culture converts to negative at the end of 6-months of treatment (among the patients enrolled 9 months from the start date of last member of cohort)
development and implementation of a joint national plan; HIV surveillance among TB patients, irre spective of HIV prevalence rates
key actions for preventing and controlling drug-resistant TB include use of recommended treatment regimens, a reliable supply of quality-assured first- and second-line anti-TB drugs, and adherence to treatment by patients and to its proper provision by health-care providers.
Learning & GrowthGoal area/Perspective
Objectives Baseline
Measure
Measures Targets
Actual Initiatives
G1 universal access
to provide standardized service by competent health care personnel
training of personnel
Cum. 12,067 (120%) GF: # of service deliverers trained233 for yr 2005
availability of a manual for personnel
YES
G2 reduce suffering
to provide inspiration, motivation and support to TB patients
NTPs should provide support to frontline health workers to help them create an empowering environment,
G3 protect groups
recognition and acknowledgement of existence of risk groups and their special requirements.
training of personnel
268 (117%) GF: Number of service deliverers trained in TB/HIV collaborative activities
advocacy to influence policy changes and sustain political and financial commitment; two-way communication between the care providers and people with TB as well as communities to improve knowledge of TB control policies, programmes and services; and social mobilization to engage society, especially the poor, and all allies and partners in the campaign to Stop TB.
Learning & GrowthGoal area/Perspective
Objectives Baseline Measure
Measures Targets Actual Initiatives
G4 support development
to participate actively in both country-led and global efforts to improve action across all major areas of health systems, including policy, human resources, financing, management, service delivery (including infrastructure and supply systems) and information systems
Number of service deliverers (community based support group
2,622 (92) GF: # of service deliverers (community based support group) trained
cordinating body that includes TB and HIV patient support groups;
67 (2006) Number of Public-private Mix
100 99