1.

9
National TB Control Program

Isabelita Samaniego, MD 29 July 2015

 The NTP has the mandate to develop TB control policies,

OUTLINE standards and guidelines, formulate the national strategic plan,
I. Introduction manage program logistics, provide leadership and technical
II. The National TB Control Program assistance (TA) to the lower health offices/units, manage data,
and monitor and evaluate the program.
III. Case Finding
 The program’s TB diagnostic and treatment protocols and
IV. Case Holding strategies are in accordance with the global strategy of STOP
V. Prevention of TB TB Partnership and the policies of World Health Organization
VI. Cases (WHO) and the International Standards for TB Care (ISTC).

KEY INITIATIVES OF THE NTP

Source: 2013 Manual of Procedures of the National 1. Public-private mix DOTS (PPMD)
 Engagement of the private sector such as private practitioners,
Tuberculosis Control Program, 5th edition
pharmacies, and hospitals to adopt the NTP policies and
guidelines and, hence, support the TB control efforts.
Included in this trans are only those that were  PPMD staff were trained on TB-DOTS including the referral
discussed. Kung masipag kayo, read the Manual. :)) system.
o They either manage TB cases or refer them to other DOTS
facilities.
INTRODUCTION  Around 6% of total TB cases nationwide were contributed by
 Tuberculosis or TB is an infectious disease caused by the this initiative in 2008.
bacteria called Mycobacterium tuberculosis.
 It is transmitted from a TB patient to another person through 2. Enhanced hospital TB-DOTS
coughing, sneezing and spitting.  Strengthening of the internal and external referral systems and
o Close contacts, especially household members, could be quality of TB diagnosis and treatment in hospitals.
infected with TB. Lungs are commonly affected but it  Hospitals could either act as a referring hospital or DOTS-
could also affect other organs such as the kidney, bones, providing hospital.
liver and others.  All or most of the TB cases are referred to the DOTS facilities
 TB is curable and preventable. However, incomplete or and the outcomes are tracked.
irregular treatment may lead to drug resistant TB or even  A pilot study from 2010-2012 showed that 73% of around
death. 13,000 TB cases were successfully referred to health centers
 In 2010, TB was the 6th leading cause of mortality with a rate and RHUs.
of 26.3 deaths for every 100,000 population and accounts for
5.1% of total deaths.1 3. Programmatic Management of Drug-resistant TB (PMDT)
 This is slightly lower than the five-year average of 28.6 deaths  Provision of diagnostic and treatment services to drug-resistant
per 100,000 population. TB through the treatment centers, satellite treatment centers
 More males died (17,103) compared to females (7,611). and treatment sites.
 The country had conducted three National TB Prevalence  The NTP coordinates PMDT while the Lung Center of the
Survey (NTPS) that describe the magnitude and the trend of Philippines (LCP) is responsible for research and capability-
the TB problem. The results were as follows: building. In 2012, only 23% of estimated MDR-TB cases had
INDICATORS NTPS 1983 NTPS 1997 NTPS 2007 been provided with quality assured second line anti-TB drugs.
Prevalence of
culture-positive 8.6/1,000 8.1/1,000 4.7/1,000 4. TB HIV collaborative activities
TB  Close coordination between the NTP and National AIDS/ STI
Prevalence of Prevention and Control Program (NASPCP) to provide services
sputum smear- 6.6/1,000 3.1/1,000 2.0/1,000 to those patients with TB and HIV co-infection.
positive TB  Key activities include provider-initiated HIV counselling and
Prevalence of testing (PICT) for TB patients and screening for TB among
those with CXR people living with HIV (PLHIV).
4.2% 4.2% 6.3%
findings
suggestive of TB 5. TB in jails/prisons
Annual Rate of  Ensuring access to TB diagnosis and treatment by the inmates
2.5% 2.3% 2.1% of jails and prisons.
infection
Rate of TB  The Department of Justice (DOJ) through the Bureau of
17% 18.4% 13.5% Corrections (BuCor) and the Department of Interior and Local
symptomatic
Governments (DILG) through the Bureau of Jail Management
and Penology (BJMP) coordinates with DOH in implementing
 TB is more prevalent among males compared to females and
this program.
among the 25 – 55 year old age group.
 It is also higher among the malnourished and diabetics.
6. TB-DOTS certification and accreditation
 The 1997 survey showed that prevalence of TB among the
 Ensuring the provision of quality TB services and generating
urban poor in Metro Manila is twice that of the general
financial support through the PhilHealth TB-DOTS outpatient
population.
benefit package.
 The first national Drug Resistance Survey was done in 2003 –
 DOTS facilities are certified by DOH through the ROs based on
2004 and revealed the following prevalence of drug resistance:
ten DOTS standards.
o 4% among the new cases
 These facilities are later accredited by PhilHealth.
o 21% among the re-treatment cases
Reimbursements amounting to PHP 4, 000 per new TB patient
o 5.7% combined.
from PhilHealth could be used for the referring physician,
 The second national Drug Resistance Survey was done in 2011
purchase of other drugs, support for EQA, monetary incentive
– 2012 and showed a decrease in the prevalence of drug
to health workers and other activities that will improve program
resistance among new cases from 4% to 2%.
implementation.’
o However, there was no change in the prevalence of drug
resistance re-treatment cases which remained at 21%.
7. Expansion of TB laboratory services
 Enabling better access to TB microscopy services through the
THE NATIONAL TB CONTROL PROGRAM
establishment of more TB microscopy centers such as those in
 The NTP is one of the public health programs being managed
the hospitals and in the private sector.
and coordinated by the Infectious Diseases for Prevention and
 There are currently 18 culture centers. Plans are underway to
Control Division (IDPCD) of the Disease Prevention and Control
expand this number to 29 culture centers by 2016.
Bureau (DPCB) of the DOH.

