Tuberculosis Prevention and Control

Program
National TB Control Program

Jonathan O. Loreche, MD, RMT, DFM, FPAFP

Associate Professor, MHAM College of Medicine

TB Prevention and Control Program

Date PCM3 A/C/E - 4th Shift Schedule of Lectures
Mar 29 Dengue Prevention and Control Program

Apr 5 Blood Donation Program

Newborn Screening Act of 2004 (RA 9288)
PTB Prevention and Control Program
Apr 12 STD/HIV AIDS Prevention and Control
Philippine Leprosy Control Program
Mental Health Act

Apr 19 Long Exam 1

Apr 26 Tobacco Act of 2003
Dangerous Drugs Act of 2002
Breastfeeding Law

May 3 Dental Health Service Law

Solid Waste Management Act of 2000
Pharmacy Law
May 10 Long Exam 2
May 17 4th Shifting Exam - DOH Programs and Laws 2
May 24 Final Exam (May 24 – June 4, 2021. June 4 – End of Classes)
Vision

 A Tuberculosis-free Philippines
 Zero deaths, disease, and suffering due to
tuberculosis
Mission

 To reduce TB burden
(TB incidence and TB mortality)
 To achieve catastrophic cost of TB-affected
households
 To responsively deliver TB service
Long Term Goal (2035)

 Reduce TB burden by decreasing TB

mortality by 95% and TB incidence by 90%.
Medium Term Goals (2022)

 Reduce TB burden by:

 Decreasing the number of TB deaths by 50% from
22,000 to 11,000
 Decreasing TB incidence rate by 15% from
554/100,000 to 470/100,000
 Reduce catastrophic costs incurred by TB-
affected households from 35% to 0%.
 At least 90% of patients are satisfied with the
services of the DOTS facilities.
Specific Objectives (2022)

 1.Improve the utilization of TB care and

prevention services by patients and
communities.
 2.Reduce catastrophic cost of TB-affected
households accessing DOTS facilities to 0%.
 3.Ensure adequate and competent human
resources for TB elimination efforts.
 4.Improve the use of TB data for effective TB
elimination efforts.
Specific Objectives (2022)

 5.Enhance quality of all TB care and prevention

services.
 6.Increase to at least 90% of DOTS facilities that
are providing expanded integrated patient
centered TB care and prevention services.
 7.Enhance the political stewardship through
high-level political commitment of national
government agencies and LGUs to implement
localized TB elimination plan in coordination
with different sectors.
Program Components

 Health Promotion
 Financing and Policy
 Human Resource
 Information System
 Regulation
 Service Delivery
 Governance
Target Population/Clients

 Presumptive TB
 TB affected households

 Area of coverage: Nationwide

Policies and Laws

 RA 10767 :
Comprehensive TB Elimination Plan Act of 2016
 Strategies, Action Points
and Timeline
 2017-2022 Philippine Strategic TB Elimination Plan
 Activate communities and patient groups to promptly
access quality TB services
 Collaborate with other government agencies to reduce
out-of-pocket expenses and expand social protection
programs
 Harmonize local and national efforts mobilize adequate
and competent human resources
 Strategies, Action Points
and Timeline
 2017-2022 Philippine Strategic TB Elimination Plan
 Innovate TB information generation and utilization for
decision making
 Enforce standards on TB care and prevention and use of
quality products
 Value clients and patients through integrated patient-
centered TB services
 Engage national, regional and local government units/
agencies on multi-sectoral implementation of TB
elimination plan
About the NTP

 The National TB Control Program, organized in

1978 and operating within a devolved health care
delivery system
One of the public health programs being
managed and coordinated by the Infectious
Diseases for Prevention and Control Division
(IDPCD) of the Disease Prevention and Control
Bureau (DPCB) of the Department of Health
(DOH).
About the NTP

Headed by a program manager and supported by 20

technical and administrative staff, it has the following
mandate:
(1) develop policies, standards and national strategic
plan,
(2) manage program logistics,
(3) provide leadership and technical assistance to the
lower health offices/units,
(4) manage data, and
(5) conduct monitoring and evaluation.
About the NTP

 The program's TB diagnostic and treatment

protocols and strategies, issued through the
Manual of Procedures, are in accordance with
the policies of World Health Organization (WHO)
and the International Standards for TB Care
(ISTC).

 Its last strategic plan was the 2010-16 Philippine

Plan of Action to Control TB or PhilPACT.
About the NTP

 The NTP closely works with various offices of the DOH,

such as the:
 National Center for Health Promotion (NCHP) for
advocacy, communication, and social mobilization;

 Epidemiology Bureau (EB), and the Knowledge and

Management Information and Technology Services
(KMITS) for data management;

 Health Policy Development and Planning Bureau

(HPDPB) for policy and strategic plan formulation;
About the NTP

 The NTP closely works with various offices of the DOH,

such as the
 Material Management Division (MMD), Central Office
Bids and Awards Committee (COBAC) and Food and
Drug Administration (FDA) for drug and supplies
management;
 National TB Reference Laboratory of the Research
Institute for Tropical Medicine (NTRL-RITM) for
laboratory network management;
 Lung Center of the Philippines (LCP) for PMDT-related
researches and training activities and the
About the NTP

