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DETECT CASES OF MDR-TB
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Detect Cases
of MDR-TB
Acknowledgements
National Library of the Philippines Cataloguing in Publication Data
Management of Drug-resistant Tuberculosis Training for Health Facility
Staff in the Philippines
1) Tuberculosis (Disease) Multidrug-Resistant Tuberculosis
2) Training Modules
ISSN # 2012-2675
Recommended citation:
Tropical Disease Foundation and Department of Health, Philippines,
2008. Management of Drug-resistant Tuberculosis Training for Health
Facility Staff in the Philippines
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Objectives of this module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1. Identify MDR-TB suspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Exercise A: Written exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.1 Refer MDR-TB suspects to the appropriate Treatment Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Exercise E
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
MODULE B
Introduction
The detection of multidrug-resistant TB (MDR-TB) is more complex and time-consuming than the detection of a case
of TB that is susceptible to first-line drugs. To stop transmission, early detection of MDR-TB is important. Failure to
detect MDR-TB will lead to the spread of the drug-resistant strain to others, intake of incorrect treatment regimens,
amplification of drug resistance and poor treatment outcomes.
Patients with pulmonary TB (PTB) excrete tubercle bacilli that can be detected by examining their sputum under
a microscope, that is, by direct sputum smear microscopy (DSSM). However, drug resistance cannot be diagnosed
with DSSM alone. This is because a positive smear of drug-resistant TB (DR-TB) looks the same as a positive smear of
drug-susceptible TB. They are caused by the same organism, Mycobacterium tuberculosis (M. tuberculosis).
To detect if the strain of TB is resistant or not, a culture and drug susceptibility test (DST) must be done. This
laboratory procedure determines if the M. tuberculosis strain does not grow in the presence of anti-TB drugs. If the
strain grows, it is said to be resistant to that drug. The sputum must therefore be cultured, and a DST of the isolated
M. tuberculosis from the culture must be done. MDR-TB demonstrates resistance to at least isoniazid and rifampicin,
the two most powerful anti-TB drugs, with or without resistance to other anti-TB drugs. All patients with suspected
MDR-TB must therefore have culture and DST in addition to smear, to confidently diagnose MDR-TB or any type of
drug resistance.
Ideally, all TB symptomatics should undergo DSSM, culture and DST. However, given the limited resources available
in the Philippines at the moment, this is not possible for all of the TB suspects in the country. To more efficiently
diagnose those patients who have MDR-TB, a list of risk groups for MDR-TB will be described in detail in the following
pages. To detect cases of resistance early, health facilities should check for MDR-TB risk factors in all TB patients or
persons who present with symptoms suggestive of PTB, primarily cough. All persons presenting at a DOTS facility
who are found to be at high risk should be referred to an MDR-TB Treatment Center for diagnosis.
Confirmed MDR-TB cases by DST, as well as those highly suspected of MDR-TB, still unconfirmed but needing
immediate treatment must be presented to the consilium for further discussion and possible initiation of a
Category IV regimen. The consilium is a multi-disciplinary case management committee composed of program
staff, physicians, nurses and other relevant health care workers with expertise on MDR-TB management. This
committee meets regularly to confirm the diagnosis, determine treatment regimens, assess response to treatment,
and determine final outcome through a consensus using standards based on the WHO Guidelines for Programmatic
Management of Drug-resistant TB.
Pulmonary MDR-TB patients are generally infectious cases since they are often chronic cases, and have more
extensive lung damage. They discharge tubercle bacilli into the air by coughing, sneezing, etc. Close contacts of
MDR-TB cases, e.g., in the home, can become infected with a drug-resistant strain of TB when they breathe in a
significant amount of tubercle bacilli. The longer MDR-TB cases are untreated, the greater will be the likelihood that
they will infect their close contacts.
Early identification of MDR-TB suspects should be a priority for every DOTS facility, in order to promptly treat the
infectious cases before they spread the drug-resistant strain to others. Early treatment of these cases increases the
likelihood of a favorable outcome and minimizes destruction of the lungs by the microorganism. It also limits the
amplification of resistance and prevents the emergence of extensively drug-resistant TB (XDR-TB).
MODULE B
Refer to section:
1
1
2
2
2
2
4
5, 6
7
8
MODULE B
MODULE B
A. Retreatment cases
1. Failure
Category I failure: a patient who remains (or becomes) sputum smear-positive on the 5th month or
later of DOTS Category I treatment
Category II failure (chronic TB case): a patient who remains (or becomes) smear-positive on the
5th month or later of DOTS Category II treatment or who remains sputum-positive at the end of a
retreatment regimen
2. Relapse of category I or II: a patient who has been declared cured or treatment completed, and is
diagnosed with bacteriologically (smear or culture) positive TB
3. Return after default: a patient who returns to treatment with positive bacteriology (smear or culture)
following interruption of treatment for two months or more
4. Other type of patient: a patient with one month or more of anti-TB drug intake under the DOTS strategy
that cannot be classified into any type of retreatment, or a patient with one month or more of non-DOTS
treatment.
a) Non-DOTS patient whether sputum-positive or sputum-negative
b) Other-positive: a sputum-positive patient with one month or more of DOTS treatment who
cannot be typed as Treatment failure, Relapse, or Return after default. For example, a patient
who is smear-negative initially then turned out to be positive at sputum follow-up during DOTS
treatment .
c) Other negative: a sputum-negative patient with one month or more of DOTS treatment who
cannot be typed as Treatment failure, Relapse, or Return after default. For example, a patient
who returns to TB treatment with negative bacteriology (smear or culture) following interruption
of treatment for two months or more
*A treatment course is defined as at least a month of intake of anti-TB drug(s) excluding primary and
prophylactic treatment.
5. Non-converter of Category II: a patient who remains smear-positive at the end of the third month of
DOTS Category II treatment
MODULE B
Case 1
A 34 year old female patient, who took only 4 months of Category I treatment last year, has returned to the DOTS
facility. The patient was sputum smear (-) on the 2nd and 4th months of follow-up but thereafter stopped treatment
since she was already feeling better. Now the patient complains of a persistent cough for the last 4 weeks with back
pain, hemoptysis and weight loss. Sputum examination result was smear-positive.
MDR-TB suspect? Yes
High-risk group
No
Case 2
A female patient who has received 3 different courses of TB medications over a period of many years with a private
doctor has come to your facility for consultation. The patient said she took all of the medicines and completed
treatment each time but now has a cough and fears it may again be TB. She also has weight loss, hemoptysis,
occasional fever, chest pain and night sweats. She has come to the DOTS facility because she no longer has money
to pay for treatment.
MDR-TB suspect? Yes
High-risk group
No
Case 3
A 55 year old male has been complaining of cough for three weeks, night sweats and fatigue. When interviewed, he
says that he has not been sick for a long time but his wife told him he must come in to be checked because their 25
year old son who lived in the same house with them died of MDR-TB last year. The patient has no history of TB and
has a normal chest x-ray.
MDR-TB suspect? Yes
High-risk group
No
MODULE B
Case 4
A 17 year-old female student has come to your DOTS facility for cough of more than two weeks and fever of five
days. She has never been diagnosed or treated for TB in the past. She denies exposure to anybody with TB in the
home or in school. You examine her and she has rales on both lower lung fields.
MDR-TB suspect? Yes
High-risk group
No
Case 5
A female patient, 18 years old, who is being treated for HIV in one of the treatment hubs in Metro Manila develops
fever, and weight loss. The DOTS facility recognized her to be the sister of a non-converting Category II patient who
has been going to this health center for TB treatment.
MDR-TB suspect? Yes
High-risk group
No
Case 6
A Category II (relapse) male patient just finished the third month of treatment and is still smear-positive. He still has
cough and back pain and has been losing weight. The patient has had no adverse events and complies with the
treatment schedule.
MDR-TB suspect? Yes
High-risk group
No
10
MODULE B
KASAKA-QI MDR-TB
Housing Facility ,
Quezon City
1
2
3
4
DOTS facilities, whether public or private, from all over Metro Manila may refer their MDR-TB suspects to any of the
Treatment Centers shown above. The Treatment Center which is most proximal to the patients residence or address
would be most convenient to the patient and should be selected.
DETECT CASES OF MDR-TB
11
MODULE B
A flow chart for the referral of MDR-TB suspects is illustrated in Figure 2, page 14.
TABLE 1. Zoning of local government units and MDR-TB Treatment Centers
ZONE
LGU
Caloocan:
North
Bayan
Malabon
Navotas
Valenzuela
Marikina
Pasig
Pateros
2
Taguig
QC
Manila
Tondo
Sta. Mesa
Sampaloc
Others
Makati
TDF-MMC DOTS Clinic
Mandaluyong
San Juan
Las Pinas
Muntinlupa
4
Paranaque
Pasay
12
MODULE B
4 / 25/ 05
Balagtas
Jose
Last
First Name
Age 50 y/o
Sex Male
Address 2425 Buendia St.
City/Province Manila
Region
NCR
Be guided
by the zoning
Amorsolo map on
Middle name
Figure 1 and
Table 1 when
identifying the
Brgy. Balut, Tondo appropriate
Treatment
(02) 244-6847
Tel. No.
Center
NCR
Dr. A. Madrid
Referring MD
MMC/TDF Clinic
KASAKA QI
PTSI Tayuman
Category I failure
Non-converter of category II
Category II failure
Relapse Category I
Relapse Category II
Other (+)
Other (-)
Where
1997
2003
September 14,
2004
By whom
Outcome
2 HRZE
4 HR
Unknown
2HRZES
4HRZE
Failed
3 HRZES 3 HRZE
Failed
To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.
DETECT CASES OF MDR-TB
13
MODULE B
x
x
MDR-TB suspects
Retreatment cases
R Failure:
Category I
Category II
R Relapse
Category I
Category II
R Return after default
R Other
R Non-converter of Category II
New or retreatment cases
R Symptomatic contact of MDR-TB patients
R HIV (+) patient
FORMS USED
x
MDR-TB Suspects
Referral Form
x
Non-MDR-TB
suspect:
Refer back
to referring
physician/DOTS
facility
MDR-TB Screening
Form
x Acknowledgement
Form
x Paunawa or Terms of
Understanding
x TB Symptomatics
Masterlist
x
Mycobacteriology
Request Form
x Laboratory Receiving
Form (Specimens)
Refer to Consilium
x
Consiliumex
x
Release of results:
DSSM: 4-5 days after the last specimen collection
Culture: 3-3.5 months after specimen collection
DST: 4-5 months after specimen collection
x
14
Acknowledgement Form
MODULE B
Case 1
34 year old female patient, Sonia Santos Sariwa, with present address at # 23 Santol St., Barangay San Antonio, Cavite
City. Tel. No. (046) 431-4086.
Date of birth: August 18, 1973
She finished 4 months of Category I treatment in your DOTS facility, Santol Health Center in the patients own
barangay. She started in June of 2002 and was sputum smear (-) on the 2nd month. After 2 months of HR, she was
again smear (-) on the 4th month of follow-up. The patient felt better and decided to abandon treatment despite
your strong advice.
Today is November 29, 2007 and the patient has returned complaining of a persistent cough for the last 4 weeks
with back pain, hemoptysis and weight loss. Sputum was smear-positive.
The contact telefax number of your health center is (046) 431-25253.
15
Age
First Name
Middle name
Sex
Address
Brgy.
( House # and name of street)
City/Province
Region
Tel. No.
Tel. No.
Address of Facility:
Fax No.
City
Region
Referring MD
Referred to (Please check)
MMC/TDF Clinic
KASAKA QI
PTSI Tayuman
Non-converter of category II
Category II failure
Relapse Category I
Relapse Category II
Where
By whom
To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.
16
Outcome
MODULE B
Case 2
Rolanda Ramirez Reloz, 49 years old, has received 3 different courses of TB medications over a period of many years
with Dr. A. Reyes as her private doctor.
The patients treatment history started in:
t August 2003: Myrin P Forte x 3 months and Myrin x 3 months
t 2nd treatment: August 2005: Myrin P Forte x 6 months
t 3rd treatment: December 2006: 3 months of Econokit- MDR and 4 months of Econopack
She said she took all the medicines and claimed to have finished treatment each time but now has a cough and
fears it may again be TB. She also has weight loss, hemoptysis, occasional fever, chest pain and night sweats. She
has come to your DOTS facility today, December 3, 2007, because she no longer has money to pay for treatment.
Chest x-ray done a week ago showed a cavitary lesion on the right upper lobe, infiltrates on the left lower lobe and
minimal pleural effusion, right.
Mrs. Reloz is presently residing at 44526 Jhonny St., Brgy. Pio del Pilar, Makati City. Tel: 989014301. Date of birth is
September 2, 1958. Your facility is Pio del Pilar Health Center, Brgy Pio del Pilar, Makati City. Telephone no. 8889045
17
Age
First Name
Middle name
Sex
Address
Brgy.
( House # and name of street)
City/Province
Region
Tel. No.
Tel. No.
Address of Facility:
Fax No.
City
Region
Referring MD
Referred to (Please check)
MMC/TDF Clinic
KASAKA QI
PTSI Tayuman
Non-converter of category II
Category II failure
Relapse Category I
Relapse Category II
Where
By whom
To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.
18
Outcome
MODULE B
Case 3
Santiago Suma Santos, a 55 year old male with present address at 2062-1 Anak Bayan, Paco, Manila. Tel. 530-55555,
has been complaining of cough for three weeks, night sweats and fatigue. When interviewed, he says that he has
come upon his wifes advice considering that their 25 year old son died of MDR-TB last year. He has had no history of
TB but now has minimal infiltrates on the left upper lobe on the film done December 1, 2007.
Date of birth: April 2, 1952
Your DOTS facility is J. Fabella Health Center, San Andres, Manila. Telefax. no. 530-444444.
Today is December 5, 2007.
19
Age
First Name
Middle name
Sex
Address
Brgy.
( House # and name of street)
City/Province
Region
Tel. No.
Tel. No.
Address of Facility:
Fax No.
City
Region
Referring MD
Referred to (Please check)
MMC/TDF Clinic
KASAKA QI
PTSI Tayuman
Non-converter of category II
Category II failure
Relapse Category I
Relapse Category II
Where
By whom
To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.
20
Outcome
MODULE B
Case 5
A female patient, Susana Sandok Sarmiento, 18 years old, who is being treated for HIV in one of the treatment hubs
in Metro Manila develops fever, and weight loss. Your staff at the Quirino Health Center recognized her to be the
sister of a non-converting Category II patient who has been going to this health center for TB treatment. Chest x-ray
of Susana done on October 8, 2007 showed a normal result.
Today is December 6, 2007.