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 1 of 9

 NATIONAL TB CONTROL PRGRAM 1.9
 There are currently three (3) DST centers, with plans equally Reduce out-of-pocket
 Secure adequate funding and
underway to expand to seven (7) by 2016. expenses related
improve allocation and
 Sixteen health facilities were provided with Xpert MTB/RIF – a to TB care
efficiency of fund utilization.
new rapid diagnostic tool that detects rifampicin resistance in (Financing)
just two hours.
o There are plans to expand access to Xpert MTB/ ROLES AND FUNCTIONS OF DIFFERENT OFFICES
RIF through the provision of at least one (1) ORGANIZATIONS AND HEALTH WORKERS INVOLVED IN
machine per province or highly urbanized city. NTP
8. Community TB care *Sabi ni Doc, “read” nalang daw. Di na namin lalagay, kung gusto
 Ensuring community participation to improve TB diagnosis and ninyo tingnan nalang dun sa MOP na binigay, page 10 (or page
management. 22 ng entire PDF)
 TB task forces consisting of former TB patients, community
volunteers and members of faith-based organizations were FUNCTIONS OF HEALTH SERVICE PROVIDERS
organized to educate the community about TB, refer 1. PHYSICIAN
presumptive TB to DOTS facilities, and act as treatment  Organize planning and evaluation of TB control activities in
partners. DOTS facilities
 This also includes the formation and strengthening of TB  Ensure that all staff have been trained on TB DOTS
patient support groups.  Supervise staff to ensure proper implementation of NTP policies
and guidelines
NTP PERFORMANCE  Evaluate presumptive TB based on clinical and laboratory
INDICATOR BASELINE in 2012 2012 evidence
1990 (Rate (Rate per (Estimated  Prescribe appropriate treatment
per 100,000) Number)  Manage adverse reactions
100,000)  Provide continuous health education and counselling to all TB
TB Incidence 393 265 260,000 patients under treatment
TB 1,000 461 450,000  Refer TB patients to other health facilities if needed
Prevalence  Encourage community and family support for TB control
TB Mortality 55 24 23,000  Mobilize and utilize resources in the area for TB control
 Coordinate with the local chief executives to ensure funds and
personnel are available for program implementation
 Coordinate with other TB stakeholders to ensure that all
detected TB cases are reported and services provided are
within the NTP policies and guidelines