 The NTP closely works with various offices of the DOH,

such as the
 17 regional offices (ROs) for technical support to the
provincial health offices (PHO) and implementing
units; and the
 Philippine Health Insurance Corporation(PhilHealth)
for the
 TB-DOTS accreditation and
 utilization of the TB-DOTS outpatient benefit package.
About the NTP

 The 17 ROs through its regional NTP teams

manages TB at the regional level

 PHOs and city health offices (CHOs), through its

provincial/city teams are responsible for the TB
control efforts in the provinces and cities.
About the NTP

 TB diagnostic and treatment services are part of the

basic integrated health services which are provided by
DOTS (Directly Observed Treatment, Short Course,
current means of delivery of treatment Services) facilities
which could either be the
 Public health facilities, such as the RHUs, health centers,
hospitals;
 Other public health facilities, such as school clinics, military
hospitals, prison/jail clinics;
 NTP-engaged private facilities, such as the private clinics, private
hospitals, private laboratories, drugstores and others.
About the NTP

 Community groups, such as the

 Community Health Teams (CHTs) and
 Barangay Health Workers (BHWs)
participate in community-level activities.
About the NTP

 NTP closely works with the 17 government offices and 5

private organizations in compliance with the
Comprehensive and Unified Policy (CUP) issued by the
Office of the President in 2003.
 Under the framework of public-private mix (PPM)
collaboration in TB-DOTS, NTP collaborates with non-
governmental organizations, such as the
 Philippine Coalition Against TB (PhilCAT), a consortium of 60
groups, and the
 100-year old Philippine TB Society, Inc. (PTSI) and
 many others.
About the NTP

 Various developmental partners and their projects

provide technical and financial support to NTP, such as
 the World Health Organization (WHO),
 United States Agency for International Development (USAID),
 Global Fund Against AIDS, TB and Malaria (Global Fund),
 Research Institute of TB/Japan Anti-TB Association (RIT/JATA),
 Korean Foundation for International Health (KOFIH) and
 Korean International Cooperation Agency (KOICA) and
 KNCV Tuberculosis Foundation.
Program Accomplishments
 In support of the Millennium Development Goals
(MDGs), three (3) impact targets were adopted by
the Stop TB Strategy to monitor the progress of
implementation.
 Philippines as one of the Member States of the
United Nations adopted also the said impact
indicators in PhilPACT.
 These targets are decreasing the trend of the TB
incidence rate and reducing by half the TB mortality
and prevalence rates against the 1990 baseline
data.
Program Accomplishments
 By the end of 2015, based on the 2016 Global
TB report of the WHO, Philippines is one of the
nine high TB burden countries that have
reached the millennium development goals or
MDGs.
 This is based on the WHO estimate prior to the
2016 NTPS.
 Table 1 shows the accomplishment of the
Philippines in addressing the problem of
tuberculosis.
Table 1 - Status of the impact targets

Indicators Target 2015 Status

accomplishment
Incidence Rate Less than the 322/100,000 Achieved
baseline
Mortality Rate 23/100,000 13/100,000 Achieved
Prevalence Rate 414/100,000 <414/100,000 Achieved
Source: WHO Global TB Report, 2016 (prior to 2016 NTPS)
Program Accomplishments

 For the outcome targets, the case detection

rate and treatment success rate for drug
susceptible TB were achieved by the end of
2016.
 However, the targets for case detection rate
and treatment success rate for drug resistant
TB cases were not achieved.
 Table 2 shows the accomplishment for the
outcome targets.
Table 2 - Status of the outcome targets

Indicators Target 2016 Status

accomplishment
Case Detection Rate, Drug 90% 92% Achieved
Susceptible (All forms)
Treatment Success Rate, 90% 92% Achieved
Drug Susceptible (All
Forms)
Case Detection Rate,Drug 62% 32% Not Achieved
Resistant TB
Treatment Success Rate, 75% 49%(2012 cohort) Not Achieved
Drug Resistant TB
Source: Data submitted by the regional TB coordinators as of February 2017
Program Accomplishments

 Of the five (5) output targets, only two (40%)

were achieved.
 These are the
 number of TB patients provided with treatment
and
 number of TB patients counseled and tested on
HIV.
 See Table 3 for the status of the said
indicators.
Table 3 - Outcome Indicators

Indicators Target Accomplishment Status

No. of TB 5.5 million 4,717,535 Not
symptomatics achieved;Patients
provided with who underwent
DSSM examination using
Xpert MTB/Rif as a
primary diagnostic
tool is not
accounted for.
No. of TB patients 1.5 million 1,701,059 Achieved
provided with
treatment
Table 3 - Outcome Indicators