Date of birth: June 18, 1989
Present address is at 1598 Interior 86 P. Quirino Avenue, Pandacan, Manila with telephone number 589-63636.
Your Health Center is located in Quirino Ave., Pandacan, Manila with telephone no. 599-0001.
21
Age
First Name
Middle name
Sex
Address
Brgy.
( House # and name of street)
City/Province
Region
Tel. No.
Tel. No.
Address of Facility:
Fax No.
City
Region
Referring MD
Referred to (Please check)
MMC/TDF Clinic
KASAKA QI
PTSI Tayuman
Non-converter of category II
Category II failure
Relapse Category I
Relapse Category II
Where
By whom
To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.
22
Outcome
MODULE B
Case 6
Patient Rodolfo Remo Robles, 30 years old, was declared cured from Category I treatment which started on June
1, 2006 in Poblacion Health Center. However, he went into relapse for which the 2nd treatment was started on
September 3, 2007. Treatment with Category II is ongoing at your DOTS facility, Poblacion Health Center in the same
street and barangay where the patient resides.
Today, December 7, 2007, the patient is on his 3rd month of treatment and the follow-up smear result came out
positive. He still has cough and back pain and has been losing weight. The patient has had no adverse events and
complies with the treatment schedule.
Present address is at 276281 Poblacion Sn Vicente St., Bayanan, Muntinlupa City. Tel 5305555.
Date of birth: March 28, 1977
Tel no. of your health center is 8098420.
23
Age
First Name
Middle name
Sex
Address
Brgy.
( House # and name of street)
City/Province
Region
Tel. No.
Tel. No.
Address of Facility:
Fax No.
City
Region
Referring MD
Referred to (Please check)
MMC/TDF Clinic
KASAKA QI
PTSI Tayuman
Non-converter of category II
Category II failure
Relapse Category I
Relapse Category II
Where
By whom
To the referring facility: Kindly attach a photocopy of the NTP Treatment Card.
24
Outcome
MODULE B
25
MODULE B
The Screening code is the unique identification number assigned to every TB symptomatic who undergoes
the process of screening at the Treatment Center (See table below). This number is given once the patient is
entered in the TB Symptomatics Masterlist for PMDT. See Reference Booklet for instructions on how to fill out
the TB Symptomatics Masterlist.
TABLE 2 :Screening code (TC-YY-MM-NNNN)
Code
TC
YY
MM
NNNN
Description
Treatment Center:
01 TDF-MMC DOTS Clinic
02 KASAKA-QI MDR-TB Housing Facility
03 LCP-PHDU DOTS Center
04 Dr. Jose N. Rodriguez Memorial Hospital (DJNRMH)- DOTS Center
05 Philippine Tuberculosis Society Inc. (PTSI) Tayuman DOTS Center
Current year the patient was screened, e.g., 08 for 2008
Current month the patient was screened, e.g., 01 for January
Accrual number that begins with 0001 at the start of every month
The example on page 28 shows that the patient, Jose Balagtas, with Screening Code 02-05-04-0081 was screened
in KASAKA-QI MDR-TB Housing Facility in April 2005 and was the 81st TB or MDR-TB suspect to be screened since
the start of the month in that Treatment Center. Permanent address is the address where the patient has stayed on
a long-term basis, e.g., in the province, while the current address is the residence where he can be contacted while
undergoing diagnosis for TB or MDR-TB, e.g., relocation address in Metro Manila.
t
t
t
26
Elaborate on the patients symptoms including duration, and other details, e.g., quantification of weight
loss, or blood during hemoptysis, etc.
Write the patients past TB treatment: what drugs were taken, where treated, whether DOTS or non-DOTS,
and the outcome of such treatments; exposure to active TB or MDR-TB; comorbid illnesses, allergy, etc.
Write the smoking, alcohol and drug use, and sexual history.
MODULE B
t
t
t
Write the physical examination findings, and laboratory procedures that were done prior to the screening,
the radiographic findings including an illustration of where the radiographic lesions are found in the
lungs.
Finally, write down your assessment of the patient, whether TB or non-TB, and if new or retreatment. If the
patient is a retreatment case, specify what category, whether failure of category I or II, return after default,
relapse of category I, II or IV, or other. Specify also if there are risk factors other than a history of treatment,
e.g., being a contact of an MDR-TB case, non-conversion of Category II treatment, TB symptomatic HIVpositive, or whether he has had 2 or more treatment courses.
Write the management plans, e.g., what sputum examinations to make and how many specimens for
each.
A filled out MDR-TB Screening Form is shown on the following pages. See Reference Booklet for instructions on how
to fill this out.
27
Screening
code:
TC: 02= KASAKA
KASAKA
Screened at:
MMC/TDF
LCP
Others, specify
YY:/05=
04 /28
052005
Screening code: (TC-YY-MM-NNNN) 02-05-04-0081
Date:
MM: 04= April
(mm/dd/yy)
0081: 81st
patient to be
I. Demographics
screened in
Balagtas
Jose
Amorsolo
Name:
KASAKA in April
Surname
Given Name
Middle
Name
2005
Sex:
Male
Date of birth:
Age:
50 y/0
Place of birth:
Nationality: Filipino
Permanent
address is the
patients long2425
Permanent
term
address address:
Religion: Roman
Catholic
Married
Civil status:
Single
Widowed
Living together
Divorced/ legally separated
Tel. no.:
(02) 244-6847
area code+ tel #
Same as above
zip code
E-mail address:
Occupation:
Office
Cityaddress:
Manila
(mm/dd/yy)
Female
City address:
01/20/ 55
Tel. no.:
area code+ tel #
None
None
None
N/A
area code+ tel #
address
Joy Balagtas
(02) 244-6847
Spouse:
Address/ Contact #:
is the
Father:
Mother: Lorna Balagtas (Deceased)
address Eduardo Balagtas (Deceased)
in Metro
Parents
address:
Tel. no.:
Manila
area code+ tel #
Daughter
whereto
the
Person
notify in case of emergency: Marites Balagtas
Relationship:
patient is 2425 Buendia St., Balut, Tondo, Manila
Address:
Tel. No.:
staying
area code+ tel #
to access
Referred
by: HC
Govt Inst
PPMD
FBO
NGO
Pvt MD/Institution
diagnosis
Sapaguita
Health
Center
Specify name,
and
#3436 Balut, Tondo, Manila
possibleof referring facility:
Address
treatment.
2 More than 10 yrs old:
3
Number of household contacts: 5
Less than or equal 10 yrs old:
Persistent
coughing
with
fresh
blood
Chief Complaint/s:
Duration in month/s
> 6 months
3 weeks
> 6 months
4 Months
6 months
3 weeks
> 1 month
> 6 months
Comments
With expectoration of yellowish sputum
Remittent, usually in the afternoon
Right upper back pain
Last episodes 4/23/05 2 TBSP
Approximately 10 kg
No
Co- morbidities
If Yes
Drugs:
1. None
Y
Y
Y
5
3
3
Non MDR
Duration
Diabetes Mellitus
Cancer
HIVinfection/AIDS
Kidney disease
Lung disease
Epilepsy
Psychiatric condition
Others
Allergy:
MDR
Outcome
(1=cured, 2=tx completed,
3=failed, 4=defaulted,
5=unknown)
year (s)
year (s)
year (s)
year (s)
year (s)
year (s)
year (s)
year (s)
NA
Type of reaction:
2.
NA
NA
Previous surgery:
None
Date of surgery:
Complications:
Pneumonectomy/ Lobectomy
Others, specify
20 sticks/day x 31yrs
Women: LMP
Alcohol
Current
Past
Never
Type /bottles /day x yrs
/
/
(mm/dd/yy)
Drug Abuse
Current
Past
Never
Type (shabu, marijuana, etc)
No
yes, specify
29
0 = Not done
1 = Normal
2 = Abnormal
System examination:
2
2
General Health:
Skin:
BCG scar:
1
1
2
Oropharynx:
Cardiovascular:
Thorax & Lungs:
Use of accessory muscles:
Abdomen:
Genito-Urinary:
Extremities:
Neurological:
Lymph Nodes:
Endocrine:
2
1
1
1
1
1
1
28
RR at rest:
Describe abnormalities
Ambulatory, cachectic
Poor skin turgor
Present
(+) wheezing, bilateral lung elds, decreased breath sounds on R lung eld
Laboratory procedures:
Smear, Culture and DST results from other laboratory
Date
AFB 2+
02/ 15 / 05
30
None
/min
MODULE B
MDR - TB SCREENING FORM | page 3 of 4
04 / 17
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
/ 2005
Right Lung
Left Lung
0 - Normal
7 - Fibrosis
1 - Cavitary
8 - Fibrothorax
2 - Infiltrate
9 - Bullae
3 - Nodule
10 - Pleural effusion
4 - Miliary TB
11 - Pneumothorax
5 - Intrathoracic
lymphadenopathy
12 - Bronchiectasis
6 - Endobronchial
spread
14 - Consolidation
13 - Atelectasis
15 - Mass
VI. Assessment:
TB suspect
New
Retreatment
II conversion,
and number
of treatment
courses, select
the appropriate
risk factors for
drug resistance.
Non-DOTS
Other (+)
Other (-)
Disease other than TB, specify
VII. Plan:
For smear x
For TB culture x 2
For Drug susceptibility testing
Start TB treatment, specify regimen:
Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment
Others
Attending MD:
Date:
4 / 28 / 05
31
MODULE B
Type of suspect
Action to take
Relapse
Return after default
Category I failure
Other with only one previous treatment
Category II failure
Previously treated patients with two or more treatment
courses in the past
MDR-TB suspects who are noted to be critically ill at the time of screening or are clinically deteriorating are
immediately referred to the Consilium for case discussion and possible expedited treatment using the appropriate
regimen. This is discussed in more detail in section 2.4 in this module.
After completing the Acknowledgement Form, give one copy to the patient to be given back to his referring physician
or facility and attach the other copy to the MDR-TB Screening Form which remains at the Treatment Center. There are
occasions when the patient is unable to give this back to the referring physician. Hence, a copy of the accomplished
Acknowledgement Form may need to be sent directly by telefax, if the contact number is known. An example of a
PMDT Acknowledgement Form is shown on the next page.
Later when DST results have been received by the Treatment Center, another Acknowledgement Form is completed
and sent to the referring physician or facility this time with the box for final diagnosis ticked and updated
information on the patient given.
32
MODULE B
Acknowledgement Form
Date:
4/28/05
To:
Dr. A. Madrid
Initial Diagnosis
Final Diagnosis
Tondo, Manila
Jose A. Balagtas
, for further TB
(+) wheezing, bilateral lung elds, decreased breath sounds on R lung eld
To consider Multidrug-resistant TB
Plans/Recommendations:
Clinic Physician:
Contact numbers:
33
MODULE B
34
02-05-04-0082 04/28/05
02-05-04-0083 04/28/05
02-05-04-0084 04/29/05
02-05-05-0001 05/02/05
02-05-05-0002 05/02/05
02-05-05-0003 05/10/05
(1) TX Centers:
01 - TDF-MMC DOTS Clinic
02 - KASAKA-QI MDR-TB Housing Facility
03 - LCP-PHDU DOTS Center
04 - DJNRMH DOTS Center
05 - PTSI Tayuman DOTS Center
06 - ________
07 - ________
02-05-04-0081 04/25/05
Name
08/03/85
19
12/23/67
39
12/23/67
39
02/02/78
27
03/28/83
23
05/26/58
48
01/20/55
50
Date of birth
(mm/dd/yy)
(5)
Address
(6)
DETECT
Detect
CASES
CasesOFofMDR-TB
MDR-TB
(8) Funding:
0- Gen fund
2- Round 2
5- Round 5
99- Others; specify
____________
(6) Sex:
1- Male
2- Female
(7)
Sex
No. of previous
TB treatment
TB Symptomatics Masterlist
(8)
Sta. Cruz HC
patient Merlie
Camias
Vergonville
DOTS Center
Dr. Artemis
Malunsay
Sta Monica
Hospital
Greenview Dots
Center
Sampaguita HC
Name of Health
facility/ Private
MD
NCR
Dr. Reyes
Dr. Lauro
Macandog
Philippine
General Hospital
Greenview Dots
Center
Sampaguita HC
Health facility/
Private MD
1 - New
2 - After Cat I failure
3 - After Cat II failure
4 - After Cat IV failure
5 - After default
6 - Cat I relapse
7 - Cat II relapse
10.1
10.1
Registration
group
(12)
8 - Cat IV relapse
9 - Transfer-in
10 - Other patient w/
10.1 Non-DOTS
10.2 Other (+)
10.3 Other (-)
NCR
Makati
NCR
Manila
NCR
Las
Pinas
Albay
NCR
Manila
NCR
Manila
NCR
Manila
City/
Region
Makati
NCR
Manila
NCR
Las Pinas
Albay
NCR
Manila
NCR
Manila
NCR
Manila
City/ Region
(9)
Source of
referral
Funding
35
2+ / MTB
04/28/05
1+ /MTB
04/28/05
0 /MTB
04/29/05
4+ /MTB
05/02/05
1+ /MTB
05/02/05
0 / MTB
05/10/05
1,2,8
04 / 17 / 05
1,2
03/ 21 /05
1,15
01 /22 /05
1,2,3
04/02/05
1,2
04 /27 /05
2
04 /25 /05
1,2
05/05/05
1, 2, 3,
4, 5, 6
1,3,4
1,3,4,5
1, 2, 3, 4,
5, 6
1,3
1, 2, 3, 4,
5, 6
05 / 02 / 05
0 /MTB
3+ /MTB
05 / 2/05
04 / 29 / 05
0 / MTB
4+ / MTB
04/26/05
/
/
/
/
/
for DOTS.
/local health center
/
/
/
9 - Bullae
10 - Pleural effusion
11 - Pneumothorax
12 - Bronchiectasis
13 - Atelectasis
14 - Consolidation
15 - Mass
16 - others, specify
______________
/ /
/
/
A/ pansusceptible
case is/ referred
to/ the
(14) Symptoms:
0- None
1- Cough
2- Fever
3- Chest/back pain
4- Hemoptysis
5- Weight loss
6- Night sweats
3+ / MTB
05/03/05
1+ / MTB
05/03/05
1+ / MTB
05/11/05
3+ / MTB
04/25/05
(15)
(14)
Date done
(13)
Risk factors
Symptoms
36
CXR results
Pending
Km
Ofx
Cfx
Lfx
ND
ND
ND
ND
ND
H - Isoniazid
R - Rifampicin
Z - Pyrazinamide
E - Ethambutol
S - Streptomycin
Km - Kanamycin
Ofx - Ofloxacin
Cfx - Cifloxacin
Lfx - Levofloxacin
8/31/05
9/23/05
10/5/05
9/14/05
10/10/05
Date DST
released
9/6/05
9/6/05
9/27/05
10/11/05
9/20/05
10/18/05
Consilium
date
Registration date
(mm/dd/yy)
(18)
4.
