Lecture Notes on EPI Diseases / National TB Control Program (DOTS)

Prepared By: Mark Fredderick R Abejo RR, MAN

Clinical Instructor

1
EPI TARGET DISEASES

Disease Causative
Agent
Mode of
Transmission
Clinical
Manifestation
Reservoir Diagnostic
Exam
Treatment Nursing
Implication

Tuberculosis
Primary
Complex is less
than 3 years old

- any child who
does not return to
normal health after
measles or
whooping cough.

Most hazardous
period: first 6-12
months after
infection
Highest in risk
of developing:
under 3 years old

Mycobacterium
Tuberculosis

Droplet Infection
( inhalation of
bacilli from
patient who
coughs and
sneeze)

Degree of
Communicability
Depends upon:
- num.of bacilli
- virulence of
bacilli
- environmental
conditions

General weakness
Loss of weight,
cough and wheeze
which does not
respond to antibiotic
therapy.
Fever and night
sweat
Abdominal swelling
with a hard painless
mass and free fluid
Hemoptysis and
chest pain
Painful firm or soft
swelling in a group of
superficial lymph
nodes.
Note:
In young children the
only sign of pulmonary
TB may be stunted
growth or failure to
thrive

Man
And
Diseased
Cattle
(Bovine TB)

Sputum
Exam
3 sample are
taken with 24
hrs:
- spot sample
(1
st
visit)
- early
morning
specimen
- spot sample
(2
nd
visit)
Note: at least 2
sample are
positive

Chest Xray
Mantoux
Test
- .1 cc
injection of
PDD and 48-
72 hours
reading
* 10 mm +
5 mm + (HIV
pt.)



DOTS
- patient is
required to take
the Ant-Tb
drugs in the
presence of a
health care
provider to
ensure
compliance to
treatment
regimen

Anti-TB drugs:
(RIPES)
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin

Pointers for
teaching on Anti-
TB drugs:

Rifampicin: taken
befor meals,
causes red urine
urine
Isoniazide: causes
peripheral neuritis,
given with Vit.B6
Pyrazinamide:
cause
hyperurucemia
Ethambutol:
causes optic
neuritis/ blurring
of vision
Streptomycin:
cause tinnitus, loss
of hearing balance,
damage to 8
th

cranial nerve

Note: After 2-4
weeks of
treatment, patient
is no longer
contagious

Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

2
The National Tuberculosis Control Program

Vision: A country where Tb is no longer a public health problem
Mission: Ensure that TB DOTS services are available, accessible and
affordable to the communities in collaboration with the LGUs
and other partners
Goal: To reduce prevalence and mortality from TB by half the year
2015 ( Millennium Development Goal )
Targets:
1. Cure at least 85% of the sputum smear- positive TB patient discovered.
2. Detect at least 70% of the estimated new sputum smear-positive TB cases.

NTP Objectives and Strategies

Objective A:
Improve access to and quality of services provided to TB patients, TB
symptomatics and communities by health care institutions and providers

Strategies:
Enhance quality of TB diagnosis.
Ensure TN patients treatment compliance.
Ensure public and private health care providers adherence to the
implementation of national standards of care for TB patients.
Improve access to services through innovative service delivery mechanisms for
patients living in challenging areas.

Objective B:
Enhance the health-seeking behavior on TB by communities, especially
the TB symptomatics

Strategies:
Develop effective, appropriate and culturally-responsive IEC/communication
materials.
Organize barangay advocacy groups



Objective C:
I ncrease and sustain support and financing for TB
control activities

Strategies:
Facilitate implementation of TB-DOTS Center certification and
accreditation
Build TB coalitions among different sectors
Advocate for counterpart input from local government units
Mobilize/extend other resources to address program limitations

Objective D:
Strengthen management (technical and operational) of TB
control services at all levels

Strategies:
Enhance managerial capability of all NTP program managers at all
levels
Establish an efficient data management system for both public and
private sectors.
Implement a standardized recording and reporting system.
Conduct regular monitoring and evaluation at all levels.
Advocate for political support through effective local governance

KEY POLICIES

Case Finding

1. DSSM ( Direct Sputum Smear Microscopy ) shall be the
primary diagnostic tool in NTP case finding.
Note: No TB diagnosis shall be made based on Xray result alone
likewise
result of PDD skin test (Mantoux Test)
2. All TB symptomatic identified shall undergo DSSM for diagnosis
before start of treatment
Note: Only contraindication for sputum collection is hemoptysis
Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

3
3. After three sputum specimen yielding negative result X-ray and culture
are necessary
Note: Diagnosis based on Xray shall be made by the TB Diagnostic
Committee.
4. Only trained medical technologist or microscopist shall perform DSSM.