Indicators Target Accomplishment Status

No. of children 730,000 181,728 Not achieved; There were
provided with inadequate stocks of drugs
treatment or for children due to quality
preventive issues of the procured drugs
therapy and low uptake of IPT.
No. of MDR-TB 19,500 18,886 Not achieved due to lack of
detected and access to diagnostic and
provided with treatment facilities for drug
second line anti- resistant TB cases.
TB drugs
No. of TB patients 45,000 57,590 Achieved
provided with
PICT on HIV/AIDS
Program Accomplishments and
Status
2017 WHO Global TB Report
Estimate TB Burden :
 Mortality 21/100,000
 Incidence 554/100,000
Total Notified Cases: 345,144
Treatment Coverage: 58%
Treatment Success Rate, All Forms (2015) : 91%
Treatment Success Rate, MDR/RRTB (2014) 46%
Calendar of Activities

 March 24 - World TB Day Commemoration

 August - Lung Month Celebration
Partner Institutions

 Department of Health :
 Food and Drug Administration
 Bureau of Quarantine
 Other Government:
 DepEd, DSWD, DILG (BJMP), DOJ (BuCor)
 Non Government Organizations:
 PhilCAT, PBSP
 International Organizations:
 WHO, USAID, GFATM, ICRC, HIVOS-KNCV
NTP Partners
 1) PARTNERS IN DOH
- Bureau of Quarantine, Epidemiology
Bureau, Food and Drugs Authority

 2) OTHER GOVT PARTNERS

- BJMP, Bureau of Corrections, DepEd,
DILG, DOJ, DSWD
NTP Partners
 3) LOCAL PRIVATE & NON-GOVT PARTNERS
 Family Health International (FHI 360)
 ICRC Switzerland
 KNCV Tuberculosis Foundation
 University Research Co, LLC (URC)
 Korean International Cooperation Agency (KOICA)
 Phil Business for Social Progress (PBSP)
 Phil Coalition Against TB (PhilCAT)
 Research Institute of Tuberculosis Japan Anti-TB
Association (RIT JATA)
NTP Partners
 4) INTERNATIONAL PARTNERS
 The Global Fund to Fight AIDS TB and Malaria
(GFATM) Switzerland
 Management Sciences for Health (MSH)
Massachusetts
 Promoting the Quality of Medicines Program
(PQM) Maryland
 United States Agency for International
Development (USAID)
 World Health Organization (WHO)
Magnitude of TB in the
Philippines
 Tuberculosis or TB is an infectious disease caused by the bacteria called Mycobacterium
tuberculosis.
 It is transmitted from a TB patient to another person through coughing, sneezing and
spitting.
 Thus, close contacts, especially household members, could be infected with TB.
 Lungs are commonly affected but it could also affect other organs such as the kidney,
bones, liver, and others. TB is curable and preventable.
 However, incomplete or irregular treatment may lead to drug-resistant TB or even death.

 Tuberculosis is a major public health problem in the Philippines. In

2010, TB was the 6th leading cause of mortality with a rate of 26.3
deaths for every 100,000 population and accounts for 5.1% of total
deaths. This is slightly lower than the five-year average of 28.6 deaths
per 100,000 population. More males died (17,103) compared to females
(7,611).
Magnitude of TB in the
Philippines
 Tuberculosis is a major public health problem in
the Philippines.
 In 2010, TB was the 6th leading cause of mortality
with a rate of 26.3 deaths for every 100,000
population and accounts for 5.1% of total deaths.
 This is slightly lower than the five-year average of
28.6 deaths per 100,000 population.
 More males died (17,103) compared to females
(7,611).
Magnitude of TB in the
Philippines
 The country had conducted three National TB
Prevalence Survey (NTPS) that describe the
magnitude and the trend of the TB problem.

 The results were as follows:

National TB Prevalence
Surveys 1983-2007
Indicators NTPS 1983 NTPS 1997 NTPS 2007

Prevalence of culture- 6.6/1,000 3.1/1,000 2.0/1,000

positive TB

Prevalence of sputum 4.2% 4.2% 6.3%

smear-positive TB

Prevalence of those 2.5% 2.3% 2.1%

with CXR findings
suggestive of TB

Rate of TB 17.0% 18.4% 13.5%

symptomatic

Prevalence of those 8.6/1,000 3.1/1,000 4.7/1,000

with CXR findings
suggestive of TB
Magnitude of TB in the
Philippines
 TB is more prevalent among males compared to
females and among the 25–55 year old age
group.
 It is also higher among the malnourished and
diabetics.
 The 1997 survey showed that prevalence of TB
among the urban poor in Metro Manila is twice
that of the general population.
Magnitude of TB in the
Philippines
 The first national Drug Resistance Survey was
done in 2003–2004 and revealed the following
prevalence of drug resistance:
 4% among the new cases
 21% among the re-treatment cases, and
 5.7% combined.
Magnitude of TB in the
Philippines
 The second National Drug Resistance Survey was
done in 2011–2012 and showed a decrease in the
prevalence of drug resistance among new cases
from 4% to 2%.

 However, there was no change in the prevalence

of drug resistance among re-treatment cases
which remained at 21%.
TB Program Manager

 Dr. Anna Marie Celina G. Garfin

Program Manager
ntpphilippines.inquiry@gmail.com

 Reference:
 https://www.doh.gov.ph/national-tuberculosis-co
ntrol-program
Frequently Asked
Questions

Reference:
World Health Organization (2013)
1) What is Tuberculosis?