5.
6.
7.
8.
05-0079
8/10/2005
09/07/05
Referred to LHC
05-0080
8/30/2005
10/4/2005
05-0097
05-0098
11/8/2005
05-0096
05-0099
11/24/2007
/
/
A Pre-enrollment No.
is/assigned
to/ all TB symptomatics
who are either a) proven MDR-TB by DST, or b) decided
Summary
by the consilium to start treatment
even without DST
1. Number of DR-TB suspects
confirmation
due to high clinical suspicion. Both groups
2. Suspects with 2 sputum specimens tested
are3. all
forwith
start
treatment.
Suspects
at leastof
1 culture
results
ND
ND
ND
ND
ND
Other Other
MODULE B
List each of the 5 MDR-TB suspects presented below in the TB Symptomatics Masterlist and fill out Columns
1-15.
Assign each, in sequence, a Screening code. Assume that the last code in the Masterlist was TC-YYMM-096.
Funding source is Round 5 GFATM.
Assume that the patients went to the Treatment Center on the day that you as the referring MD made the
MDR-TB Suspects Referral Form.
37
Case 1:
Screened at:
MMC/TDF
KASAKA
LCP
Others, specify
Date:
11/29/2007
(mm/dd/yy)
I. Demographics
Sariwa
Name:
Sonia
Surname
Sex:
Male
Female
Nationality:
Santos
Given Name
Date of birth:
Middle Name
Age:
(mm/dd/yy)
Filipino
Permanent address:
Religion:
Catholic
34
Place of birth:
Cavite
Tel. no.:
(046) 431-40086
area code+ tel #
City address:
zip code
E-mail address:
Occupation:
Office address:
none
none
none
Tel. no.:
10
Family monthly income:
Employer:
Tel. no.:
Spouse: none
Address/ Contact #:
Eufronio
Sariwa
(deceased)
Sofriana Sariwa
Father:
Mother:
Parents address: 23 Santol St., Barangay San Antonio, Cavite City
Tel. no.:
Person to notify in case of emergency: Sofriana Sariwa
Address: 23 Santol St., Barangay San Antonio, Cavite City
Relationship:
Tel. No.:
000 Php
(046) 431-40086
area code+ tel #
mother
(046) 431-40086
area code+ tel #
Govt Inst
PPMD
FBO
NGO
Pvt MD/Institution
HC
Specify name, Santol Health Center
Address of referring facility: Barangay San Antonio, Cavite City
3
Number of household contacts:
Less than or equal 10 yrs old: 0
More than 10 yrs old:
persistent cough with hemoptysis
Chief Complaint/s:
Referred by:
Cough
Fever
Back/ chest pain
Hemoptysis
Weight loss
Night sweats
Other symptoms:
Dyspnea at rest
Dyspnea on exertion
Pedal edema
38
Duration in month/s
1
1
1
1
Comments
productive, minimal amt., whitish in color
( mm/dd/yyyy )
( mos.)
1. June
2.
3.
4.
5.
6.
7.
2002
No
Co- morbidities
Allergy:
If Yes
MDR
Non MDR
Duration
Diabetes Mellitus
Cancer
HIVinfection/AIDS
Kidney disease
Lung disease
Epilepsy
Psychiatric condition
Others
DOTS
(Y/N)
2 HRZE / 2 HR
Treatment facility
Drugs:
Status
Type of reaction:
1.
2.
Concomitant drugs / Duration:
Previous surgery:
Date of surgery:
Complications:
None
/
Pneumonectomy/ Lobectomy
Others, specify
Women: LMP
Alcohol
Current
Past
Never
Type /bottles /day x yrs
11
/ 29 / 2007
(mm/dd/yy)
sexually active
Drug Abuse
Current
Past
Never
Type (shabu, marijuana, etc)
0
No
yes, specify
pills
39
Vital Signs:
Height: 155
cm
Temp: 37.5
Celsius
BP: 130/90
mmHg
System examination:
General Health:
Skin:
BCG scar:
Oropharynx:
Cardiovascular:
Thorax & Lungs:
Use of accessory muscles:
Abdomen:
Genito-Urinary:
Extremities:
Neurological:
Lymph Nodes:
Endocrine:
Weight: 43 Kg.
PR/ HR: 98 / min
O2 sat by Pulse oximeter:
0 = Not done
1 = Normal
2 = Abnormal
2
2
0
0
2
1
0
1
0
2
0
25
RR at rest:
%
Describe abnormalities
(+) crackles heard on both upper lung elds, more on the right
Laboratory procedures:
Smear, Culture and DST results from other laboratory
DSSM 0 / 2+ / 1+
40
/min
Date
11
/ 25 / 2007
/
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
Right Lung
Left Lung
0 - Normal
7 - Fibrosis
1 - Cavitary
8 - Fibrothorax
2 - Infiltrate
9 - Bullae
3 - Nodule
10 - Pleural effusion
4 - Miliary TB
11 - Pneumothorax
5 - Intrathoracic
lymphadenopathy
12 - Bronchiectasis
6 - Endobronchial
spread
14 - Consolidation
13 - Atelectasis
15 - Mass
VI. Assessment:
TB suspect
New
Retreatment
None
Symptomatic contact of confirmed/
suspected MDRTB patient
Non-converter of Category II
Symptomatic HIV-positive
2 or more non-DOTS treatment course
Non-DOTS
Other (+)
Other (-)
Disease other than TB, specify
VII. Plan:
For smear x
2
For TB culture x
Category II Treatment while awaiting DST;
For Drug susceptibility testing
Start TB treatment, specify regimen: stop treatment if non-converter on 3rd month
Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment
Others
Attending MD:
Dave Verzosa, MD
Date:
11/29/2007
41
Case 2:
Screened at:
MMC/TDF
KASAKA
LCP
Others, specify
Date:
12/03/2007 (Saturday)
(mm/dd/yy)
I. Demographics
Reloz
Name:
Rolanda
Surname
Sex:
Male
Female
Nationality:
City address:
Date of birth:
Middle Name
Age:
(mm/dd/yy)
Filipino
Permanent address:
Ramirez
Given Name
Religion:
Catholic
49
Place of birth:
Makati
Civil status:
Single
Married Widowed
Living together
Divorced/ legally separated
Tel. no.:
989014301
area code+ tel #
Tel. no.:
989014301
area code+ tel #
E-mail address:
Occupation:
Office address:
none
50 000 Php
Family monthly income:
Manager
Mano
Mano
Manufacturing Company
Employer:
44526 Jhonny St., Pio del Pilar, Makati City
Tel. no.:
none
Son
Relationship:
Tel. No.: 989014301
Govt Inst
PPMD
FBO
NGO
Pvt MD/Institution
HC
Specify name, Pio del Pilar Health Center
Address of referring facility: Barangay Pio del Pilar, Makati City
5
Number of household contacts:
Less than or equal 10 yrs old: 3
More than 10 yrs old:
persistent cough
Chief Complaint/s:
Referred by:
Cough
Fever
Back/ chest pain
Hemoptysis
Weight loss
Night sweats
Other symptoms:
Dyspnea at rest
Dyspnea on exertion
Pedal edema
42
Duration in month/s
2 wks
1 wk
1
1
1
Comments
productive, minimal amt., whitish in color
usually in the afternoon
on both lung area, greater in right upper area
dark red in color, 1 episode for the last wk
approximately 7 kg
( mm/dd/yyyy )
( mos.)
1. Aug. 2003
2. Aug. 2005
3. Dec. 2006
4.
5.
6.
7.
No
Co- morbidities
If Yes
Allergy:
MDR
5
5
5
Drugs:
N
N
N
Non MDR
Duration
Diabetes Mellitus
Cancer
HIVinfection/AIDS
Kidney disease
Lung disease
Epilepsy
Psychiatric condition
Others
DOTS
(Y/N)
Treatment facility
Status
Type of reaction:
1.
2.
Concomitant drugs / Duration:
Previous surgery:
Date of surgery:
Complications:
None
/
Pneumonectomy/ Lobectomy
Others, specify
Women: LMP
Alcohol
Current
Past
Never
Type /bottles /day x yrs
11
/ 25 / 2007
(mm/dd/yy)
Drug Abuse
Current
Past
Never
Type (shabu, marijuana, etc)
yes, specify
No
sexually inactive_for more than a year
43
Vital Signs:
Height: 157
Temp: 37.5
BP: 130/90
System examination:
General Health:
Skin:
BCG scar:
Oropharynx:
Cardiovascular:
Thorax & Lungs:
Use of accessory muscles:
Abdomen:
Genito-Urinary:
Extremities:
Neurological:
Lymph Nodes:
Endocrine:
cm
Celsius
mmHg
Weight: 44 Kg.
98 / min
PR/ HR:
O2 sat by Pulse oximeter:
0 = Not done
1 = Normal
2 = Abnormal
2
2
0
0
2
1
0
1
0
2
0
24
RR at rest:
Describe abnormalities
distressed, cachectic
(+) pallor of skin, conjunctiva, palms, & nail beds
(-) BCG scar
(+) crackles heard on both lung elds
(+) use of accessory muscles
Laboratory procedures:
Smear, Culture and DST results from other laboratory
44
/min
Date
11
26
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
2007
Right Lung
Left Lung
10
0 - Normal
7 - Fibrosis
1 - Cavitary
8 - Fibrothorax
2 - Infiltrate
9 - Bullae
3 - Nodule
10 - Pleural effusion
4 - Miliary TB
11 - Pneumothorax
5 - Intrathoracic
lymphadenopathy
12 - Bronchiectasis
6 - Endobronchial
spread
14 - Consolidation
13 - Atelectasis
15 - Mass
VI. Assessment:
TB suspect
New
Retreatment
None
Symptomatic contact of confirmed/
suspected MDRTB patient
Non-converter of Category II
Symptomatic HIV-positive
2 or more non-DOTS treatment course
Non-DOTS
Other (+)
Other (-)
VII. Plan:
2
For smear x
2
For TB culture x
For Drug susceptibility testing
Start TB treatment, specify regimen:
Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment
Others
Await DST results prior to initiation of treatment if DSSM (+). If DSSM (-), refer to TBDC.
Attending MD:
Dave Verzosa, MD
Date:
12/03/2007
45
Case 3:
Programmatic Management of Drug - Resistant TB
(PMDT)
MODULE B
Screened at:
MMC/TDF
KASAKA
LCP
Others, specify
Date:
12/05/2007
(mm/dd/yy)
I. Demographics
Santos
Name:
Santiago
Surname
Sex:
Male
Female
Nationality:
City address:
Date of birth:
Middle Name
Age:
(mm/dd/yy)
Filipino
Permanent address:
Suma
Given Name
Religion:
Catholic
Makati
Tel. no.:
53055555
area code+ tel #
zip code
none
Accounting Clerk
Padre Burgos St., Manila
Place of birth:
Civil status:
Single Married
Widowed
Living together
Divorced/ legally separated
E-mail address:
Occupation:
Office address:
55
1007
Tel. no.:
53055555
30
Family monthly income:
Employer: Manila City Hall
Tel. no.:
Relationship:
Tel. No.:
000 Php
5247141
53055555
53055555
area code+ tel #
Referred by:
HC
Govt Inst
PPMD
FBO
NGO
Pvt MD/Institution
Specify name, J. Fabella Health Center
Address of referring facility: San Andres, Manila
3
0 More than 10 yrs old:
Number of household contacts:
Less than or equal 10 yrs old:
persistent cough
Chief Complaint/s:
Cough
Fever
Back/ chest pain
Hemoptysis
Weight loss
Night sweats
Other symptoms:
Dyspnea at rest
Dyspnea on exertion
Pedal edema
46
Duration in month/s
3 wks
Comments
productive, minimal amt., whitish in color
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
( mm/dd/yyyy )
( mos.)
DOTS
(Y/N)
No previous TB treatment
1.
2.
3.
4.
5.
6.
7.
No
Co- morbidities
Treatment facility
If Yes
MDR
Non MDR
Duration
Diabetes Mellitus
Cancer
HIVinfection/AIDS
Kidney disease
Lung disease
Epilepsy
Psychiatric condition
Others
Allergy:
Drugs:
Status
Type of reaction:
1.
2.
Concomitant drugs / Duration:
Previous surgery:
Date of surgery:
Complications:
None
/
Pneumonectomy/ Lobectomy
Others, specify
Women: LMP
Alcohol
Current
Past
Never
Type /bottles /day x yrs
/
/
(mm/dd/yy)
Drug Abuse
Current
Past
Never
Type (shabu, marijuana, etc)
No
yes, specify
47
Vital Signs:
Height: 169
Temp: 37.3
BP: 130/80
System examination:
General Health:
Skin:
BCG scar:
Oropharynx:
Cardiovascular:
Thorax & Lungs:
Use of accessory muscles:
Abdomen:
Genito-Urinary:
Extremities:
Neurological:
Lymph Nodes:
Endocrine:
cm
Celsius
mmHg
Weight: 60 Kg.