Patients with the following conditions shall be recommended for
hospitalization:
massive hemoptysis
pleural effusion
military TB ( TB of the Spine Pots Disease)
TB meningitis
TB pneumonia
and those requiring surgical intervention

Anti-TB drugs:
(RIPES)
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin

Two Formulation of Anti-TB Drugs
1. Fixed-Dose Combination ( FDCs) two or more first line anti-TB drugs
are combined in one tablet. There are 2,3, or 4 drug fixed dose
combinations.
2. Single Drug Formulation (SDF) each drug is prepared individually.
Isoniazid, Pyrazinamide and Ethambuto are in tablet form while
Rifampicin is in capsule form and streptomycin is injectable.







RECOMMENDED CATEGORY OF TREATMENT REGIMEN

Category
Type of TB
Patient
Treatment Regimen

Intensive
Phase
Continuation
Phase
Total
Period


I
New smear
positive PTB
New smear
positive PTB
with extensive
parenchymal
lesion
EPTB and
Severe
concomitant
HIV disease


2 RIPE


4 RI


6
mos.

II
Treatment
Failure
Relapse
Return after
default


2 RIPES
/1 RIPE

5 RIE

8
mos.

III
New smear-
negative PTB
With minimal
parenchymal
lession

2 RIP

4 RI

6
mos.

IV
Chronic ( still
smear-positive
after supervised
re-treatment )
Refer to
or DOTS
to City

Specialized
Plus Center
Provincial
Coordinator

facility
refer
NTP



Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

4
DOSAGE PER CATEGORY OF TRATMENT REGIMEN

A. Fixed-Dose Combination Formulation
The number of tablets of FDCs per patient will depend on the body
weight.


Categories I and I II : 2 RIPE / 4 RI ( FDC)


Body Weight
(kg)
No.of tablets per day
Intensive Phase
( 2 months )
FDC-A ( RIPE)
No. of tablets per day
Continuation Phase
( 4 months )
FDC-B (RI)
30 - 37 2 2
38 54 3 3
55 70 4 4
More than 70 5 5



Categories I I : 2 RI PES / RI PE / 4RI E (FDC)

Body
Weight
Intensive
Phase
Continuation Phase
First
Two (2)
Months 3
rd

Month
FDC-B
( RI )
E
400
mg
FDC-A
(RIPE)
Streptomycin FDC-A
(RIPE)

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
More
than 70
5 0.75 g 5 5 3



B. Single Dose Formulation ( SDF )
Simply add 1 tablet of Isoniazid ( 100mg) , Pyrazinamide
(500mg) and Ethambutol ( 400mg) each for the patient weighing more
than 50kg before treatment initiation. Modify drug dosage within
acceptable limits according to patients body weight, particularly those
weighing less than 30 kg at the time of diagnosis.

Categories I and I II : 2 RIPE / 4 RI (SDF)


Anti-TB Drugs No. of tablets per day
Intensive Phase
( 2 months )
No. of tablets per day
Continuation Phase
( 4 months )
Rifampicin 1 1
Isoniazid 1 1
Pyrazinamide 2
Ethambutol 2



Categories I I: 2 RI PES / 1 RI PE / 5 RI E

Anti-TB
Drugs
No. of Tablets /
Intensive
(3months )
Vial per day
Phase

No.of Tablets per
day
Continuation Phase
( 5 months )
First 2 months 3
rd
months
Rifampicin 1 1 1
Isoniazid 1 1 1
Pyrazinamide 2 2
Ethambutol 2 2 2
Streptomycin 1 vial per day

Note: 56 vials of Streptomycin for two months


Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

5
Drug Dosage per Kg. Body Weight

Anti-TB Drugs

Dose per Kg Body Weight and Maximum Dose
Rifampicin 5 ( 4 6 ) mg/kg and not to exceed 400 mg daily
Isoniazid 10 ( 8 12 ) mg/kg and not to exceed 600 mg daily
Pyrazinamide 25 ( 20 30 ) mg/kg and not to exceed 2 mg daily
Ethambutol 15 ( 15 20 ) mg/kg and not to exceed 1.2 g daily
Streptomycin 15 ( 12 18 ) mg/kg and not to exceed 1 g daily

D.O.T.S ( Directly-Observed Treatment Shortcourse ) TuTok Gamutan

5 Elements of D.O.T.S
Sustained political commitment
Access to quality-assured sputum microscopy
Standardized short-course chemotherapy for all cases of TB
Uninterrupted supply of essential drugs
Recording and reporting system enabling outcome assessment of all patients
and assessment of overall program performance.