2. NURSE
 Manage the process of detecting TB cases in coordination
 Assist the physician in counselling and initiating treatment of
TB patient
 Accomplish the NTP treatment card
 Agree with TB patient the mode of DOT including the treatment
partner
 Supervise midwives to ensure the proper implementation of
DOTS
 Maintain and update the presumptive TB master list and TB
VISION register
 Facilitate requisition and distribution of anti-TB drugs,
TB-free Philippines by 2016 laboratory supplies and forms
 Maintain records on logistics and ensure proper storage of
GOAL drugs
By 2016, the following should have been achieved:  Provide continuous health education to all patients
 Incidence rate of 264/100,000  Conduct training of health workers and community volunteers
 Prevalence rate of 414/100,000  Prepare, analyze, and submit quarterly reports
 Mortality rate of 23/100,000
TARGETS BY 2016 3. MIDWIFE
Case-Detection Rate, all 90%  Under the supervision of the nurse, do the following:
forms o Identify presumptive TB patients and ensure proper
Treatment Success Rate, all 90% collection and transport of sputum specimen
forms o Refer all diagnosed TB patients to physician and nurse
Case Detection Rate, MDR- 62% (of estimated MDR for clinical evaluation and initiation of treatment
TB among notified TB cases) o Maintain and update NTP treatment cards
Treatment Success Rate, 75%  Implement DOT with treatment partners:
MDR-TB cases o Provide continuous health education to patients
o Supervise intake of anti-TB drugs
OBJECTIVES AND STRATEGIES o Collect sputum for follow0up examination
o Report and retrieve defaulters within 2 days
PhilPACT Objectives o Refer patients with adverse reactions to physician for
STRATEGIES evaluation and management
(UHC Pillars)
Reduce local variation o Supervise and mentor treatment partners
 Localize implementation of TB
in
control. 4. MEDICAL TECHNOLOGISTS/ MICROSCOPISTS
TB control performance
 Monitor health system  Do DSSM for diagnosis and follow-up
(Governance and
performance.  Perform Xpert MTB RIF examination as needed
health information).
 Perform HIV testing for TB patients as needed
 Engage both public and
 Inform the referring health worker or facility of the result of
private health care providers.
Scale up and sustain DSSM or Xpert
 Promote and strengthen
coverage of DOTS  Maintain and update the NTP laboratory register
positive behavior of
implementation  Prepare quarterly report on laboratory services and submit to
communities.
(Health service delivery the nurse of physician
 Address MDR-TB, TB/HIV, and
and human resource).  Do internal quality control within the laboratory
needs of vulnerable
 Prepare and submit quarterly laboratory supplies requirement
population.
to the nurse
 Regulate and make available
 Stores sputum smears for sampling of the provincial/city TB
Ensure provision of quality TB diagnostic tests and
coordinators for blinded re-checking
quality TB services drugs.
 Ensure that microscope and Xpert machine are properly
(Regulation)  Certify and accredit TB care
maintained and functional
providers.

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 2 of 9

 NATIONAL TB CONTROL PRGRAM 1.9

5. BARANGAY HEALTH WORKERS/ COMMUNITY HEALTH CLASSIFICATION BASED ON ANATOMICAL SITE AND
VOLUNTEERS BACTERIOLOGICAL STATUS
 Identify and refer presumptive TB to DOTS facility for sputum A patient with at least one (1)
collection sputum specimen positive for AFB,

Bacteriologically confirmed
Smear
 Collect and ensure transport of sputum specimen with or without radiographic
positive
 Assist health staff in doing DOT to TB patient abnormalities consistent with
 Keep and update the NTP ID cards active TB
 Report and retrieve defaulters within two days A patient with positive sputum
 Attend regular consultation with the health personnel, Culture culture for MTB complex, with or
together with patient and treatment partners positive without radiographic abnormalities
 Refer patient with adverse reaction to the health personnel consistent with active TB
 Provide health education to the patient, family members and A patient with sputum positive for
the community Rapid MTB complex using rapid
diagnostic diagnostic modalities such as Xpert
CASE FINDING test- MTB/RIF, with or without
DEFINITION OF TERMS positive radiographic abnormalities
Any person whether adult or child with consistent
signs and/or symptoms suggestive of A patient with two (2) sputum specimens
Presumptive
TB whether pulmonary or extra- negative for AFB or MTB, or with smear not done
TB
pulmonary, or those with CXR findings due to specified conditions but with radiographic
suggestive of active TB abnormalities consistent with active TB; and

Pulmonary TB
Any person whether adult or child, who there has been no response to a course of
belongs to any of the DR-TB high-risk empiric antibiotics and/ or symptomatic
groups, such as: re-treatment cases, medications; and who has been decided (either
Presumptive
new TB cases that are contacts of by the physician and/or TBDC) to have TB
Drug-resistant-
confirmed DR-TB cases or non- disease requiring a full course of anti-TB
TB (DRTB)
converter of Category I, and people chemotherapy