PR/ HR: 84 / min
O2 sat by Pulse oximeter:
0 = Not done
1 = Normal
2 = Abnormal
1
1
0
0
2
1
0
1
0
2
0
22
RR at rest:
%
Describe abnormalities
Laboratory procedures:
Smear, Culture and DST results from other laboratory
48
Date
/min
MODULE B
MDR - TB SCREENING FORM | page 3 of 4
12
01
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
Right Lung
2007
Left Lung
0 - Normal
7 - Fibrosis
1 - Cavitary
8 - Fibrothorax
2 - Infiltrate
9 - Bullae
3 - Nodule
10 - Pleural effusion
4 - Miliary TB
11 - Pneumothorax
5 - Intrathoracic
lymphadenopathy
12 - Bronchiectasis
6 - Endobronchial
spread
14 - Consolidation
13 - Atelectasis
15 - Mass
VI. Assessment:
TB suspect
New
Retreatment
None
Symptomatic contact of confirmed/
suspected MDRTB patient
Non-converter of Category II
Symptomatic HIV-positive
2 or more non-DOTS treatment course
Non-DOTS
Other (+)
Other (-)
Disease other than TB, specify
VII. Plan:
2
For smear x
2
For TB culture x
For Drug susceptibility testing
Start TB treatment, specify regimen:
Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment
Others
Present to consilium
Attending MD:
Dave Verzosa, MD
Date:
12/05/2007
49
Case 5:
Programmatic Management of Drug - Resistant TB
(PMDT)
MODULE B
Screened at:
MMC/TDF
KASAKA
LCP
Others, specify
Date:
12/06/2007
(mm/dd/yy)
I. Demographics
Sarmiento
Name:
Susana
Sandok
Surname
Given Name
Middle Name
Sex:
Male
Female
Nationality:
Date of birth:
Age:
(mm/dd/yy)
Filipino
Permanent address:
City address:
Catholic
18
E-mail address:
Occupation:
Office address:
none
none
Spouse: none
Father: Sergio
Parents address:
Manila
Place of birth:
Tel. no.:
20
Family monthly income:
Employer:
Tel. no.:
599-00001
area code+ tel #
000 Php
Address/ Contact #:
Sarmiento
Marie Sarmiento
Mother:
1598 Interior 86 P. Quirino Avenue, Pandacan, Manila
Tel. no.:
Manila
Relationship:
Tel. No.:
599-00001
mother
599-00001
Referred by:
HC
Govt Inst
PPMD
FBO
NGO
Pvt MD/Institution
Quirino
Health
Center
Specify name,
Address of referring facility: Quirino Avenue, Pandacan, Manila
7
4 More than 10 yrs old:
Number of household contacts:
Less than or equal 10 yrs old:
fever and weight loss
Chief Complaint/s:
Cough
Fever
Back/ chest pain
Hemoptysis
Weight loss
Night sweats
Other symptoms:
Dyspnea at rest
Dyspnea on exertion
Pedal edema
50
Duration in month/s
2 wks
1
Comments
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
( mm/dd/yyyy )
( mos.)
DOTS
(Y/N)
No previous TB treatment
1.
2.
3.
4.
5.
6.
7.
No
Co- morbidities
Treatment facility
If Yes
Non MDR
Duration
Diabetes Mellitus
Cancer
HIVinfection/AIDS
Kidney disease
Lung disease
Epilepsy
Psychiatric condition
Others
Allergy:
MDR
Drugs:
Type of reaction:
1.
2.
Concomitant drugs / Duration:
Previous surgery:
Date of surgery:
Complications:
None
/
Pneumonectomy/ Lobectomy
Others, specify
Women: LMP
Alcohol
Current
Past
Never
Type /bottles /day x yrs
11
30 / 2007
/
(mm/dd/yy)
sexually inactive for a year
0
No
Drug Abuse
Current
Past
Never
Type (shabu, marijuana, etc)
shabu
yes, specify
51
Vital Signs:
Height: 157
Temp: 37.8
BP: 130/80
System examination:
General Health:
Skin:
BCG scar:
Oropharynx:
Cardiovascular:
Thorax & Lungs:
Use of accessory muscles:
Abdomen:
Genito-Urinary:
Extremities:
Neurological:
Lymph Nodes:
Endocrine:
Weight: 42 Kg.
PR/ HR: 100 / min
O2 sat by Pulse oximeter:
cm
Celsius
mmHg
0 = Not done
1 = Normal
2 = Abnormal
2
2
0
0
1
26
RR at rest:
%
Describe abnormalities
1
0
1
0
2
0
Laboratory procedures:
Smear, Culture and DST results from other laboratory
52
Date
/min
MODULE B
MDR - TB SCREENING FORM | page 3 of 4
10
08
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
Right Lung
2007
Left Lung
0
0
0 - Normal
7 - Fibrosis
1 - Cavitary
8 - Fibrothorax
2 - Infiltrate
9 - Bullae
3 - Nodule
10 - Pleural effusion
4 - Miliary TB
11 - Pneumothorax
5 - Intrathoracic
lymphadenopathy
12 - Bronchiectasis
6 - Endobronchial
spread
14 - Consolidation
13 - Atelectasis
15 - Mass
VI. Assessment:
TB suspect
New
Retreatment
None
Symptomatic contact of confirmed/
suspected MDRTB patient
Non-converter of Category II
Symptomatic HIV-positive
2 or more non-DOTS treatment course
Non-DOTS
Other (+)
Other (-)
Disease other than TB, specify
VII. Plan:
2
For smear x
2
For TB culture x
For Drug susceptibility testing
Start TB treatment, specify regimen: Start Catergory I while awaiting culture and DST results
Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment
Others
Attending MD:
Dave Verzosa, MD
Date:
12/06/2007
53
Case 6:
Programmatic Management of Drug - Resistant TB
(PMDT)
MODULE B
Screened at:
MMC/TDF
KASAKA
LCP
Others, specify
Date:
12/07/2007
(mm/dd/yy)
I. Demographics
Robles
Name:
Surname
Sex:
Male
Female
Nationality:
Date of birth:
Remo
Middle Name
Age: 30
(mm/dd/yy)
Filipino
Permanent address:
Rodolfo
Given Name
Religion:
Catholic
Place of birth:
Manila
City address:
E-mail address:
Occupation:
Office address:
none
laborer
Spouse: none
Father: Pablo Robles
Parents address:
20 000 Php
Address/ Contact #:
Rita Robles (deceased)
Mother:
Tel. no.:
(deceased)
Manila
Relationship:
Tel. No.:
brother
599-10001
Referred by:
HC
Govt Inst
PPMD
FBO
NGO
Pvt MD/Institution
Specify name, Poblacion Health Center
Address of referring facility: Sn. Vicente St., Putatan, Muntinlupa City
0
0 More than 10 yrs old:
Number of household contacts:
Less than or equal 10 yrs old:
persistently
symptomatic
Chief Complaint/s:
54
Duration in month/s
3
Comments
productive, minimal in amt., whitish color
approx. 10 kg
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
1.
2.
3.
4.
5.
6.
7.
Start date
( mm/dd/yyyy )
( mos.)
06/01/06
09/03/07
No
Co- morbidities
If Yes
Allergy:
MDR
1
ongoing
Drugs:
Y
Y
Non MDR
Duration
Diabetes Mellitus
Cancer
HIVinfection/AIDS
Kidney disease
Lung disease
Epilepsy
Psychiatric condition
Others
DOTS
(Y/N)
2 HRZE / 4 HR
2 HRZES / 1 HRZE
Treatment facility
Status
Type of reaction:
1.
2.
Concomitant drugs / Duration:
Previous surgery:
Date of surgery:
Complications:
None
/
Pneumonectomy/ Lobectomy
Others, specify
Women: LMP
Alcohol
Current
Past
Never
Type /bottles /day x yrs
/
/
(mm/dd/yy)
sexually inactive
Drug Abuse
Current
Past
Never
Type (shabu, marijuana, etc)
No
yes, specify
55
Vital Signs:
Height: 160
Temp: 37.4
BP: 130/80
System examination:
General Health:
Skin:
BCG scar:
Oropharynx:
Cardiovascular:
Thorax & Lungs:
Use of accessory muscles:
Abdomen:
Genito-Urinary:
Extremities:
Neurological:
Lymph Nodes:
Endocrine:
Weight: 45 Kg.
PR/ HR: 93 / min
O2 sat by Pulse oximeter:
cm
Celsius
mmHg
0 = Not done
1 = Normal
2 = Abnormal
2
2
0
0
23
RR at rest:
Describe abnormalities
cachectic, in distress
1
0
1
0
2
0
Laboratory procedures:
Smear, Culture and DST results from other laboratory
DSSM 2+
56
/min
Date
12 /
03 / 2007
MODULE B
MDR - TB SCREENING FORM | page 3 of 4
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
Right Lung
Left Lung
0 - Normal
7 - Fibrosis
1 - Cavitary
8 - Fibrothorax
2 - Infiltrate
9 - Bullae
3 - Nodule
10 - Pleural effusion
4 - Miliary TB
11 - Pneumothorax
5 - Intrathoracic
lymphadenopathy
12 - Bronchiectasis
6 - Endobronchial
spread
14 - Consolidation
13 - Atelectasis
15 - Mass
VI. Assessment:
TB suspect
New
Retreatment
None
Symptomatic contact of confirmed/
suspected MDRTB patient
Non-converter of Category II
Symptomatic HIV-positive
2 or more non-DOTS treatment course
Non-DOTS
Other (+)
Other (-)
Disease other than TB, specify
VII. Plan:
2
For smear x
2
For TB culture x
For Drug susceptibility testing
Start TB treatment, specify regimen:
Prescribe ancillary drugs or drugs for co-morbidity, or symptomatic treatment
Others
Attending MD:
Dave Verzosa, MD
Date:
12/07/2007
57
MODULE B
2.4 Make a referral to the Consilium if necessary and enter the patient in the Category IV Register
The diagnosis of MDR-TB through laboratory tests takes a number of months. In general, patients wait for confirmation
of the diagnosis of MDR before they are prepared for the start of treatment. However, there are occasions that the
MDR-TB suspect may be critically ill at the time of first consultation. The physician having interviewed the patient
and made a physical examination must be able to assess the patients general condition. Some patients may need to
be started on treatment urgently before the DST results are available or they will be at risk of dying. These patients
should be recognized by the physician, and these cases should be presented immediately to the Consilium.
The Consilium must approve for start of treatment all patients who require MDR-TB treatment. These are patients
who have either been confirmed MDR-TB by DST, or are clinically suspected MDR-TB needing urgent treatment even
prior to DST results.
DST results together with other factors in the patients history allow the design of treatment regimens that are
tailored to the specific resistance pattern of the patient to increase the likelihood of treatment success. To present
cases to the consilium, the Treatment Center physician must fill out the Consiliumex for every patient. He will then
present these cases in a Consilium meeting. An example of the Consiliumex and a discussion of the necessary steps
to present a case to the Consilium can be found in section 6 of this module. See the Reference Booklet for instructions
on how to fill out the Consiliumex.
The following criteria must be met among MDR-TB suspects screened to qualify for urgent treatment without the
benefit of DST results:
1.
2.
3.
The patient must first be sputum smear-positive (at least two) and/or culture-positive (at least once) if
pulmonary, but not necessarily for children and for extra-pulmonary TB (EPTB).
The patient must be suspected to be MDR-TB based on history and risk factors.
The patient must have any ONE of the criteria for Category IV treatment listed in Table 4 below.
Criteria
Condition
1.
2.
a.
b.
c.
Hypotension
RR > 28/min or 02 < 90% at room air
PR > 100/min with RR > 28/min or 02 sat <90% at room
air
58
MODULE B
4.
a.
b.
c.
4.
a.
b.
c.
d.
Infiltrates
Cavities
Pneumothorax
Pleural effusion, etc.
PLUS any one of the above clinical signs and symptoms (no. 2
above)
5.
a.
b.
c.
d.
HIV-positive
Cancer
Post-organ transplant
On any immunosuppressive agent
5.
6.
59
MODULE B
t
t
Steps in the diagnosis of MDR-TB; diagnostic tests to be done (DSSM, culture, DST)
Possibility of stopping present TB treatment to prevent amplification of resistance
Timelines for receiving test results: Patient must call for results after the expected timeline for the release of
results:
t DSSM: 4-5 days after specimen collection
t Culture: 3-3.5 months after specimen collection
t DST: 4-5 months after specimen collection
Contact numbers of the MDR-TB Treatment Center where screening was done; other contact numbers which
patients can call
Ways to prevent transmission of TB to household contacts
The Paunawa or Terms of Understanding should be read to the patient and explained in a way that the patient can
understand. The Paunawa or Terms of Understanding form can be found in the Reference Booklet. For more information
about how to speak with a patient at this stage, see Module D: Inform Patients about MDR-TB.
60
MODULE B
Treatment Center
Culture Center
DST Center
TDF TB Laboratory
TDF TB Laboratory
PTSI Laboratory
NTRL
LCP Laboratory
LCP Laboratory
PTSI Laboratory
NTRL
TDF TB Laboratory
NTRL
NTRL
The diagnosis of MDR-TB is crucial and must be accurate since treatment required is very long with expensive drugs
that have many side effects. Hence, even if an MDR-TB suspect has culture and DST results from other referral sites,
he must submit 2 more sputum samples at the MDR-TB Treatment Center for DST confirmation by a laboratory
with quality assurance from a supranational laboratory. At present, these laboratories include the Tropical Disease
Foundation (TDF) TB Laboratory, and the National TB Reference Laboratory (NTRL). The Cebu Regional Reference
Laboratory (CRRL) will also be undergoing DST proficiency testing as well as other laboratories in the Philippines and
will become future DST Centers for PMDT.
61
MODULE B
specimens are sent to the Culture Center on the day of collection; hence, write DSSM X 1 and culture X 1 for this first
collection and fill out another request form for the second collection.
For the example below who was referred as a Category II failure, DSSM, TB culture and DST are ticked with the
number of specimens needed for DSSM and culture. Under Schedule, Screening refers to the first time the patient
is being seen as a TB suspect. Baseline refers to the time when a patient is about to be started on Category IV
treatment or has just been started on treatment (30 days before treatment and 7 days after start of treatment).
Follow-up refers to the sputum examination requested after Category IV treatment has started beyond 7 days.
Post-treatment refers to the period after a final outcome of cured or completed has been declared. Fill out
the date the sputum was collected not the date when the sputum was sent. Indicate whether the specimen
was collected as a spot specimen collected at the Treatment Center or at the patients home or elsewhere.
The receiving laboratory will fill out the portion on Laboratory No., Volume and Consistency.
4/28/05
Date requested:
(if enrolled)
Age/Sex: 50/M
DST center:
Culture center:
TDFI
LCP
PTSI
CTRL (Cebu)
NTRL
TDFI
Specimen:
Sputum
NTRL
Extrapulmonary
specimen,
specify:
CTRL
Requested procedure:
2
DSSM x
TB culture x 2
DST
No
Others
Schedule:
Screening
Enrolled:
Yes
Baseline
No
Months post-treatment:
New
Category:
Retreatment
1st specimen
2nd specimen
3rd specimen
Type of collection
(Please encircle)
Spot
Spot
Spot
Laboratory No.
02-P-058283-1
02-P-058283-2
Salivary
Muco-purulent
Date of collection
Home
Home
62
10ml
8ml
Home
MODULE B
Sample one is collected on the spot. Give instructions to the patient. Explain why the sputum is needed
and show the MDR-TB suspect how to cough up sputum and handle the labeled container. The MDR-TB
suspect goes outdoors or to a well-ventilated place or to a sputum collection booth, if available, to collect
the sample. Observe and guide the MDR-TB suspect during sample collection. Instruct the patient to collect
5-10 ml of sputum. After the MDR-TB suspect gives the sample to you, give him another labeled container
to take home and use the next morning, while you tightly close the lid of the first container.
t
PMDT
Tx center: __________________
MMC
Lab No.: ___________________
Name: ____________________
Jose Balagtas
Date collected: _____________
May 5, 2008
t
Sample two is collected at home by the MDR-TB suspect upon waking up the next morning. The patient
brings this second sample to you at the Treatment Center right after collection.