 Tuberculosis (TB) is an infectious disease

caused by a type of bacteria called
Mycobacterium tuberculosis.
 TB most commonly affects the lungs, when it
is called pulmonary tuberculosis, but also can
involve any other organ of the body in which
case it is called extra-pulmonary tuberculosis.
 These FAQs are about pulmonary TB.
2) What is TB Infection?

 When a person breathes in the TB bacteria, in most

cases, the body is able to get them to stop them from
growing.
 The bacteria become inactive, but do not die.
 They lie latent, and can become active later.
 This state is called TB infection.
 People who are infected with TB do not feel sick, do not
have any symptoms, and cannot spread the disease.
 But they could develop TB disease at some time in the
future.
3) What is TB Disease?

 Not all people with TB infection get active TB disease.

 Only when people infected with the TB bacteria start
showing signs and symptoms associated with TB are
they considered to have active TB disease.
 Some people develop TB disease soon after becoming
infected, before their immune system can ght back.
 Other people may get sick later, when their immune
system becomes weak for some reason.
4) Who are prone to TB?
 People with weak immune systems are more
vulnerable to TB.
 This includes babies and young children,
people infected with HIV and those who have
the following conditions:
 diabetes mellitus, silicosis, cancer of the head or
neck, leukemia or Hodgkin’s disease, severe
kidney disease, low body weight, certain medical
treatments (such as corticosteroid treatment or
organ transplants).
5) What are PTB Symptoms?

 The most common symptoms of TB are

 chronic cough
 fever, especially rising in the evening (low grade
afternoon fever)
 night sweats
 chest pain
 weight loss, loss of appetite
 hemoptysis (coughing up blood)
6) How is it transmitted?

TB is spread primarily from person to person through

infected air during close contact.
The bacteria get into the air when someone infected
with TB of the lung coughs, sneezes, shouts, or spits.
A person can become infected when they inhale minute
particles of the infected sputum from the air.
It is not possible to get TB by just touching the clothes
or shaking the hand of someone who is infected.
6) How is it transmitted?

 TB germs spread more easily in crowded conditions as

the bacteria sometimes stay alive in the air for a few
hours, especially in small closed places with no fresh air.
 Fresh air scatters the germs and sunlight acts as a
bactericide, killing the TB organisms.
 Exposure to moderately hot temperatures for extended
periods of time is sufficient to kill these bacteria.
 Extra-pulmonary TB does not spread from person to
person.
7) If a person is exposed to someone with
active TB disease, can he/she transmit TB to
others?
 Only persons with active TB disease (i.e. those who also
show signs and symptoms of the disease) can spread TB
to others.
 People with latent TB infection (i.e. people who have the
TB bacteria but do not show any symptoms) cannot
spread TB bacteria to others.
 A person exposed to someone with active TB disease,
may become infected with the TB bacteria, but would
not be able to spread the infection unless he or she starts
showing symptoms of the disease.
 People who have latent TB infection can, however, be
treated to prevent them from developing active TB.
8) TB in Pregnancy?

 If you are pregnant and have active TB, you should start
treatment as soon as TB is suspected.
 Although the TB drugs used during treatment cross the
placenta, they do not appear to have any harmful effects
on the fetus.
 TB medications such as isoniazid, rifampin, and
ethambutol are often used for treatment during
pregnancy.
 While dealing with TB during pregnancy is not easy,
proper treatment is crucial for the health of the mother
and the baby.
8) TB in Pregnancy?

 Untreated TB disease represents a greater

hazard to a pregnant woman and her fetus
than does its treatment.

 Treatment of pregnant women should be

initiated whenever the probability of TB is
moderate to high.
8) TB in Pregnancy?

 Infants born to women with untreated TB

may be of lower birth weight than those born
to women without TB and, in rare
circumstances the infant may be born with
TB.
8) Harmful TB drugs in Pregnancy?

 The drug Streptomycin should not be used

because it has been shown to have harmful
effects on the fetus.

 In most cases, pyrazinamide is also not

recommended because its effect on the fetus
is unknown.
9) Is a person with HIV infection
more at risk of developing TB?
 Yes, because HIV infection weakens the
immune system, people with TB infection
and HIV infection are at very high risk of
developing TB disease.
 All HIV-infected people should be tested for
TB. If they have TB disease, they must take
TB medicines.
10) What is Drug-resistant TB?

 Sometimes the anti-TB drug being taken by the patient

can no longer kill the TB bacteria. This is referred to as
drug-resistant TB.

 Drug-resistant TB can occur when the drugs used to treat

TB are misused or mismanaged. Examples include:
 when people do not complete the full course of treatment
 when health-care providers prescribe the wrong treatment, the
wrong dose, or wrong length of time for taking the drugs
 when the supply of drugs is not always available
 when the drugs are of poor quality.
11) Who is at risk for drug-resistant TB?