Clinically diagnosed
living with HIV with signs and symptoms OR
of TB. A child with two (2) sputum specimens negative
A condition in which an individual is in for AFB or with smear not done, who fulfills three
close contact with an active adult TB (3) of the five (5) criteria for disease activity
case, but without any signs and (i.e., signs and symptoms suggestive of TB,
TB exposure
symptoms of TB, with negative TST exposure to an active TB case, positive
reaction, and no radiologic and tuberculin test, abnormal chest radiograph
laboratory findings suggestive of TB. suggestive of TB, and other laboratory findings
TB infection or A condition in which an individual has no suggestive of TB); and who has been decided to
latent TB signs and symptoms presumptive of TB have TB disease requiring a full course of anti-
infection nor radiologic or laboratory evidence, TB chemotherapy
(LTBI) but has a positive TST reaction. OR
A presumptive TB who after clinical and A patient with laboratory or strong clinical
TB disease diagnostic evaluation is confirmed to evidence for HIV/AIDS with two (2) sputum
have TB. specimens negative for AFB or MTB or with
smear not done due to specified conditions but
CLASSIFICATIONS OF TB DISEASE who, regardless of radiographic results, has
CLASSIFICATION BASED ON BACTERIOLOGICAL been decided to have TB disease requiring a full
STATUS course of anti-TB chemotherapy.
 A TB patient from whom a
biological specimen is positive
Bacteriologically

Bacteriologically-
by smear microscopy, culture or
confirmed
confirmed

rapid diagnostic tests (such as A patient with a smear/culture/rapid diagnostic

Xpert MTB/RIF). test from a biological specimen in an extra-
Extra-pulmonary TB

 A PTB patient who does not fulfill pulmonary site (i.e., organs other than the
the criteria for bacteriological lungs) positive for AFB or MTB complex
confirmation but has been
diagnosed with active TB by a
clinician or other medical
practitioner who has decided to
Clinically-diagnosed give the patient a full course of
diagnosed
Clinically

TB treatment A patient with histological and/or clinical or

 Includes cases diagnosed on the radiologic evidence consistent with active extra-
basis of CXR abnormalities or pulmonary TB and there is a decision by a
suggestive histology, and extra- physician to treat the patient with anti-TB drugs
pulmonary cases without
laboratory confirmation.

CLASSIFICATION BASED ON ANATOMICAL SITE CLASSIFICATION BASED ON HISTORY OF PREVIOUS

 Refers to a case of tuberculosis TREATMENT
involving the lung parenchyma  A patient who has never had
 A patient with both pulmonary treatment for TB or who has
Pulmonary TB (PTB) taken anti-TB drugs for less
and extra-pulmonary TB should
be classified as a case of than one (<1) month.
New case
pulmonary TB.  Isoniazid preventive therapy or
 Refers to a case of tuberculosis other preventive regimens are
involving organs other than the not considered as previous TB
lungs. treatment.
 Histologically-diagnosed EPTB  A patient who has been
through biopsy of appropriate previously treated with anti-TB
Retreatment case
Extra-pulmonary TB sites will be considered drugs for at least one (1) month
(EPTB) clinically-diagnosed TB. in the past.
 Laryngeal TB, though likely
sputum smear-positive, is
considered an extrapulmonary
case in the absence of lung
infiltrates on CXR