Remember:
t
t
t
t
t
Attach the label on the container (not the lid) before collecting the sputum samples.
Collect sputum in a well-ventilated area, preferably outdoors or in a sputum collection
booth.
Check whether the sample contains sufficient sputum (5-10ml), not saliva. If not, ask the
MDR-TB suspect to add more.
After collecting the sputum, be sure that the lid is closed tightly.
Wash your hands thoroughly with soap and water.
Remind the MDR-TB suspect when to return for the results and inform him that the specimen regardless of the
DSSM results, will be cultured.
63
MODULE B
Sputum induction: is a simple procedure for obtaining a sputum sample through deep 15-minute inhalation of a
salt solution or hypertonic saline (3% NaCl) with the help of a nebulizer to induce a deep cough, which allows the
coughing up of lung secretions. These samples are usually diluted or watery and should be labeled as induced so
they will not be mistaken for saliva at the laboratory.
Induction can be used for patients who cannot expectorate effectively or provide a quality sample, particularly
those who are asymptomatic but have evidence of TB disease such as an abnormal chest x-ray, e.g., in children, or
persons with HIV/AIDS. Patients should have fasted for 3-4 hours prior to the procedure to prevent vomiting and
aspiration. Induction should be carried out in a well-ventilated place and all personnel in the room should use an
N95 mask to avoid infection.
Gastric aspiration is performed by inserting a tube through the patients nose and introducing it into the stomach.
The idea is to obtain a sputum sample that has been coughed up and then swallowed. The procedure is usually
performed first thing in the morning as the patient tends to swallow sputum during the night. Generally, it is
performed only when a sample cannot be obtained through expectoration or induction. Most often, it is used to
obtain samples from children. It is recommended that children should not have had food intake in the past 2-3
hours. For logistic reasons gastric aspiration is usually carried out in a hospital setting or in a procedure room that
has the necessary materials.
Bronchial aspiration with fiberoptic bronchoscopy is done for the collection of bronchial secretions by
aspiration, through the fiberoptic bronchoscope (which is an instrument used for this procedure) performed by a
bronchoscopist. These samples are usually diluted or watery and should be labeled as bronchoscopy specimens so
they will not be rejected at the laboratory. Bronchoscopy should be carried out in a procedure room with infection
control measures. This is usually the last resort when sputum is very difficult to collect.
MODULE B
procedures (for screening patients: DSSM, culture and DST). At the bottom, the one preparing the form signs on the
space for Endorsed by with the date and the one picking up the box signs on the space provided for Received by
with the date. See the Reference Booklet for more instructions on how to fill out this form.
Later when the culture turns out positive for TB at the Culture Center, the isolate is sent to the DST Center. The
Culture Center fills out the Laboratory Receiving Form, also keeps blank the Category IV Registration No. but writes
the Laboratory No. assigned which is TC-C-YY-NNNN-nth specimen.
TABLE 6. Laboratory No. (TC-C-YY-NNNN-Nth specimen)
Code
Description
TC
Culture Center
T for TDF TB Laboratory
N for NTRL
L for LCP Laboratory
P for PTSI Laboratory
YY
NNNN
The consecutive specimen accrual that begins with 0001 at the start of every year
Nth specimen
For example, the Laboratory No. 02-P-050021-2 means that the Treatment Center origin of the specimen is the
KASAKA-QI MDR-TB Housing Facility, and was sent for smear and culture to PTSI Laboratory in 2005; was the 21st
specimen received by the laboratory for the year, and was the second isolate for the patient.
Before sending the transport box to the laboratory, the Treatment Center must check the following:
The number of sputum specimens listed in the Laboratory Receiving Form for Specimens are consistent with
the actual number of specimen cups in the transport box.
The names of patients listed on the Laboratory Receiving Form are consistent with the ones written on the
labels on the sputum cups in the transport box.
Individual Mycobacteriology Request Forms are enclosed for each of the specimens being sent.
Once the above are done, close and seal the transport box carefully. Then, put the Laboratory Receiving Form
for Specimens in an envelope together with the individual Mycobacteriology Request Forms and attach the
envelope to the top cover of the transport box or hand it directly to the receiving person.
At the Culture Center, the laboratory staff receiving the transport box will check the contents of the box against
the Laboratory Receiving Form for Specimens and sign the form and keep a file copy at the Culture Center. If all
specimens and requests in the list are accounted for, he will affix his initials on the form and date and keep a file
copy at the Culture Center. If there is a discrepancy, he will call the Treatment Center for verification, document on
the Form whatever discussion or agreement was made before filing this form at the Culture Center. The same is done
at the DST Center when receiving culture isolates from the Culture Center.
A delivery schedule will be arranged with the laboratory receiving the sample to make sure that the samples can be
quickly transported and processed once they are received. On the following page is an example of the Laboratory
Receiving Form for Specimens.
65
From:
To:
NTRL
Isolates
Name
No. of
specimens
/ isolates
Date
collected
(mm/dd/yy)
Remarks/
Request
Balagtas, Jose
2/2
4/28/05
Salcedo, Myrna
4/28/05
DSSM, TBC
Tan, Vincent
Santos, Sylvia
1/1
Roces, Maria
2/2
Benito, Gerald
Cortez, Juan
1/1
4/28/05
DSSM
Uy, Susan
1/1
4/28/05
DSSM
Mendoza, Tina
2/2
4/28/05
No.
Category IV
Registration
No.
DST Center
Laboratory no.*
(Applicable to ISOLATES
only c/o Culture Center
If two4/28/05
specimens are
4/28/05
being submitted
together,
write
4/28/05
the date of
collection
of the
4/28/05
FIRST specimen.
10
11
12
13
14
15
16
17
18
19
20
21
22
Not applicable
for screening
cases.
Applicable
only for
enrolled cases
with followup specimens
being sent.
Not applicable
to Treatment
Centers.
Applicable
only to Culture
Centers
submitting
isolates to DST
Centers.
Verify this
information
against the
Mycobacteriology Request
Form.
23
24
25
* Laboratory no. : TC-C-YY, NNNN - Nth specimen
66
4/29/05
Date: _________________________
4/29/05
Date: _________________________
MODULE B
For each of the following patients, fill out the Mycobacteriology Request Form.
2.
Please refer to page 61 for the designated Culture and DST center for the different Treatment Centers.
Assumptions:
t All first specimens were collected spot at the Treatment Center while the second specimen was collected
at the patients home.
t All first samples of the patients were collected on the day of screening and the second samples on the
following day except for Case #2 who first came on a Saturday and came back for his second sample on the
following Monday.
t The date the MDR-TB Suspects Referral Form from the DOTS facility was filled out is the date of screening at
the Treatment Center.
67
MODULE B
Case 1
Date requested:
(if enrolled)
Age/Sex:
Name:
Requesting physician:
Address:
(City/ Province)
DST center:
Culture center:
TDFI
LCP
PTSI
CTRL (Cebu)
NTRL
Specimen:
TDFI
NTRL
CTRL
Sputum
Extrapulmonary
specimen,
specify:
Requested procedure:
DSSM x
TB culture x
DST
Others
Schedule:
Enrolled:
Screening
Yes
Baseline
No
Months post-treatment:
Category:
New
Retreatment
1st specimen
2nd specimen
3rd specimen
Spot
Spot
Spot
Date of collection
Type of collection
(Please encircle)
Home
Home
68
Home
MODULE B
Case 2
Date requested:
(if enrolled)
Age/Sex:
Name:
Requesting physician:
Address:
(City/ Province)
DST center:
Culture center:
TDFI
LCP
PTSI
CTRL (Cebu)
NTRL
Specimen:
TDFI
NTRL
CTRL
Sputum
Extrapulmonary
specimen,
specify:
Requested procedure:
DSSM x
TB culture x
DST
Others
Schedule:
Enrolled:
Screening
Yes
Baseline
No
Months post-treatment:
Category:
New
Retreatment
1st specimen
2nd specimen
3rd specimen
Spot
Spot
Spot
Date of collection
Type of collection
(Please encircle)
Home
Home
Home
69
MODULE B
Case 3
Date requested:
(if enrolled)
Age/Sex:
Name:
Requesting physician:
Address:
(City/ Province)
DST center:
Culture center:
TDFI
LCP
PTSI
CTRL (Cebu)
NTRL
Specimen:
TDFI
NTRL
CTRL
Sputum
Extrapulmonary
specimen,
specify:
Requested procedure:
DSSM x
TB culture x
DST
Others
Schedule:
Enrolled:
Screening
Yes
Baseline
No
Months post-treatment:
Category:
New
Retreatment
1st specimen
2nd specimen
3rd specimen
Spot
Spot
Spot
Date of collection
Type of collection
(Please encircle)
Home
Home
70
Home
MODULE B
Case 5
Date requested:
(if enrolled)
Age/Sex:
Name:
Requesting physician:
Address:
(City/ Province)
DST center:
Culture center:
TDFI
LCP
PTSI
CTRL (Cebu)
NTRL
Specimen:
TDFI
NTRL
CTRL
Sputum
Extrapulmonary
specimen,
specify:
Requested procedure:
DSSM x
TB culture x
DST
Yes
No
Others
Schedule:
Enrolled:
Screening
Yes
Baseline
No
Months post-treatment:
Category:
New
Retreatment
1st specimen
2nd specimen
3rd specimen
Spot
Spot
Spot
Date of collection
Type of collection
(Please encircle)
Home
Home
Home
71
MODULE B
72
MODULE B
PTSI
To:
DST Center
No.
1
2
3
4
5
6
7
8
9
10
Laboratory no.*
Name
Test requested
Date
collected
mm/dd/yy
02-P-050001-2
Balagtas, Jose
TBC
04/28/05
02-P-050002-1
Tan, Vincent
TBC
04/28/05
02-P-050004-1
Roces, Maria
TBC
02-P-050005-1
Benito, Jamora
TBC
04/28/05
02-P-050007-1
Uy, Susan
DSSM
04/27/05
02-P-050002-1
02-P-050003-1
02-P-050007-1
02-P-050006-1
02-P-050007-2
Salcedo, Myra
TBC
Santos, Sylvia
04/28/05
DSSM
Mendoza, Tina
04/26/05
04/28/05
TBC
Cortez, Juan
04/28/05
DSSM
Mendoza, Tina
Remarks
04/27/05
TBC
04/28/05
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
DSSM
Culture (TBC)
DST
Francia Gonzales(PTSI)
Endorsed by: ___________________________
07/30/05
Date: _________________________
07/30/05
Date: _________________________
73
MODULE B
74
Yes
mm/dd/yy
2/12/07
DSSM
No
3+
On-going
2+
On-going
Laboratory Technician
2/8/2007
2/7/2007
Retreatment
01-L-070080-2
03-L-070080-1
New
2nd specimen
Category:
Months post-treatment
1st specimen
TB Culture
Baseline
Date collected
3rd specimen
DST center:
LCP laboratory
Culture center:
Laboratory Supervisor
On page 81, column 16 of the TB Symptomatics Masterlist is filled out. It shows 2+ on February 7, 2007 and 3+ for February 8, 2007.
Date Released:
TB culture
DSSM
Date of collection
Lab No.
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex: 45/F
Sputum
Specimen:
Treatment center:
MODULE B
75
MODULE B
If any of the sputum specimens is smear-positive, this result means that the MDR-TB suspect has
infectious pulmonary TB. This result does not signify anything about the possibility of drug resistance for
the MDR-TB suspect. The MDR-TB suspect should be informed of the results and reminded to follow up for
the culture results in 3-3.5 months from sputum collection. The MDR-TB suspect should also be educated
on the infection control precautions to take while at home to avoid spreading TB to those around him.
Important messages to give to the patient are described in Module D: Inform Patients about MDR-TB.
t
If all specimens are smear-negative, the Culture Center also automatically processes them for culture. The
MDR-TB suspect can call the Treatment Center for the culture results on or after 3-3.5 months from sputum
collection.
76
Yes
Date Released:
mm/dd/yy
Laboratory Technician
MTB
MTB
TB culture
06/04/07
3+
2+
Date of collection
Lab No.
DSSM
Retreatment
2/8/2007
2/7/2007
New
03-L-070080-2
TB Culture
Category:
Months post-treatment
03-L-070080-1
2nd specimen
DSSM
No
Baseline
Date collected
1st specimen
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex: 45/F
Sputum
Specimen:
3rd specimen
DST center:
LCP laboratory
Culture center:
Laboratory Supervisor
Treatment center:
MODULE B
77
MODULE B
As soon as this is received at the Treatment Center, write Mtb for the February 7 and 8, 2007 specimens after putting
a slash to separate this from the DSSM result. See how this is done on page 81, column 16 of the TB Symptomatics
Masterlist.
If the culture is positive (10 or more colonies), the Culture Center will send the culture isolate to the DST
center.
t
If one sputum culture yields a count of < 10 colonies, the second sputum culture must also have a
growth of at least < 10 colonies for the culture to be interpreted as positive. Between these two isolates
with both < 10 colonies each, send the isolate with more colonies or more luxuriant growth to the DST
Center while keeping the other one at the Culture Center.
t
If one sputum culture has <10 colonies and the second culture has negative growth, DST will still be
performed on the isolate with < 10 colonies as this is a diagnostic specimen. This is not done for follow-up
specimens.
t
If both culture results are negative or have no growth, no further test will be done.
t
If culture result is negative and smear result is positive, refer to the consilium for further discussion and
decision on management.
For screening and baseline specimens, the isolates are sent to the DST Center for DST. However, for follow-up
specimens, the isolates are simply kept at the Culture Center unless otherwise requested for DST by the Treatment
Center.
When the patient with a positive culture calls the Treatment Center for the results, he should be informed that the
culture was positive and that the result of the final stage of diagnostic testing will be available in the following
weeks. The patient is advised to make a follow-up call 1-2 months after to find out the results of the DST and asked
to come in for further examination.
The Culture Center will send the isolates to the DST Center along with the other isolates for DST. All isolates are
listed one by one on the Laboratory Receiving Form for Specimens. Tick the Isolates box; write down the names of
the patients with positive culture results, indicate the laboratory numbers of the isolates. All isolates will be packed
in a biobottle and prepared according to guidelines on proper packing and transportation of infectious materials.