 Drug-resistant TB is more common in people

who:
 do not take their TB drugs regularly
 do not take all of their TB drugs
 develop TB disease again, after being treated for
TB disease in the past
 come from areas of the world where drug-
resistant TB is common
 have spent time with someone known to have
drug-resistant TB disease.
12) How is drug-resistant TB spread?

 Drug-resistant TB spreads the same way that

drug- sensitive (i.e. normal) TB is spread.
 TB is spread through the air from one person to
another, when a person with TB disease of the
lungs coughs, sneezes, speaks, spits or sings.
 These bacteria can remain airborne for several
hours, depending on the environment.
 Persons who breathe in the air containing these
TB bacteria can become infected.
12) How is drug-resistant TB spread?

However, it is NOT spread by:

shaking someone's hand
sharing food or drink
touching bed linen or toilet seats
sharing toothbrushes
kissing
13) What is multi-drug resistant TB (MDR-TB)?

 Multidrug-resistant TB (MDR-TB) is caused by

a TB germ that is resistant to at least
isoniazid and rifampin, the two most potent
TB drugs.

 These drugs are used to treat all persons with

TB disease.
14) What is extensively drug-resistant (XDR-TB)?

Extensively drug-resistant TB (XDR-TB) is a

rare type of MDR-TB that is resistant to
 isoniazid and rifampin, plus
 any fluoroquinolone and
 at least one of three injectable second-line drugs
(i.e. amikacin, kanamycin, or capreomycin).
14) What is extensively drug-resistant (XDR-TB)?

 Because XDR-TB is resistant to the most

potent TB drugs, patients are left with
treatment options that are much less
effective.
 XDR-TB is of special concern for persons with
HIV infection or other conditions that can
weaken the immune system.
 These persons are more likely to develop TB
disease once they are infected, and also have a
higher risk of death once they develop TB.
15) How to prevent spreading TB to other people?

 If you are infectious while you are taking rest at home,

you can do the following things to protect others near
you.
 Take your medicines as directed. This is very important!
 Always cover your mouth with a tissue when you cough, sneeze,
or laugh. Put the tissue in a closed bag and throw it away safely.
 Isolate yourself from others and avoid close contact with anyone.
Sleep in a bedroom away from other family members for the first
few weeks.
15) How to prevent spreading TB to other people?

 If you are infectious while you are taking rest at home,

you can do the following things to protect others near
you.
 Air out your room often to the outside of the building (if it is not
too cold outside). TB spreads in small closed spaces where air
doesn’t move. Put a fan in your window to blow out air that may
be filled with TB bacteria. If you open other windows in the room,
the fan also will pull in fresh air. This will reduce the chances that
TB bacteria will stay in the room and infect someone who
breathes the air.
15) How to prevent spreading TB to other people?

 After you take the medicines for about 2 or 3

weeks, you might no longer be able to spread
TB bacteria to others.
 If your doctor or nurse agrees, you will be able
to go back to your daily routine, including
returning to work or school.
 But remember, you will only get well if you
take your medicines exactly as directed by
your doctor or nurse.
15) How to prevent spreading TB to other people?

 Think about people who may have spent time

with you, such as family members, close friends,
and co-workers.
 The local health department may need to test
them for TB infection.
 TB is especially dangerous for children and HIV-
infected persons.
 If these people are infected with TB bacteria,
they need medicines right away to keep them
from developing active TB disease.
16) BCG uses/limitations?

 BCG is a vaccine for TB, routinely given to

infants and small children.
 BCG vaccine protects against the severe, life-
threatening forms of extra-pulmonary TB
such as TB meningitis and miliary TB in
childhood.
 However, it is unreliable protection against
pulmonary TB, the main form of tuberculosis.
17) MDR-TB Prevention?

 The most important thing a person can do to prevent the

spread of MDR-TB is to take all their medications exactly
as prescribed by their health-care provider.
 No doses should be missed and treatment should never
be stopped early.
 Patients should tell their health-care provider if they are
having trouble taking the medications.
 If patients plan to travel, they should talk to their health-
care providers and make sure they have enough
medicine to last while away.
17) MDR-TB Prevention?

 Health-care providers can help prevent MDR-

TB by
 quickly diagnosing cases
 following recommended treatment guidelines
 monitoring patients’ response to treatment
 making sure therapy is completed.
17) MDR-TB Prevention?

 Another way to prevent getting MDR-TB is to avoid

exposure to known MDR-TB patients in closed or
crowded places such as hospitals, prisons, or homeless
shelters.
 If you work in hospitals or health- care settings where TB
patients are likely to be seen, you should consult
infection control or occupational health experts.
 Ask about administrative and environmental procedures
for preventing exposure to TB. Once those procedures
are implemented, additional measures could include
using personal respiratory protective equipment.
18) TB Diagnostic Tests?

 The best way to get tested for pulmonary TB is

by getting the sputum examined.
 The TB-causing germs can be seen through a
microscope.
 At least two samples of sputum should be
examined for accurate diagnosis.
 #1 - Early morning specimen
 #2 - Spot specimen - upon returning specimen#1 to
the health center/laboratory
18) TB Diagnostic Tests?