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 3 of 9

 NATIONAL TB CONTROL PRGRAM 1.9
CLASSIFICATION BASED ON DRUG-SUSCEPTIBILITY DEFINITION OF TERMS
TESTING  Cases are assigned a registration
 Resistance to one first-line anti- group based on history of previous
Monoresistant-TB
TB drug only treatment in addition to classification
 Resistance to more than one based on anatomical site and
Polydrug-resistant first-line anti-TB drug (other bacteriologic confirmation.
TB than both Isoniazid and  The registration groups of TB cases is
Rifampicin). necessary in determining the correct
Multidrug-resistant  Resistance to at least both treatment regimen.
TB (MDR-TB) Isoniazid and Rifampicin.  Patients who had been registered in a
 Resistance to any TB Disease DOTS facility and are transferred to
fluoroquinolone and to at least Registration another DOTS facility with proper
Extensively drug- Group referral slip to continue the current
one of three second-line
resistant TB (XDR- treatment regimen, or Transfer-in
injectable drugs (Capreomycin,
TB) patients, will be designated a
Kanamycin and Amikacin), in
addition to multidrug resistance. registration group based on the
 Resistance to Rifampicin registration group of the referring
detected using phenotypic or facility aside from Transfer-in.
genotypic methods, with or  These cases should NOT be reported
without resistance to other anti- in the case finding and case-holding
Rifampicin-resistant TB drugs. quarterly reports since they will be
TB (RR-TB)  It includes any resistance to reported by the referring facility.
Rifampicin, whether  DOT is a method developed to ensure
monoresistance, multidrug, treatment compliance by providing
polydrug or extensive drug constant and motivational supervision
Directly
resistance. to TB patients.
Observed
 DOT works by having a responsible
Treatment
POLICIES person, referred to as treatment
(DOT)
 Direct Sputum Smear Microscopy (DSSM) partner, watch the TB patient take
o Whether by light or fluorescence microscopy, shall be anti-TB drugs every day during the
the primary diagnostic tool in NTP case finding whole course of treatment.
o All presumptive TB who could expectorate - whether Fixed–dose combination (FDCs)
pulmonary or extra-pulmonary - shall undergo DSSM  Two or more first-line anti-TB drugs
prior to treatment initiation are combined in one tablet. There are
o However, non-compliance with DSSM should not be a 2-, 3-, or 4-drug fixed-dose
deterrent to treatment initiation among EPTB cases. combinations, namely: HR, HRE and
 All presumptive TB should undergo DSSM unless this is not HRZE. These are usually provided in
possible due to the following situations: Drug kits with boxes of blister packs
o Mentally incapacitated as decided by a specialist or formulations corresponding to treatment phases of
medical institution an average-weight patient.
o Debilitated or bedridden
o Children unable to expectorate Single drug formulation (SDF)
o Patient unable to produce sputum despite sputum  Each drug is prepared individually,
induction either as tablet, capsule, syrup or
 Two sputum specimens of good quality shall be collected, injectable (Streptomycin) form.
either as frontloading (i.e., spot-spot one-hour apart) or spot-
early morning specimens, based on the patient’s preference. TB REGISTRATION GROUPS
o The two specimens should be collected at most within 3 Registration
Definition of Terms
days. Group
 Available rapid diagnostic test (e.g., Xpert MTB/RIF) shall be A patient who has never had treatment for
used for TB diagnosis among presumptive DRTB, PLHIV with New TB or who has taken anti-TB drugs for <1
signs and symptoms of TB, smear-negative adults with CXR fi month.
ndings suggestive of TB smear-negative children and EPTB. A patient previously treated for TB, who
 If Xpert MTB/RIF is inaccessible, smear-negative patients has been declared cured or treatment
shall be evaluated by the DOTS physician who shall decide completed in their most recent treatment
using clinical criteria and best clinical judgment. Relapse
episode, and is presently diagnosed with
o If in doubt, the case may be referred to a bacteriologically-confirmed or clinically-
clinician/specialist within the area or to a TB Diagnostic diagnosed TB.
Committee (TBDC) as long as the recommendation
A patient who has been previously treated
could be made within two (2) weeks.
for TB and whose treatment failed at the
 Tuberculin skin test (TST)
end of their most recent course. This
o shall not be used as the sole basis for TB diagnosis
includes:
Retreatment

o shall be used as a screening tool for children.

 A patient whose sputum smear or culture
o A 10mm induration is considered a positive TST Treatment
is positive at 5 months or later during
reaction. After
treatment
o Only trained health worker shall do the testing and Failure
 A clinically diagnosed patient (e.g. child
reading.
or EPTB) for whom sputum examination
cannot be done and who does not show
CASE HOLDING
clinical improvement anytime during
 Is the set of procedures which ensures that patients complete
treatment.
their treatment
A patient who was previously treated for
 While effective anti-TB drugs are available in the country, there
Treatment TB but was lost to follow-up for two-
are still many TB patients who are not cured because they stop
After Lost months or more in their most recent
taking anti-TB drugs or take them irregularly
to Follow- course of treatment and is currently
o This may lead to chronic infectious illness, drug
Up (TALF) diagnosed with either bacteriologically-
resistance, or death.
confirmed or clinically-diagnosed TB.
o The best way to prevent the occurrence of these events
Previous Patients who have been previously treated
is through the regular intake of appropriate drugs for the
Treatment for TB but whose outcome after their most
prescribed duration.
Outcome recent course of treatment is unknown or
 Case holding involves assignment of the appropriate treatment
Unknown undocumented.
regimen based on diagnosis and previous history of treatment,
(PTOU)
supervised drug intake with support to patients, and
monitoring responses to treatment through follow-up sputum Patients who do not fit into any of the
Other
smear microscopy. categories listed above.