The person receiving the box signs the form and brings the box to the DST Center. The DST Center staff will carefully
unpack the package in a safety hood and check the isolates against the Laboratory Receiving Form for Specimens. If
there is no discrepancy, he affixes his initials and date on the form and files it. However, if there is a discrepancy, the
DST Center will call the Culture Center and document their agreement on the form. He then files the form at the DST
Center.
78
MODULE B
79
45/F
Screening
Yes
mm/dd/yy
Laboratory Technician
'
Retreatment
Disc Elution / 7H10
New
Michael S. Evangelista
Levofloxacin (Lfx)
07/10/07
Ciprofloxacin (Cfx )
Date Released:
Ofloxacin (Ofx)
2/7/2008
Date collected
Laboratory Supervisor
Claudette Guray
Amikacin (Ak)
TDF Laboratory
DST center:
LCP Laboratory
Culture center:
Specimen:
Sputum
03-L-070080-1
Laboratory ID no.
Treatment center:
Months post-treatment
METHOD USED:
Category:
Streptomycin (S)
No
Baseline
EXAMINATION DONE:
Enrolled:
Schedule:
Morelos, Maria
Requesting physician:
Age/Sex:
Patients name:
As soon as the DST result is received, staff at the LCP-PHDU DOTS Center should fill out Column no. 17 DST Results of the TB Symptomatics Masterlist with S to mean
susceptible and R to mean resistant.
80
The DST result of the same patient, Maria Morelos, in Section 5.3 is shown below. This was received by the LCP-PHDU DOTS Center on July 10, 2007 showing that the
patient was resistant to H, R and S and susceptible to Z, E, Km, Am, Cfx and Lfx.
MODULE B
Symptoms
(14)
1,2,3,4,5,6
Risk factors
(13)
02/07/07
02/08/07
2+ / MTB
1,2,7
2/2/07
3+ / MTB
Km
ND
Ofx
Cfx
Lfx
Other
Other
Am
7/10/07
7/12/07
Consilium
date
Registration date
(mm/dd/yy)
(18)
Date DST
released
(15)
Date done
CXR results
TB Symptomatics Masterlist
7/21/07
07-0419
Column 18 Registration date refers to the date that confirmed the need for Category IV treatment either by a) the DST result or, b) consilium decision even without the
DST result by virtue of a high clinical suspicion for MDR-TB. For the latter group of patients, write the date when the Consilium decided to start Category IV treatment
under Consilium date of the same column, and keep blank the boxes for DST results and Date DST released. Both groups, when presented to the Consilium, are
generally approved for treatment and all patients belonging to either group will be assigned a Pre-enrollment No. which will be explained in the next few pages.
Below, you will find the completed Columns 16, 17 and 18 of the TB Symptomatics Masterlist for patient, Maria Morelos.
MODULE B
81
MODULE B
For Treatment Site staff, skip Exercie E and continue reading from section 6.2, page 92
until the Summary of important points and tell your facilitator
when you have reached that point.
Exercise E
Recording Results on the TB Symptomatics Masterlist
In this exercise you will practice recording the results of the laboratory tests in the TB Symptomatics Masterlist for
three patients. Use the information written on actual result forms provided to you. Work individually on this exercise.
If any of the instructions are unclear, ask a facilitator for clarification.
The DSSM, culture and DST results for Cases 1, 2 & 3 who were MDR-TB suspects listed on the TB Symptomatics
Masterlist in Exercise C page 37 are shown in the next pages. The results for the other MDR-TB suspects, Cases 5 & 6
have not yet been released.
Record the results of the sputum examination of the patients on columns 16, 17 and 18 of the TB Symptomatics
Masterlist provided to you in the previous exercise.
82
34/F
Yes
Date Released:
TB culture
DSSM
Date of collection
Lab No.
DSSM
No
mm/dd/yy
Sputum
2QJQ
2QJQ
Laboratory Technician
2nd specimen
Retreatment
7
1st specimen
New
Months post-treatment
Specimen:
7
Category:
3rd specimen
TDF Laboratory
Culture center:
Laboratory Supervisor
Treatment center:
TB Culture
Baseline
12/07/07
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex:
DSSM result:
MODULE B
83
84
49/F
Yes
Date Released:
TB culture
DSSM
Date of collection
Lab No.
DSSM
No
mm/dd/yy
2QJQ
2QJQ
Laboratory Technician
Retreatment
7
7
New
2nd specimen
Category:
Months post-treatment
1st specimen
TB Culture
Baseline
12/08/07
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex:
Sputum
Specimen:
3rd specimen
TDF Laboratory
Culture center:
Laboratory Supervisor
Treatment center:
DSSM result:
MODULE B
45/M
Yes
Date Released:
TB culture
DSSM
Date of collection
Lab No.
DSSM
No
mm/dd/yy
Sputum
2QJQ
2QJQ
Laboratory Technician
7
Retreatment
7
2nd specimen
New
Months post-treatment
Specimen:
1st specimen
Category:
3rd specimen
TDF Laboratory
Culture center:
Laboratory Supervisor
Treatment center:
TB Culture
Baseline
12/10/07
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex:
DSSM result:
MODULE B
85
86
34/F
Yes
Date Released:
TB culture
DSSM
Date of collection
Lab No.
DSSM
No
mm/dd/yy
Sputum
0
0
Laboratory Technician
2nd specimen
Retreatment
7
1st specimen
New
Months post-treatment
Specimen:
7
Category:
3rd specimen
TDF Laboratory
Culture center:
Laboratory Supervisor
Treatment center:
TB Culture
Baseline
03/15/08
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex:
Culture result:
MODULE B
49/F
Date Released:
TB culture
DSSM
Date of collection
Lab No.
mm/dd/yy
03/25/08
DSSM
1HJD
0
Laboratory Technician
Retreatment
7
7
New
2nd specimen
Category:
Months post-treatment
1st specimen
TB Culture
No
Yes
Baseline
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex:
Sputum
Specimen:
3rd specimen
TDF Laboratory
Culture center:
Laboratory Supervisor
Treatment center:
Culture result:
MODULE B
87
88
45/M
Santos, Santiago S.
Yes
Date Released:
mm/dd/yy
Laboratory Technician
TB culture
03/17/08
Date of collection
Lab No.
DSSM
Retreatment
New
7
TB Culture
Category:
Months post-treatment
7
Sputum
Specimen:
2nd specimen
DSSM
No
Baseline
3rd specimen
TDF Laboratory
Culture center:
Laboratory Supervisor
Treatment center:
1st specimen
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex:
Patients name:
Culture result:
MODULE B
Yes
mm/dd/yy
Laboratory Technician
Michael S. Evangelista
Levofloxacin (Lfx)
Pyrazinamide (Z)
04/20/08
Ciprofloxacin (Cfx )
Ethambutol (E)
Date Released:
Ofloxacin (Ofx)
Rifampicin (R)
New
'
Retreatment
Months post-treatment
METHOD USED: Disc Elution / 7H10
Streptomycin (S)
Category:
5
No
Baseline
Isoniazid (H)
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Laboratory Supervisor
Claudette Guray
Amikacin (Am)
Kanamycin (Km)
DST center:
Date collected
TDF Laboratory
TDF Laboratory
Sputum
11/29/2007
Culture center:
Specimen:
Age/Sex: 34/F
01-T-079781-1
Laboratory ID no.
Treatment center:
DST result:
MODULE B
89
90
Yes
Levofloxacin (Lfx)
Pyrazinamide (Z)
mm/dd/yy
Laboratory Technician
Michael S. Evangelista
Ciprofloxacin (Cfx )
Ethambutol (E)
Ofloxacin (Ofx)
Rifampicin (R)
New
'
Retreatment
Laboratory Supervisor
Claudette Guray
Amikacin (Am)
Kanamycin (Km)
TDF Laboratory
12/3/2007
Months post-treatment
DST center:
Date collected
Category:
Streptomycin (S)
No
Baseline
Isoniazid (H)
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex: 49/F
TDF Laboratory
Sputum
Specimen:
01-T-079781-1
Culture center:
Laboratory ID no.
Treatment center:
DST result:
MODULE B
DST result:
Yes
mm/dd/yy
Laboratory Technician
Michael S. Evangelista
Levofloxacin (Lfx)
Pyrazinamide (Z)
04/28/08
Ciprofloxacin (Cfx )
Ethambutol (E)
Date Released:
Ofloxacin (Ofx)
Rifampicin (R)
New
'
Retreatment
Months post-treatment
12/5/2007
Date collected
Category:
Streptomycin (S)
No
Baseline
Isoniazid (H)
Screening
EXAMINATION DONE:
Enrolled:
Schedule:
Age/Sex: 45/M
Sputum
Laboratory Supervisor
Claudette Guray
Amikacin (Am)
Kanamycin (Km)
TDF Laboratory
DST center:
TDF Laboratory
Culture center:
Specimen:
01-T-079783-1
Laboratory ID no.
Treatment center:
TDF-MMC DOTS Clinic
MODULE B
91
MODULE B
92
MODULE B
6.3 Record the results in the patients chart and in the Consiliumex
Patients who are confirmed to be MDR-TB by DST and those who are critically ill and highly suspected for MDRTB need to be presented to the Consilium. The consilium determines treatment regimens, assesses response to
treatment and treatment outcome through a consensus utilizing WHO Guidelines for drug-resistant TB.
The Treatment Center physician will fill out the Consiliumex for one case in preparation for presentation to the
Consilium. An example of the Consiliumex can be found on the following pages. There are many sections of the
Consiliumex. At this point, the physician will be completing first the patients general information, TB treatment
history, DST pattern and chest x-ray results, then Consilium Discussion 001 Recommendation on Enrollment
Regimen.
93
MODULE B
CONSILIUMEX
Category IV Registration No:
Balagtas
Jose
(Last)
50
(First)
SEX
Amorsolo
(Middle)
WEIGHT ON SCREENING
49.2
KGS
Same as above
PERMANENT ADDRESS
REGION
NCR
TREATMENT CENTER
KASAKA
MD IN CHARGE
TB treatment history is
important in making
decisions regarding the
patients regimen design.
NAME OF OTHER
LABORATORY
LCP
DST RESULT
10 / 10 / 05
CULTURE CENTER
(Screening)
TDF
DATE SPECIMEN
COLLECTED
10/18/06
DST CENTER
(Screening)
TDF
02/26/07
DST RESULT
(Screening)
Resistant to:
HRES
Susceptible to:
Z Km Cfx Ofx Lfx
Susceptible to:
Not available
WEIGHT MONITORING: (TO BE CONSTANTLY UPDATED EVERY CONSILIUM MEETING BY THE SECRETARIAT)
94
CONSILIUM
DISCUSSION
DATE
WEIGHT (KGS)
CONSILIUM
DISCUSSION
001 (E)
03 / 01 / 07
49.2
006
002
007
003
008
004
009
005
010 (TO)
DATE
WEIGHT (KGS)
MODULE B
49.2
SECOND-LINE DRUG
ZKmOfxPtoCs
MD IN CHARGE
DAR
KGS
REGIMEN
SYMBOL
DAY 1
DAY 2
DAY 3
DAY 4
DAY 5
DAY 6
DAY 7
Cycloserine
Cs
1 cap
1 cap
1 cap
2 caps
2 caps
2 caps
FD
Prothionamide
Pto
1 tab
1 tab
1 tab
2 tabs
2 tabs
2 tabs
FD
PASER
PAS
1 sachet
1 sachet
1 sachet
2 sachets
2 sachets
2 sachets
2 sachets
PREPARATION
500 mg
Ofx
200 mg
Km
1G
Pto
250 mg
Cs
250 mg
750
4
COMMENTS:
For enrollment
CONSILIUM OFFICER
DATE
03 / 01 / 07
95
96
11 / 24/ 05
11 / 08/05
10/4/2005
Treatment
start date
mm/dd/yy
(3)
02-05-0097
4/25/2005
02-05-0096
4/28/2005
02-05-0095
4/29/2005
Category IV
Registration No.
TC-YY-NNNN
(2)
Date
screened
mm/dd/yy
(1)
JOSE AMORSOLO
(5) Sex
1- Male
2- Female
8 Fibrothorax
9 Bullae
10 Pleural effusion
11 Pneumothorax
12 Bronchiectasis
13 Atelectasis
14 Consolidation
15 Mass
16 Others, specify
_______________
Site of
disease
(8)
1-New
2-After Cat I failure
3-After Cat II failure
4-After Cat IV
failure
5-After default
6-Cat I relapse
7-Cat II relapse
8-Cat IV relapse
9-Transfer-in
10.1 Non-DOTS
10.2 Other (+)
10.3 Other (-)
10.3
10.1
1- New
2- First line drugs only
3- First and second-line
drugs
/
/
04/28/05
/
/
04/27/05
/
/
04/29/05
Date DST
specimen
collected
mm/dd/yy
(12) t
Registration Previous TB
group
treatment
(10)
(11)
10-Other patient w/
10/21/05
1,2,8
11/08/05
1, 15
10/03/05
1,2,3
Date done
mm/dd/yy
Chest x-ray
result
(9)
01 / 20 / 55
0 Normal
1 Cavitary
2 Infiltrate
3 Nodule
4 Miliary TB
5 Intrathoracic
lymphadenopathy
6 Endobronchial spread
7 Fibrosis
50
BALAGTAS,
23
Manila, NCR
27
02 / 02 / 78
Date of birth
mm/dd/yy
Address (7)
03/28/83
Sex
(5)
Age (yrs)
(6)
VINCENT LIM
TAN,
SYLVIA GOMEZ
SANTOS,
Last name
First name and middle name
Name
(4)
Category IV Register
04/28/05
04/27/05
Km
Ofx
R - Resistant
Cfx
Lfx
ND
ND
ND
Other
ND - Not Done
ND
ND
ND
Other
10/10/05
10/5/05
9/23/05
Date DST
released
mm/dd/yy
(14)
S - Susceptible
Row 2: Baseline DST or DST done within 30 days prior to treatment start
or 7 days post-treatment start (result not yet available upon treatment)
04/29/05
Date DST
specimen
collected
mm/dd/yy
(12)
10/11/05
10/10/05
9/26/05
Date received by
Tx center
mm/dd/yy (15)
mm/dd/yy
s/c
mo 0
s/c
09/29/05
09/28/05
2+/MTB
11/07/05
11/04/05
3+/MTB
/ /
/ /
/ /
/ /
10/22/05
10/21/05
4+/MTB
2+/MTB
3+/MTB
3+/MTB
/ /
/ /
/ /
/ /
12/22/2005
/ /
/ /
1/25/2006
0/0
/ /
/ /
mm/dd/yy
s/c
mo 3
/ /
/ /
11/24/2005
0/0
/ /
/ /
02+/0
mm/dd/yy
s/c
mo 2
mm/dd/yy
s/c
mo 1
/ /
/ /
2/23/2006
0/0
/ /
/ /
mm/dd/yy
s/c
mo 4
/ /
/ /
3/24/2006
/ /
/ /
mm/dd/yy
s/c
mo 5
/ /
/ /
/ /
/ /
/ /
mm/dd/yy
s/c
mo 7
s/c
mo 8
/ /
/ /
/ /
/ /
/ /
mm/dd/yy
/ /
/ /
4/20/2006
/ /
/ /
mm/dd/yy
s/c
mo 6
/ /
/ /
/ /
/ /
/ /
mm/dd/yy
s/c
mo 9
97
98
mm/dd/yy
mm/dd/yy
s/c
s/c
mo 11
mo 10
mm/dd/yy
s/c
mo 12
s/c
mo 13
mm/dd/yy
mm/dd/yy
s/c
SUMMARY
mm/dd/yy
s/c
mo 16
mm/dd/yy
s/c
mo 17
mm/dd/yy
s/c
mo 19
mm/dd/yy
s/c
mo 20
mm/dd/yy
s/c
mo 21
mm/dd/yy
s/c
mo 22
mm/dd/yy
s/c
mo 23
1. Extrapulmonary
2. Trans-in
3. Other
Excluded
mm/dd/yy
s/c
mo 24
Post-treatment
follow-up monitoring
(18)
HIV status
(19)HIV status
0-Negative
1-Positive
2-Unknown
Date of last
intake of
Ff up 1 Ff up 2 Ff up 3 Ff up 4 (19)
meds
Treatment
outcome
(17)
mm/dd/yy
s/c
mo 18
Interim Outcome
1. Culture-positive at month 0
2. Culture-negative at month 6
Final Outcome
1. Cured
2. Treatment completed
3. Died
4. Failed
5. Defaulted
Still receiving treatment
mm/dd/yy
s/c
mo 14
MODULE B
MODULE B
99
MODULE B
Acknowledgement Form
Date:
To:
Dr. A. Madrid
Initial Diagnosis
Tondo, Manila
Final Diagnosis
Jose A. Balagtas
, for further TB
4/26/05
3+
4+
Culture
M. tuberculosis
M. tuberculosis
Plans/Recommendations:
Final diagnosis is MDR-TB
For category IV treatment
Please inform patient that he is ready for enrollment.