 The examination is available at public health

facilities, often within easy reach of the patients.
 In the facility, the health-care provider may ask
the person suspected of TB to collect two
sputum samples and explain how to produce and
collect them.
 It is important to carefully follow what the
health-care provider advises to make sure the
diagnosis is correct.
18) TB Diagnostic Tests?

 The health-care provider may also advise a chest

X-ray if
 Patient is suspected of having symptoms of TB
(TB Symptomatic patient)
 TB germs are not seen through the sputum
examination (Negative direct sputum smear
examination/DSSM/Sputum for AFB)
19) Rapid tests to diagnose TB and
drug resistance?
 In 2010, WHO endorsed Xpert MTB/RIF, a
rapid molecular test that can diagnose TB and
rifampicin resistance within 90 minutes.
20) How can a patient know whether
he/she has TB or MDR/XDR-TB?

 Both MDR and XDR-TB can only be diagnosed in

a well-equipped laboratory.
 Symptoms of XDR-TB are no different from
ordinary TB:
 a cough with thick, cloudy mucus (or sputum),
sometimes with blood, for more than 2 weeks;
 fever, chills, and night sweats;
 fatigue and muscle weakness; weight loss;
 and in some cases shortness of breath and chest pain.
20) How can a patient know whether
he/she has TB or MDR/XDR-TB?

 If you have these symptoms, it does not

mean you have MDR/XDR-TB.
 But it does mean you must go and see a
doctor for a check-up.
 If you are already on treatment for TB, and at
least some of these symptoms are not
improving after a few weeks of medication,
you should inform your clinician or nurse.
21) Is TB curable?

 Yes. TB can be cured if the full course of the

prescribed drugs is taken regularly, and
without interruption.
 The WHO-approved standardized and
effective cure for TB, called DOTS (directly-
observed treatment, short-course) is
available in all countries of the South-East
Asia Region.
21) Is TB curable?

 It takes at least 6–8 months of medication to

completely treat the disease.
 It is very important that the patient takes all
the prescribed drugs for the recommended
duration.
21) Is TB curable?

 It is dangerous, both for the patient, family

members and the community, if he/she stops
taking medication before the prescribed course
is completed and without medical advice.
 The TB germs/bacilli that are still alive become
even stronger, or “resistant” to the drugs.
 Stronger drugs are then needed to kill these
“super” TB germs if the treatment is not
completed the first time.
 Tuberculosis

Reference: steemit.com
Treatment of TB in Children

 Most children with TB can be treated with

Isoniazid and Rifampin for 6 months, along
with Pyrazinamide for the first 2 months if
the culture from the source case is fully
susceptible.

https://emedicine.medscape.com/article/230802-treatment#d10
Treatment of MDR - TB

 The complexity of MDR-TB treatment lies in

the futility of using isoniazid and rifampin.
 Isoniazid has the strongest antibactericidal
action and significantly contributes to making
patients rapidly noninfectious; rifampin has
unique antibacterial properties against
dormant bacilli that are no longer in the
active phase of replication.
https://emedicine.medscape.com/article/230802-treatment#d12
Treatment of MDR - TB

 When initiating treatment, utilize at least 3-5

previously unused drugs for which there is in
vitro susceptibility.

 Levofloxacin, which is a fluoroquinolone, has

been shown to be best suited long-term and
should be included in the regimen.
Treatment of MDR - TB

 Never add a single new drug to a failing

regimen. Administer at least 3 (preferably 4-
5) of the following medications, according to
drug susceptibilities:
 An aminoglycoside - Ie, streptomycin, amikacin,
capreomycin, kanamycin
 A fluoroquinolone - Ie, levofloxacin, ciprofloxacin,
ofloxacin
 A thioamide - Eg, ethionamide, prothionamide
 Pyrazinamide
Treatment of MDR - TB

 Ethambutol
 Cycloserine
 Terizidone
 Para-aminosalicylic acid
 A diarylquinoline: Bedaquiline
 A nitroimidazooxazine: Pretomanid (plus
bedaquiline and linezolid
Treatment of MDR - TB

 Consider rifabutin as a substitute for

rifampin, as approximately 15% of rifampin-
resistant strains are rifabutin sensitive.
 Successful MDR-TB treatment is more likely
in association with such factors as lower prior
patient exposure to anti-TB drugs, a higher
number of anti-TB drugs to which the
infection is still susceptible, and a shorter
time since the first TB diagnosis (indicating
less advanced disease).
Treatment of MDR - TB

 Continue treatment for MDR-TB for 18-24

months after sputum culture conversion. The
drugs should be prescribed daily (no
intermittent therapy), and the patient should
always be on DOT.
 Weekend DOT may not be possible;
therefore, giving self-administered oral drugs
on Saturdays and Sundays may be
reasonable.
Treatment of MDR - TB

 All patients should be closely observed for 2

years after completion of treatment, with a
low threshold for referral to TB centers.
 Novel drugs for TB are currently under
development and may prove valuable for
treatment of MDR-TB. The diarylquinoline
antimycobacterial, bedaquiline (Sirturo), was
approved by the FDA in December 2012 as
part of a 22-week multidrug regimen for
pulmonary MDR-TB.
Treatment Regimen: MDR - TB