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 4 of 9

 NATIONAL TB CONTROL PRGRAM 1.9
POLICIES supply interruptions to ensure the continuity of treatment
within their area of jurisdiction.
1. All diagnosed TB cases shall be provided with adequate and 7. Quality of FDCs must be ensured. FDCs must be ordered
appropriate anti-TB treatment regimen promptly. from a source with a track record of producing FDCs
2. Anti-TB treatment shall be done through a patient- according to WHO-prescribed strength and standard of
centered, directly observed treatment (DOT) to foster quality.
adherence. DOT should be carried out in facilities that are 8. Out-patient treatment shall be the preferred mode of
most accessible and acceptable to the patient. Exert all efforts care. However, patients with life-threatening conditions
to decentralize DR-TB patients as soon as possible to a shall be recommended for hospitalization.
treatment facility most accessible to the patient 9. A TB patient diagnosed during confinement in a
3. Anti-TB treatment regimen shall be based on hospital may start treatment using NTP drug supply
anatomical site, bacteriologic confirmation and history upon the approval of the hospital TB team. Once
of prior treatment. Except in cases of adverse drug discharged, the patient shall be referred by the hospital TB
reactions and special circumstances requiring treatment team to a DOTS facility for registration and continuation of
modifications, TB treatment under the NTP shall conform to the assigned standard treatment regimen.
standardized regimens specified in the table below. 10. Treatment response of PTB patients shall be monitored
by follow-up of DSSM results and clinical signs and
Category Classification and Treatment symptoms. All ADRs, whether minor or major, shall be
of Tx Registration Group Regimen reported based on the official reporting form of the FDA.
 Pulmonary TB, new 11. Tracking mechanism for lost to follow-up patients
(whether shall be put in place to ensure that patients who fail to
bacteriologically follow-up as scheduled are immediately traced.
confirmed or 12. Appropriate infection control measures shall be
clinically diagnosed) observed at all times based on “Guidelines on Infection
Category  Extra-pulmonary TB, 2HRZE/ Control for TB and Other Airborne Infectious Diseases”.
I new (whether 4HR 13. All registered TB patients in Category A and B sites,
bacteriologically shall be offered Provider-initiated HIV Counselling and
confirmed or Testing (PICT).
clinically diagnosed) Category A and B sites are areas for prioritization based on
except CNS/ bones the number of reported cases, HIV prevalence, Most At Risk
or joints) Population (MARP) size, results of the Rapid Assessment of
Category EPTB, new (CNS*/ 2HRZE/ HIV vulnerability and presence of multiple risks as
Ia bones or joints) 10HR categorized by the Philippine National AIDS Council.
14. All confirmed drug resistant TB cases shall be offered
Pulmonary or extra- PICT.
pulmonary, Previously
treated drug- DRUG DOSAGE PER Kg BODY WEIGHT
susceptible TB *if using single dose formulation (SDFs)
(whether DRUG ADULTS CHILDREN
bacteriologically- 5 (4 – 6) mg/kg, 10 (10-15) mg/kg,
confirmed or clinically Isoniazid (H) not to exceed not to exceed
2HRZES/
Category diagnosed) 400mg daily 300mg daily
1HRZE/
II  Relapse
5HRE 10 (8 – 12)
 Treatment After 15 (10-20) mg/kg,
mg/kg,
Failure Rifampicin (R) not to exceed
not to exceed
 Treatment After Lost 600mg daily
600mg daily
to Follow-up (TALF)
25 (20 – 30)
 Previous Treatment 35 (30-40) mg/kg,
Pyrazinamide mg/kg,
Outcome Unknown not to exceed 2g
(Z) not to exceed 2g
 Other daily
daily
Extra-pulmonary,
15 (15 – 20)
Previously treated 20 (15-25) mg/kg,
mg/kg,
drug-susceptible TB Ethambutol (E) not to exceed 1.2g
2HRZES/ not to exceed 1.2g
Category (whether daily
1HRZE/ daily
IIa bacteriologically-
9HRE 15 (12 – 18)
confirmed or clinically 30 (20-40) mg/kg,
Streptomycin mg/kg,
diagnosed – CNS/bones not to exceed 1g
(S) not to exceed 1g
or joints) daily
daily
Standard  Individualized Note: Dosage for children are higher since there are more
Regimen Rifampicin-resistant TB once DST result is metabolizing enzymes among children than adults leading to
Drug or Multidrug-resistant available. faster metabolism.
Resistant TB  Tx duration for at
(SRDR) least 18 months MONITORING RESPONSE TO TREATMENT
 Treatment response of PTB patients shall be monitored by
Individualized follow-up DSSM (i.e. one specimen for each instance)
based on DST according to the standard schedule below.
XDR TB Extensively Drug-
result and history
Regimen resistant TB
of previous Schedule of Follow-up DSSM for Category I Px
treatment