Please contact the number below for any queries and further instructions.
Clinic Physician:
100
MODULE B
7.1.1 Inform the patient of the results and explain the Consilium process
When you inform the patient that the DST showed resistance to TB drugs, explain in simple terms what drug
resistance is, and what that means for treatment. Reassure the patient that MDR-TB can be cured, but that it will
take dedication and many months of treatment. Drug-resistant TB is a very serious disease but it can be cured and,
treatment is given free of charge. It is also important to ensure that the patient will be ready to start treatment once
his case has been discussed and is approved for enrollment. Explain that this process may take some time but that
they should be ready to begin treatment in the near future.
This is a very important meeting with the MDR-TB patient. At this initial discussion, you will begin to provide
important information and support and tell the patient about the future treatment. This is the beginning of a long
relationship with the patient, one that is essential for the successful treatment of the disease. All communication
must be kind, supportive and medically correct.
Inform the patient about MDR-TB, supervised treatment, the treatment regimen, possible adverse drug reactions,
TB transmission, etc. Discuss the patients main worries or doubts and answer any questions clearly and positively
to encourage him as he prepares to start a long and difficult treatment course. See Module D: Inform Patients about
MDR-TB.
101
MODULE B
all children aged less than five years even without symptoms
Studies have shown the increased vulnerability to TB of children less than five years of age among family
contacts and the increased estimated risk of progression to disease after infection. Hence, even without the
manifestation of symptoms, children of this age group should be screened
2.
five years and above who have cough of greater than two weeks
Cough of more than two weeks is a cardinal symptom of TB and any person regardless of age manifesting with
such should be investigated.
If you are sure that the patient has no more questions, ask him to affix his signature on the second page with the
date. The family member or relative should also sign together with the Treatment Center staff. For more information
about how to speak with a patient see Module D:Inform Patients about MDR-TB.
Before any contact tracing can be performed, a Kasunduan/Contract must be signed by the patient. Patients may
not want to sign or may be wary about doing so. You should explain to the patient the reasons for asking for his
signature.
t In order to talk to contacts of the patient, consent is required to respect the patients privacy.
t If the patient signs in agreement to undergo treatment, it means that he understands the potential side effects
of the drugs, pledges to adhere to the requirements of treatment and follow-up.
t Each patient has certain rights and responsibilities when receiving treatment for MDR-TB and these need to be
explained and agreed upon.
The Kasunduan/Contract is shown on the next page and can also be found in the Reference Booklet.
102
MODULE B
Ang mga gamot na tinatawag na second-line drugs para sa tuberkulosis na gagamitin para sa akin ay mahal at di
madaling bilihin at nagkakahalaga ng P200,000 o higit pa.
Ito ay galing pa sa ibang bansa at kinakailangan pa ng tulong ng Green Light Committee (GLC) at ng World Health
Organization (WHO) upang makamit.
Ang mga sakit katulad ng diabetes, high blood at iba pang sakit na walang kinalaman sa TB ay di na sakop ng klinikang
ito. Itoy maaaring ipakonsulta at ipagamot sa ibang doktor.
7.
Ang aking kalagayang pinansyal ay aalamin ng mga social worker upang maging basehan ng kakayahan ko
sa pagpapatuloy sa aking gamutan at kakayahang tustusan ang iba ko pang pangangailangan habang ako ay
nagpapagamot.
103
9.
MODULE B
Programmatic Management of Drug - Resistant TB (PMDT)
Upang mas lalong masiguro ang aking kalusugan at kalusugan ng aking mga kasambahay, dadalhin ko ang aking mga
kasambahay sa itinakdang Treatment Center upang suriin sa sakit na tuberkulosis. Kukunan ng x-ray at eksaminasyon
sa plema ang aking mga kasambahay kung kinakailangan.
Jose A. Balagtas
Petsa
Normando C. Cuervo
Pangalan at lagda ng Clinic Staff
Marites S. Sisaldo
Pangalan at lagda ng kamag-anak o
kasambahay ng pasyente
Petsa
Oct.
2005
Make sure that both
the 23,
patient
and family
members understand the importance
of daily DOT
Petsa
and completion of treatment.
Treatment Center Staff to please check accordingly and write the telephone and address.
104
Address:
Address:
Address:
Address
Address:
Address:
MODULE B
8.2 Complete the list of the patients contacts on the Contact Initial Investigation Form and conduct
interviews
A Contact Initial Investigation Form (CIIF) records all of the patients household contacts eligible for contact tracing
which include a) all children less than five years even without symptoms, and b) five years and above who have
cough for more than 2 weeks. Information on each of the patients eligible household contacts should be recorded
on the CIIF as shown in the example on the next page.
On the right upper corner of the CIIF, note the total number of contacts regardless of criteria for contact tracing.
From this number, note the number eligible for contact tracing and list their names down. Then, note how many
among the eligible were actually traced since not all contacts will be able to come.
105
106
Address:
Telephone Number/s:
(4)
(5)
Angelo Balagtas
4.
8.
7.
6.
Normando Cuervo
_____________________________________
Interviewer
Sex
(M/F)
son
son
16
31
39
49
Weight
( kgs )
1, 3
1,4
10/21/05
10/21/05
10/21/05
10/21/05
Mtb
ND
ND
ND
Date
TST
17
mm
4 Non-response to antibiotic
for lower resp. tract infection
5 Failure to regain previous
state of health 2 wks after
viral infection
0 Normal/Negative
1 Cavitary
2 Infiltrate
3 Nodule
4 Miliary Tb
5 Intrathoracic
lymphadenopathy
6 Endobronchial
spread
7 Fibrosis
8 Fibrothorax
9 Bullae
10 Pleural effusion
10/21/05
10/21/05
10/21/05
5
4
4
Initial Official
0/P
0/P
For TBDC/
Pedia
For TBDC
For TBDC
Other
comments
ND Not done
R Refused
P Pending
For ALL
Procedures
0/P
0/P
0/P
Result
0/P
BACTERIOLOGY
Smear Culture
0
0
1+
MTB
2+
3+
4+
10/21/05
10/21/05
ND
10/21/05
Date
Smear/ Culture
11 Pneumothorax
12 Bronchiectasis
13 Atelectasis
14 Consolidation
15 Mass
16 Others,
specify _____
CXR
(11)
# of contacts identified
(10) # of eligible contacts for tracing
(9)
SUMMARY:
10/21/05
Date
mendations.
_______________________________________________________________________________________________________________
Retrieve old CXR lm of Joy Balagtas for comparative reading & presentation to TBDC/ Follow up TBDC recomREMARKS: _______________________________________________________________________________________________________
0 None
1 Cough / wheezing >2wks
2 Unexplained fever >2 wks
3 Loss of weight or appetite/
Failure to gain weight
96
157
150
153
Height (cm)
HRES
Negative
Negative
Susceptible: ZCfxOfxLfxKm
DST: Resistant:
Culture
Smear
Positive
11/24/2007
Baseline mycobacteriology
Date enrolled:
(8)
(7)
(6)
daughter
wife
Relationship
11/4/01
5/3/91
4/13/87
9/14/53
Date of
Birth
DEFINITIONS
MDRTB household contact:
Someone who sleeps in the same dwelling unit with common
arrangement for food preparation & consumption with an
MDR-TB patient for at least 3 months.
14
Paul Balagtas
5.
18
Marites Balagtas
48
Age
3.
Joy Balagtas
(02) 244-6847
2.
1.
Date of birth:
(3)
02-05-0097
1/20/1955
Age: 50 Sex: M
F
2425 Buendia Street, Balut Tondo, Manila
Index name:
(2)
Jose A. Balagtas
(1)
MODULE B
MODULE B
8.3 Instruct patients symptomatic household contacts to receive appropriate care and follow-up
A household contact of an MDR-TB patient with symptoms possesses a risk factor for MDR-TB. He is therefore
regarded as an MDR-TB suspect and because he has symptoms, he will need to be entered into the TB Symptomatics
Masterlist during screening. This household contact must begin the process of TB detection as other patients in the
high-risk groups for MDR-TB. If the contact is confirmed MDR-TB or will be empirically treated with second-line drugs
after Consilium approval, then the contact will be entered in the Category IV Register.
All household contacts of a confirmed MDR-TB patient should be interviewed at the Treatment Center for symptoms
of TB. Those who are eligible for contat tracing should be evaluated by a physician by history and physical
examination.
For all ages with cough of more than two weeks, sputum smear and culture will be done.
For children less than five years old with or without symptoms, the following procedures will be done:
t
t
t
TB and to a greater extent, MDR-TB are very difficult to diagnose in children. Many times children are unable to
produce or expectorate sputum on their own for examination. Other methods of collection such as sputum
induction and gastric aspiration are necessary. See Annex B: Procedures for obtaining sputum specimens in children.
A child may also have extrapulmonary (EPTB) disease and may manifest with enlarged perihilar lymph nodes by
chest x-ray examination.
Patients with three of the five clinical symptoms should be entered into the TB Symptomatics Masterlist. Once all of
the diagnostic information has been obtained (physical exam, TST and chest x-ray results) the attending physician in
concurrence with the Consilium will come up with a consensus decision as to diagnosis for young children.
All children approved by the Consilium for MDR-TB treatment will be assigned a Pre-enrollment No. recorded on
Column 19 of the TB Symptomatics Masterlist. Once enrolled, the treatment start date will be written under the Preenrollment No. and as in adults, the patient will be entered in the Category IV Register and a Category IV Registration
No. will be assigned. All patients entered in the Category IV Register should have been entered first into the TB
Symptomatics Masterlist.
107
MODULE B
Health workers should keep in mind that all previously treated patients, as well as non-converters of Category
II, symptomatic contacts of MDR-TB, and HIV-positive patients with symptoms of TB, are considered MDR-TB
suspects.
t
Any person in these high-risk groups for MDR-TB should be immediately referred to the appropriate Treatment
Center using the MDR-TB Suspects Referral Form for screening and diagnosis.
t
At the Treatment Center, screen every MDR-TB suspect and fill out an MDR-TB Screening Form. This includes
a physical examination by a physician and his preliminary diagnosis and plans for further diagnosis and/or
treatment.
t
Be sure to write down the complete name and complete address of every MDR-TB suspect in the TB
Symptomatics Masterlist, so that the TB suspect can be located once the results of the various tests show that
the patient has TB and in case the TB suspect does not return.
t
Inform the MDR-TB suspect about the process and discuss the Paunawa or Terms of Understanding with him to
continue the diagnosis.
t
Collect two sputum samples from every MDR-TB suspect for diagnosis. Use the Mycobacteriology Request Form
and the Laboratory Receiving Form for Specimens to request for sputum examinations and to send the samples
to the corresponding Culture Center. When the results of the smear, culture and DST are received from the
laboratory, record the results in the TB Symptomatics Masterlist.
All specimens will be cultured at the Culture Center automatically regardless of the smear result.
If culture results are positive, the culture isolate will be sent for DST to a DST Center
If the culture results are negative, the treatment center Physician may refer the patient to the Consilium
for clinical assessment on whether or not sputum should be recollected or empiric treatment should be
given.
If the DST shows that the DR-TB suspect has confirmed MDR, the patient will be assigned a Pre-enrollment
No. by the Treatment Center.
Likewise, a patient not confirmed to be MDR-TB by DST but highly suspected to be MDR and decided by the
Consilium to start treatment will be assigned a Pre-enrollment No. by the Treatment Center.
t
A patient who has confirmed drug resistance or MDR-TB or those decided by the Consilium to be started on
treatment must be informed immediately. If he does not call or visit the Center, locate this patient as soon as
possible. Assign a Pre-enrollment No.
t
Present MDR-TB cases confirmed by DST to the Consilium to be able to start treatment immediately to prevent
the spread of the disease to others in the household and community and to improve the condition of the
patient. Assign a Pre-enrollment No.
108
MODULE B
t
Present also to the Consilium cases highly suspected to be MDR-TB even without DST confirmation as not
all patients can wait for DST results and there are some culture-negative patients who deserve Category IV
treatment.
t
A patient who is started on treatment is entered into the Category IV Register and is assigned a Category IV
Registration No.
t
Ask patients with confirmed drug resistance to bring to the DOTS facility all his contacts for interview of
symptoms.
t
109
MODULE B
Self-assessment questions
1.
List 7 different high-risk groups for MDR-TB who should be referred for testing.