 Those patients identified with MDR-TB will

be switched to the standard regimen:
 8 months of Pyrazinamide, Kanamycin, Ofloxacin,
Prothionamide, and Cycloserine, followed by
 12 months of Ofloxacin, Prothionamide, and
Cycloserine.

https://www.ncbi.nlm.nih.gov/books/NBK138752/
XDR - TB

 XDR-TB, an abbreviation for extensively drug-resistant

tuberculosis (TB), is a form of TB which is resistant to at
least four of the core anti-TB drugs.
 XDR-TB involves resistance to the two most powerful
anti-TB drugs, isoniazid and rifampicin, also known as
multidrug-resistance (MDR-TB), in addition to resistance
to any of the fluoroquinolones (such as levofloxacin or
moxifloxacin) and to at least one of the three injectable
second-line drugs (amikacin, capreomycin or
kanamycin).
https://www.who.int/tb/areas-of-work/drug-resistant-tb/xdr-tb-faq/en/
XDR - TB

 MDR-TB and XDR-TB both take substantially

longer to treat than ordinary (drug-
susceptible) TB, and require the use of
second-line anti-TB drugs, which are more
expensive and have more side-effects than
the first-line drugs used for drug-susceptible
TB.
Treatment of XDR - TB

 Use pyrazinamide and any other Group 1 agent that may

be effective.
 Use an injectable agent to which the strain is susceptible
and consider an extended duration of use (12 months or
possibly the whole treatment). If resistant to all injectable
agents it is recommended to use one the patient has never
used beforea or consider designing the regimen without an
injectable agent. If toxicity is a limiting factor for the use of
the injectable agent, and one of the injectable agents is
considered effective, consider using inhaled version via a
nebulizerb.

https://www.ncbi.nlm.nih.gov/books/NBK247431/box/ch5.box2/?report=objectonly
Treatment of XDR - TB

 Use a higher-generation fluoroquinolone such as

moxifloxacin or gatifloxacin.
 Use all Group 4 agents that have not been used extensively
in a previous regimen or any that are likely to be effective.
 Add two or more Group 5 drugs (consider adding
bedaquiline.
 Consider adding a new investigational drug eligible for use
under the compassionate use scheme if policy of the WHO
endorsesc its use for XDR-TB.

https://www.ncbi.nlm.nih.gov/books/NBK247431/box/ch5.box2/?report=objectonly
Treatment of XDR - TB

 Consider high-dose isoniazid treatment if low-level

resistance or absence of the katG gene is documented.
 Consider adjuvant surgery if there is localized disease.
 Ensure rigorous respiratory infection control measures at
the site where the patient is being treated.
 Consider the option of treatment in a hospital if the
clinical condition of the patient is poor or major
comorbidities coexist, or a shelter if the social condition
of the patient prevents proper home care
Treatment of XDR - TB

 Manage HIV coinfection .

 Provide comprehensive monitoring and full
social support to enable adherence to treatment
 Ensure that all patients have full access to
palliative and end-of-life care services, with a
patient-centred approach to relief the suffering
of the disease and its treatment.
22) What is DOTS?

 DOTS (directly-observed therapy, short-

course) means that the patient taking the
medicine should be observed by a nominated
person, and the taking of the medicine should
be recorded.
 This ensures that the patient takes the medication
regularly, which is essential for the medicines to
be effective – and to prevent the bacteria from
becoming resistant and the drug from becoming
ineffective.
22) What is DOTS?

 The best way to remember to take medicines

is to get directly-observed therapy.
 If following the DOTS regimen, the patient
will meet with a health care worker every day
or several times a week.
 This can be at the TB clinic, your home or
work, or any other convenient location.
 You will take your medicines at this place
while the health care worker observes.
22) What is DOTS?

DOTS helps in several ways:

The health care worker can help the TB patient
remember to take the medicines and complete the
treatment. This means he/she will get well as soon
as possible.
The health care worker will make sure that the
medicines are working as they should. This person
will also watch for side-effects and answer
questions about TB.
22) What is DOTS?

 The TB patient must be checked at different

times to make sure everything is going well.
 He/ she should see their doctor or nurse
regularly while taking the medicines.
 This will continue until the patient is cured.
23) How is TB Disease treated?

 Tuberculosis is usually treated through the use of a

combination of several drugs called antibiotics to kill all
the bacteria and preventing them from becoming
resistant to one or more drugs.
 The most common drugs used to fight TB are:
 Isoniazid
 Rifampin
 Pyrazinamide
 Ethambutol
 Streptomycin
 The medication is administered to the patient for at least
6 months as per the advice of the doctor.
23) How is TB Disease treated?

 People with TB of the lungs should initially stay

home from work or school so that they do not
spread TB bacteria to other people.
 After taking TB drugs for 2 weeks, they will feel
better and may not be infectious to others.
 However, to be completely cured they would
need to take the drugs as prescribed for at least
6–8 months.
24) Why is it important to take TB medicines
regularly for the entire duration of the
prescribed course?