MANAGEMENT OF CHILDREN WITH TB

Prevention
BCG vaccination shall be given to all infants.
BCG vaccine is moderately effective. It has a protective efficacy of:
50 % against any TB disease
64 % against TB meningitis
74 % against death from TB

Case Finding
Cases of TB in children are reported and identified in two instances:
- The patient sought consultation.
- The patient was reported to have been exposed to an adult with TB

All TB symptomatic children 0-9 years old, except sputum positive
child shall subject to PDD testing
- Only trained nurse and midwife shall do the PDD test and recording
- Testing and reading shall be conducted once a week either on Monday
or
Tuesday.
Note: 10 children shall be gathered for testing to avoid wastage.

A child shall be suspected as having TB and considered symptomatic
if with any three (3) of the following sign and symptoms:
cough and wheezing for 2 weeks or more
unexplained fever for 2 weeks or more
loss of appetite, loss of weight, failure to gain weight
failure to respond to a 2 weeks of appropriate antibiotic therapy
failure to regain state of health 2 weeks after a viral infection or after
having measles.

A child shall be clinically diagnosed or confirmed of having TB if he
has any three (3) of the following condition:
positive history of exposure to an adult/ adolescent TB case
presence of sign and symptoms suggestive of TB
positive Mantoux Test
abnormal chest radiograph suggestive of TB

Management

For children with exposure to TB

Should undergo physical examination and PDD testing (Mantoux Test)
A child with productive cough shall be referred for DSSM, if found
positive, treatment shall be started immediately. PDD testing shall no
longer needed.
Children without sign/symptoms of TB but with positive Mantoux Test
and those with symptoms of TB but negative Mantoux Test shall
referred for chest x-ray examination.


Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

6
For children with signs and symptoms of TB

A child to have signs and symptoms of TB with either known or unknown
exposure shall be referred for Mantoux test.
For children with known contact but with negative Mantoux and those
unknown contact but with positive Mantoux shall be referred for chest x-ray
examination.
For a negative x-ray report, Mantoux test shall be repeated after 3 months.
Chemoprophylaxis of Isoniazid for 3 months shall be given to children less
than 5 years old with negative chest x-ray after which Mantoux test shall be
repeated

Treatment
D.O.T.S will still be followed just like in adult
Short course regimen:
- at least 3 anti-TB drugs for 2 months ( intensive phase )
- 2 anti-TB drugs for 4 months ( continuation phase )

* For Extra Pulmonary TB Cases:
- 4 anti-TB drugs for 2 months ( intensive phase )
- 2 anti-TB drugs for 10 months ( continuation phase )

Domiciliary treatment shall be the preferred mode of care
No treatment shall be initiated unless the patient and health worker has agreed
upon a caseholding mechanism for treatment compliance.

Treatment Regimen

A. Pulmonary TB

Drugs Daily Dose (mg/kg per body
weight )
Duration
Intensive Phase
Rifampicin
Isoniazid
Pyrazinamide

10-15 mg/kg body weight
10-15 mg/kg body weight
20-30 mg/kg body weight

2 months
Continuation
Phase
Rifampicin
Isoniazid

10-15 mg/kg body weight
10-15 mg/kg body weight


4 months


B. Extra Pulmonary TB

Drugs Daily Dose (mg/kg per body weight ) Duration
Intensive Phase
Rifampicin
Isoniazid
Pyrazinamide

Plus
Ethambutol
OR
Streptomycin

10-15 mg/kg body weight
10-15 mg/kg body weight
20-30 mg/kg body weight


15-25 mg/kg body weight

20-30 mg/kg body weight




2
months
Continuation
Phase
Rifampicin
Isoniazid

10-15 mg/kg body weight
10-15 mg/kg body weight


10
months

Public Health Nurse Responsibilities ( Childhood TB )

1. Interview and open treatment cards for identified TB children.
2. Perform Mantoux testing and reading to eligible children
3. Maintain NTP records
4. Manage requisition and distribution of drugs
5. Assist the physician in supervising the other health workers of the
RHU in the proper implementation of the policies and guidelines
on TB in children.
6. Assist in the training of other health workers on Mantoux testing
and reading.

Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

7
EPI TARGET DISEASES

Disease Causative
Agent
Mode of
Transmission
Clinical
Manifestation
Reservoir Diagnostic
Exam
Treatment Nursing
Implication

Diphteria it is an
acute pharyngitis,
acute
nasopharyngitis
or acute laryngitis
with Pseudo
membrane
grayish white in
color with leathery
consistency in the
throat and on the
tonsil

Corynebacterium
diphtheriae

Respiratory
Droplets

Nasal
dryness of the
upper lip
serosanguinous
secretion in the
nose

Pharyngeal
Bullneck
appearance
because of the
enlarge cervical
lymph nodes.

Laryngeal
sore throat
hoarseness
brassy metallic
cough

Man

Schicks Test
- test for the
susceptibility to
Diptheria

Moloney Test
- for hyper-
sensitivity to
Diptheria toxin

Antibiotics

Pen G
Potassium
Erythromycin

Isolate patient
until 2-3 cultures
taken at least
24hrs apart are
negative
Small frequent
feeding
Promote
absolute rest
Use ice collar to
relieve pain of
sore throat
May put on soft
diet
Pertussis
- 100 days cough
- Whooping cough
- tuspirina
Bordetella
Pertussis
Airborne
droplet
Primarily by
direct contact
with he
discharge from
respiratory
mucous
membranes of
infected person
At first, the
infected child may
have a common
cold with runny
nose, sneezing
and mild cough
Intermittent
episode of
paroxysmal
cough followed
by a whoop
ending vomiting



Man


Bordet-
Gengou Agar
Plate
- used for
culture medium



Erythromycin
Ampicillin

- is given 5-7 days


Place the patient
on NPO during
paroxysmal stage
to prevent
aspiration
Position prone
for infants and
upright for older
Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

8

Neonatal Tetanus

Clostridium
Tetani

- which produces
the exotoxins:
Tetanolysin
Tetanospasmin

Unhygienic
cutting of
umbilical cord

Improper
handling of cord
stump esp. when
treated with
contaminated
substance

Assess the
NEWBORN for a
history of all 3 of the
following:

Normal suck and
cry for the first 2
days of life
Onset of illness
between 3 and 28
days
Inability to suck
followed by
stiffness of the
body and
convulsion

In OLDER
CHI LDREN, the
following may be
observed:

Trismus
lockjaw
Opisthotonus
arching of the
neck and back
Ridus
Sardonicus
sardonic smile















Soil
Intestinal
canal of
animal
Man


Blood Culture

CSF analysis


Penicillin
Erythromycin
Tetracycline

- administered
within 4 hours of
injury


Prevention

Aseptic
handling of the
neonatal
umbilical cord
Tetanus Toxiod
immunization for
mothers
Active
immunization of
DPT
Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

9

Poliomyelitis
Infantile
Paralysis


3 Types of Polio
Virus
Type I
Brunhilde
Type II
Lansing
Type III Leon

Fecal-oral route

Oral route
through
pharyngeal
secretion

Contact with
infected person

Abortive - did not
progress to systemic
infection

Non-paralytic
slight involvement
of the CNS

Poker spine or
stiffness of the
spinal column

Spasms of the
hamstring
With paresis

Paralytic severe
involvement of CNS

Hoynes Sign
head falls back
when he is in
supine with
shoulder elevated
Paralysis
Head log/drop
Tripod position
extend his arm
behind for support
when he sits up
Kernigs sign
Brudzinski sign





Man

Throat swab

Stool exam

Lumbar exam

Pandys test
- for CSF
analysis



Strict Isolation
Hot moist
compress to
relieve spasm

Use protective
devices:
- handroll to
prevent claw hand



- trochanter roll, to
prevent outer
rotation of femur
- footboard
Lecture Notes on EPI Diseases / National TB Control Program (DOTS)
Prepared By: Mark Fredderick R Abejo RR, MAN
Clinical Instructor

10

Hepatitis B
- it is liver
infection caused by
the B type of
hep.virus.
It attacks livers the
liver often
resulting in
inflammation


Hepa B Virus


3 Ps

Person to person
Parenteral
Placental

Prodromal/pre-
icteric
Symptoms of
URTI
Weight loss
Anorexia
RUQ pain
Malaise
Icteric
Jaundice
Acholic stool
bile-colored
urine



Man


Liver
Function Test


Increase CHO
Moderate fat
Low CHON

Observed universal
precaution

Measles

Paramyxo Virus

Droplet
3 Cs
Conjunctivitis
Coryza
Cough
Kopliks spot
bluish gray spot on
the buccal mucosa.
Generalized blotch
rash


Man




Observe
respiratory
isolation
Should kept out
of school for at
least 4 days after
rash appear
For
Photophobic,
darkened room,
sunglasses