2.
How many sputum samples are needed for examination for diagnosis? ___________
When and where are these samples collected? ____________
3.
The __________________________________ is an individual form for each MDR-TB suspect that holds a large
amount of background information about the patient. The __________________________________ is a record
of all TB suspects, including TB and MDR-TB suspects seen at the MDR-TB Treatment Center.
4.
List the data recorded in the TB Symptomatics Masterlist before sputum examination.
(For TC staff only)
5.
What are the three tests that are generally to be performed to diagnose MDR-TB?
Under what circumstances can a patient be enrolled in treatment without these tests?
6.
If an MDR-TB suspects DST results show resistance to H, R and E, the __________________ should be completed
to present the case to the _____________ in order to make a decision about treatment. (for TC staff only)
7.
What should the health worker tell the patient, if an MDR-TB suspects DST results show resistance to H, R
and E ?
8.
If an MDR-TB suspects culture result is negative but the patient is clinically deteriorating, what should you do?
9.
If culture results show that an MDR-TB suspect is positive for TB and the DST results show resistance to H and R,
but the suspect does not return to the health facility, what should the health worker do?
10. An MDR-TB suspect who is found to have confirmed MDR-TB may have infected other people with MDR-TB. Who
should the confirmed MDR-TB patient ask to come to the health facility to be screened for MDR-TB?
110
MODULE B
The following groups are considered high risk for MDR-TB and should be referred for testing at a Treatment Center
Retreatment cases
1. Failure
- Category I failure
- Category II failure (chronic TB case)
2.
Relapse of category I or II
3.
4.
5.
Non-converters of category II
7.
HIV-positive patients who have pulmonary or extra-pulmonary TB symptoms or have chest x-ray
findings suggestive of TB
2.
3.
The MDR-TB Screening Form is an individual form for each MDR-TB suspect that holds a large amount of
background information about the patient. The TB Symptomatics Masterlist is a record of all TB suspects,
including TB and MDR-TB suspects seen at the MDR-TB Treatment Center.
4.
Screening Code, date of screening, complete name and address, age, date of birth, and sex, no. of previous
TB treatment, source of referral (site or doctor), site where last treated for TB, registration group, risk factors,
symptoms, chest x-ray results (if available)
5.
6.
If an MDR-TB suspects DST results show resistance to H, R and E, the Consiliumex should be completed to
present the case to the Consilium in order to make a decision about treatment.
7.
Inform the patient clearly and in a sensitive way. It is important to inform the MDR-TB suspect as soon as possible
about drug resistance and the next steps that will be taken to start treatment.
8.
The physician must present the case to the Consilium immediately. Either the culture needs to be repeated or empiric
treatment needs to be started.
111
MODULE B
9.
All efforts should be made to contact or locate the person. Call the patient or his contacts within the week. You may
ask the referring DOTS facility to help locate the patient. This may require you to visit the patients address recorded
in the TB Symptomatics Masterlist.
Patients with MDR-TB who are left untreated can infect many others with MDR-TB and delays in treatment can lead
to worse treatment outcomes.
10. If possible, all household contacts of a confirmed MDR-TB patient should be interviewed at the Treatment center
for symptoms of TB. All those with symptoms regardless of age, and all children less than five years even without
symptoms should be evaluated by a physician by history and physical examination. For all ages with cough of more
than two weeks, sputum smear and culture will be done.
End of Module B
Congratulations on finishing this module!
112
MODULE B
References
1.
Guidelines for the Programmatic Management of Drug-resistant Tuberculosis, World Health Organization,
Geneva, Switzerland, 2006. (WHO/HTM/TB/2006.361)
2.
National Tuberculosis Control Program Revised Manual of Procedures. Manila, Department of Health, 2005.
3.
Balane, G. I., Pancho, J. S. R., Tupasi, T. E., et al. Tuberculosis among household contacts of infectious multi-drug
resistant TB patients. The International Journal of Tuberculosis and Lung Disease. Vol. 11, No. 11, (November)
2007, Supplement 1: S252
4.
Quelapio, M. I. D., Auer, C., Tupasi, T. E., et al. Mainstreaming DOTS-Plus to DOTS: when is culture indicated in
DOTS? The International Journal of Tuberculosis and Lung Disease. Vol. 9, No. 11, (November) 2005, Supplement
1: S291
5.
Auer, C., Lagahid, J. Y., Tupasi, T. E., et al. Smear positivity at two/three months of treatment: does it indicate
MDR-TB? The International Journal of Tuberculosis and Lung Disease. Vol. 9, No. 11, (November) 2005,
Supplement 1: S245
6.
Concepcion, A. A. L., Maramba, E. K., Tupasi, T. E., et. al. Internal consilium: a standardized approach for MDRTB management. The International Journal of Tuberculosis and Lung Disease, Vol. 10, No. 11, (November) 2006,
Supplement 1: S126
7.
Concepcion, A. A. L., Quelapio, M. I. D., Tupasi, T. E., et. al. Case management discussions in an internal
consilium. The International Journal of Tuberculosis and Lung Disease, Vol. 10, No. 11, (November) 2006,
Supplement 1: S125
8.
Concepcion, A. A. L., Quelapio, M. I. D., Tupasi, T. E., et. al. Impact of Union Management Courses: Internal
Consilium opportunity for learning, coordination and peer support. The International Journal of Tuberculosis
and Lung Disease, Vol. 11, No. 11, (November) 2007, Supplement 1: S203
9.
Orillaza Chi, R. B., Concepcion, A. A. L., Tupasi, T. E., et. al. Internal consilium for programmatic MDR-TB
management: Makati, Philippines. The International Journal of Tuberculosis and Lung Disease. Vol. 11, No. 11,
(November) 2007, Supplement 1: S263
10. Guidelines for National TB Programmes on the Management of TB in Children, World Health Organization,
Geneva, Switzerland, 2006. (WHO/HTM/TB/2006.371; WHO/FCH/CAH/2006.7)
11. Rieder, H. L. Contacts of TB patients in high-incidence countries. The International Journal of Tuberculosis and
Lung Disease. 2003, S333 S336
12. van Rie, A., Beyers, N., Gie, R. P., et. al. Childhood TB in an urban population in South Africa: burden and risk
factors. Arch Dis Child. 1999, 80: 433 437
13. Miller, F. J. W., Seal, R. M. E., & Taylor, M. D. (1963). Tuberculosis in children. Boston: Little, Brown and Co.
14. Guidelines for the Implementation of the Programmatic Management of Drug-resistant Tuberculosis (PMDT).
Administrative Order No. 2008-0018. Department of Health, Manila, Philippines, May 26, 2008.
Annexes
A: Proper collection of specimen for the diagnosis of TB
B: Procedures for obtaining sputum specimens in children
C: Proper labeling, sealing and transportation of sputum
113
MODULE B
Annex A.
PROPER COLLECTION
OF
SPECIMEN
FOR THE DIAGNOSIS
OF
TB
What is TB ?
TB (tuberculosis) is a disease that is caused by a bacterium known as Mycobacterium tuberculosis.
It can affect any organ of the body, with the lungs being the most common causing pulmonary TB or TB of the
lungs.
It is an infectious disease that can be acquired / transmitted by airborne spread of infectious droplets.
A person with TB of the lungs who is coughing is a source of infection.
MODULE B
What is TB culture?
TB culture is a procedure that detects the presence of the bacteria causing TB by allowing it to grow in a system
designed for its isolation. Since it grows very slowly compared to other disease-causing bacteria, it may take eight
(8) weeks or two (2) months for its growth to be detected. If it is positive for growth, an additional four (4) weeks is
required for its final identification.
To be able to do the test, clinical samples from the patient suspected to have TB are collected. Sputum (phlegm) is
the most common and the specimen of choice.
Two (2) consecutive early morning sputum samples are preferred but spot-collection is acceptable since the finding
of the organism is greater with two (2) sputum samples (Diagnostic specimens) than a single collection only.
Proper collection:
1.
2.
3.
4.
5.
Rinse your mouth with sterile distilled water before entering the collection booth.
Once inside the collection booth, take about three (3) deep breaths and cough forcefully simultaneously
upon exhale with the third deep breath.
Hold the sputum cup close to the lips and expectorate into it gently after a productive cough.
Collect about 5-10ml. (At least up to the first line of the container).
Collect only sputum not saliva. Sputum is usually thick and mucoid and produced from deep in the lungs.
Saliva is thin, clear and is of little diagnostic value for tuberculosis.
115
MODULE B
6.
7.
8.
When the required volume has been collected, close the container tightly to avoid spilling of contents.
Allow one minute to stand.
Leave the collection booth immediately and submit the specimen to the medical technologist in-charge.
Rinse your mouth with sterile distilled water before entering the collection booth.
Collect sputum inside the collection booth.
Inhale the vapor coming out of the induction machine for about 10 minutes.
Forcefully cough and collect about 5-10ml sample.
The sample will appear like saliva but it is acceptable since it is an induced sputum.
3.
4.
116
MODULE B
A. Expectoration
Background
All sputum specimens produced by children should be sent for smear microscopy and, where available,
mycobacterial culture. Children who can produce a sputum specimen may be infectious, so, as with adults, they
should be asked to do this outside and not in enclosed spaces (such as toilets) unless there is a room especially
equipped for this purpose.
Procedure (adapted from Laboratory services in tuberculosis control. Part II. Microscopy (1))
1.
2.
3.
4.
5.
Give the child confidence by explaining to him or her (and any family members) the reason for sputum
collection.
Instruct the child to rinse his or her mouth with water before producing the specimen. This will help to remove
food and any contaminating bacteria in the mouth.
Instruct the child to take two deep breaths, holding the breath for a few seconds after each inhalation and then
exhaling slowly. Ask him or her to breathe in a third time and then forcefully blow the air out. Ask him or her to
breathe in again and then cough. This should produce sputum from deep in the lungs. Ask the child to hold the
sputum container close to the lips and to spit into it gently after a productive cough.
If the amount of sputum is insufficient, encourage the patient to cough again until a satisfactory specimen is
obtained. Remember that many patients cannot produce sputum from deep in the respiratory tract in only a
few minutes. Give the child sufficient time to produce an expectoration which he or she feels is produced by a
deep cough.
If there is no expectoration, consider the container used and dispose of it in the appropriate manner.
B. Gastric aspiration
Background
Children with TB may swallow mucus which contains M. tuberculosis. Gastric aspiration is a technique used to collect
gastric contents to try to confirm the diagnosis of TB by microscopy and mycobacterial culture. Because of the
distress caused to the child, and the generally low yield of smear-positivity on microscopy, this procedure should
only be used where culture is available as well as microscopy. Microscopy can sometimes give false-positive results
(especially in HIV-infected children who are at risk of having nontuberculous mycobacteria). Culture enables the
determination of the susceptibility of the organism to anti-TB drugs.
Gastric aspirates are used for collection of samples for microscopy and mycobacterial cultures in young children
when sputa cannot be spontaneously expectorated nor induced using hypertonic saline. It is most useful for young
hospitalized children. However, the diagnostic yield (positive culture) of a set of three gastric aspirates is only about
2550% of children with active TB, so a negative smear or culture never excludes TB in a child. Gastric aspirates are
collected from young children suspected of having pulmonary TB. During sleep, the lungs mucociliary system beats
mucus up into the throat. The mucus is swallowed and remains in the stomach until the stomach empties. Therefore,
the highest-yield specimens are obtained first thing in the morning.
DETECT CASES OF MDR-TB
117
MODULE B
Gastric aspiration on each of three consecutive mornings should be performed for each patient. This is the number
that seems to maximize yield of smear-positivity. Of note, the first gastric aspirate has the highest yield. Performing
the test properly usually requires two people (one doing the test and an assistant). Children not fasting for at least 4
hours (3 hours for infants) prior to the procedure and children with a low platelet count or bleeding tendency should
not undergo the procedure.
The following equipment is needed:
t gloves
t nasogastric tube (usually 10 French or larger)
t 5, 10, 20 or 30 cm3 syringe, with appropriate connector for the nasogastric tube
t litmus paper
t specimen container
t pen (to label specimens)
t laboratory requisition forms
t sterile water or normal saline (0.9% NaCl)
t sodium bicarbonate solution (8%)
t alcohol/chlorhexidine.
Procedure
The procedure can be carried out as an inpatient first thing in the morning when the child wakes up, at the childs
bedside or in a procedure room on the ward (if one is available), or as an outpatient (provided that the facility is
properly equipped). The child should have fasted for at least 4 hours (infants for 3 hours) before the procedure.
1.
2.
3.
4.
Wipe the specimen container with alcohol/chlorhexidine to prevent cross-infection and label the container.
Fill out the laboratory requisition forms.
Transport the specimen (in a cool box) to the laboratory for processing as soon as possible (within 4 hours).
If it is likely to take more than 4 hours for the specimens to be transported, place them in the refrigerator (48
C) and store until transported.
Give the child his or her usual food.
Safety
Gastric aspiration is generally not an aerosol-generating procedure. As young children are also at low risk of
transmitting infection, gastric aspiration can be considered a low risk procedure for TB transmission and can safely
be performed at the childs bedside or in a routine procedure room.
118
MODULE B
C. Sputum induction
Note that, unlike gastric aspiration, sputum induction is an aerosol-generating procedure. Where possible, therefore,
this procedure should be performed in an isolation room that has adequate infection control precautions (negative
pressure, ultraviolet light (turned on when room is not in use) and extractor fan).
Sputum induction is regarded as a low-risk procedure. Very few adverse events have been reported, and they include
coughing spells, mild wheezing and nosebleeds. Recent studies have shown that this procedure can safely be
performed even in young infants (2), though staff will need to have specialized training and equipment to perform
this procedure in such patients.
General approach
Examine children before the procedure to ensure they are well enough to undergo the procedure. Children with the
following characteristics should not undergo sputum induction.
t
t
t
t
t
t
Inadequate fasting: if a child has not been fasting for at least 3 hours, postpone the procedure until the
appropriate time.
Severe respiratory distress (including rapid breathing, wheezing, hypoxia).
Intubated.
Bleeding: low platelet count, bleeding tendency, severe nosebleeds (symptomatic or platelet count <50/ml
blood).
Reduced level of consciousness.
History of significant asthma (diagnosed and treated by a clinician).
Procedure
1.
2.
3.
4.
5.
Any equipment that will be reused will need to be disinfected and sterilized before use for a subsequent patient.
119
MODULE B
1.
8.
7.
6.
5.
PMDT
Tx center: __________________
Lab No.: ___________________
Name: ____________________
Date collected: _____________
2.
3.
120
4.
Tighten cap
121
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