 Sometimes patients stop taking TB medicines on their

own before the entire course is completed. However, if
the patient does not complete the course of the
treatment of TB,
 it can become harder or impossible to cure
 the person can stay sick for a longer time
 the medicines can stop working, and the person may have to take
different medicines that have more side effects
 even the new medicines may not cure the TB
 TB germs can be passed on to others.
24) Why is it important to take TB medicines
regularly for the entire duration of the
prescribed course?

 TB bacteria die very slowly. It takes at least 6

months to kill all the TB bacteria.
 People start feeling well after only a few
weeks of treatment.
 But TB bacteria are still alive in the body.
That is why it is important to continue to take
the medicine until all the TB bacteria are
dead, even though the person may feel better
and no longer have symptoms of TB disease.
24) Why is it important to take TB medicines
regularly for the entire duration of the
prescribed course?

 If a person with TB disease stops taking his/ her

prescribed medicines when they feel better, or are
not regular in taking the medicines, TB bacteria
will grow again.
 The person will become sick again because the bacteria
may become resistant to the drugs he or she was
taking.
 When this happens he/ she may need different drugs to
kill the TB bacteria if the old drugs no longer work.
 These new drugs need to be taken for a longer time and
usually have more serious side-effects.
24) Why is it important to take TB medicines
regularly for the entire duration of the
prescribed course?

 If a patient on TB treatment becomes

infectious again, he/she could spread TB
bacteria to their family, friends, or anyone
else who spends time with them.
 It is thus very important to finish the course of
medication as per the doctor’s advice.
24) Why is it important to take TB medicines
regularly for the entire duration of the
prescribed course?

 TB patients should talk to their health-care

provider if their TB medicine is making them
feel sick.
 Any medicine can cause side-effects,
including TB pills.
 But most people can take their TB medicine
without any problems.
25) Side effects of TB drugs?

 Very few people develop side-effects to TB

drugs.
 Minor side-effects
 vomiting, nausea, loss of appetite, joint pain,
orange/red urine, or skin rash, which can be managed
using simple medicines or adjusting the dosages of the
drugs.
25) Side effects of TB drugs?

 Major side-effects include

 Ototoxicity - deafness and dizziness (with the use of
streptomycin);
 Hepatotoxicity - jaundice, vomiting (mainly with
rifampicin and isoniazid);
 Optic neuritis - visual impairment (ethambutol),
 Shock, purpura, or acute renal failure (rifampicin).
 These side-effects need to be managed by a trained
physician and may require hospitalization.
25) Side effects of TB drugs?

 It is important to talk to the health-care provider

if the medicine is making you feel sick.

 However, most people can take their TB

medicine without any problems.
26) Once a person completes treatment for TB
disease and is cured, can he/she get TB
again?

 This is unlikely but can, rarely, occur. If the

patient has taken the medicine in the right
way for as long as the doctor advises, the
chances of getting TB again are low.

 However, if he/she notices any of the signs

and symptoms, consult the doctor
immediately.
27) Dietary tips for TB patients?

 It is important to eat a balanced diet to provide your

body with the nutrients that you need to ght TB.
 The diet should be simple, easily digestible, and to the
liking of the patient to encourage consumption.
 Meals should be small, but at frequent intervals.
 Larger meals can be given if the condition of the patient
improves.
 Fluid intake should be sufficient.
 It is particularly important to avoid drinking any alcohol
during the entire course of your treatment as this could
result in treatment complications and side- effects.
27) Dietary tips for TB patients?

 Weight gain generally improves during TB

treatment and appropriate nutritional
supplementation.
 It is very important that children with TB get
enough energy and nutrients, since children have
increased requirements as a result of both
growth and TB.
27) Dietary tips for TB patients?

 TB disease often adversely affects nutritional

intake, due to poor appetite, putting patients
at risk for malnutrition.
 6 smaller meals per day are advised instead of
3 meals.
 The meals should provide enough energy and
protein, and be appetizing in appearance and
taste so as to encourage the patient to eat.
27) Dietary tips for TB patients?

 People with HIV and/or (active) TB need more

calories and nutrients in their diet, but they
may also have lower appetites and be less
able to absorb the nutrients in their food.
 Force-feeding of the patient to gain extra
weight is known to do more harm than good.
 Too much food–especially fat–frequently
causes gastric upsets and diarrhea.
27) Dietary tips for TB patients?

 During treatment for TB,

 eat healthy foods and
 get enough sleep and
 some exercise
to help your body fight the infection.
28) Can a lactating mother receiving anti-TB
treatment breastfeed her baby?

 Breastfeeding should not be discouraged for

women being treated with the 1st-line anti-TB
drugs because the concentrations of these drugs
in breast milk are too small to produce toxicity in
the nursing newborn.
 For the same reason, drugs in breast milk are not
an effective treatment for TB disease or latent
TB infection in a nursing infant.
 Breastfeeding women taking isoniazid should
also take pyridoxine (vitamin B6) supplements.