4. All retreatment patients should be referred to a PMDT

treatment facility for MDR-TB screening before
initiating Category II treatment regimen. Initiating
Category 2 treatment regimen without MDR-TB screening
can only be done in areas where access to PMDT services is
not possible.
5. A patient’s anti-TB regimen shall be comprised of at least
4 first-line drugs in fixed-dose combination (FDC) –
except in children unable to take tablet formulations.
6. The national and local government units shall ensure
provision of drugs to all TB cases. LGUs should allocate
funds for drugs and supplies in the event of unforeseen

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 5 of 9

 NATIONAL TB CONTROL PRGRAM 1.9
Schedule of Follow-up DSSM for Category II Px Give aspirin or NSAID.
If symptoms persist,
consider gout and
Arthralgia due to
Z request for blood
hyperuricemia
chemistry (uric acid
determination) and
manage accordingly.
Flu-like symptoms
(fever, muscle
R Give antipyretics.
pains, inflam of the
respiratory tract)
 For new cases on Category I, follow-up DSSM shall be done at MAJOR
the end of the intensive phase, at the end of the 5th month, Severe skin rash Any kind of Discontinue anti-TB
and at the end of treatment. due to drugs (esp. drugs and refer to
a. If sputum positive at the end of the intensive phase, hypersensitivity S) appropriate specialist.
proceed to the continuation phase but repeat DSSM at
Discontinue anti-TB
the end of the 3rd month.
Any kind of drugs and refer to
1. If still smear-positive at the end of the 3rd month,
Jaundice due to drugs appropriate specialist.
refer to a DOTS facility with PMDT services for
hepatitis (esp.H/R/Z If symptoms subside,
screening or to an Xpert MTB/RIF site for testing.
) resume treatment and
Continue treatment while waiting for PMDT
monitor clinically.
recommendations or Xpert MTB/RIF result.
Impairment of
2. If smear-negative at the end of the 3rd month, Discontinue E and
visual acuity and
repeat DSSM at the end of the 5th month. If smear- E refer to an
color vision due to
negative at the end of intensive phase, repeat ophthalmologist.
optic neuritis
DSSM at the end of the 5th month. (Note: For
Hearing
clinically-diagnosed new patients, no need to repeat
impairment,
DSSM follow-up at the 5th month and end of
ringing of the ear, Discontinue S and
treatment if already smear-negative at end of
and dizziness due S refer to appropriate
intensive phase)
to damage of the specialist.
b. If smear-positive at the end of the 5th month, classify
eighth cranial
outcome as treatment failed and refer to a DOTS facility
nerve
with PMDT services for screening or to an Xpert MTB/RIF
site for testing. Oliguria or Discontinue anti-TB
S/R
If sputum-negative at 5th month, repeat DSSM at the albuminuria due to drugs and refer to
end of treatment. renal disorder appropriate specialist.
c. If smear-positive at the end of treatment, classify Discontinue H and
Psychosis and
outcome as treatment failed and refer to a DOTS Facility H refer to appropriate
convulsion
with PMDT services for screening or to an Xpert MTB/RIF specialist.
site for testing. Discontinue anti-TB
Thrombocytopenia,
If sputum-negative at the end of treatment, classify R drugs and refer to
anemia, shock
outcome as cured or treatment completed appropriate specialist
 For retreatment cases on Category II, follow-up DSSM shall be
done at the end of the intensive phase, at the end of the 5th MANAGEMENT OF CASES WHO INTERRUPTED TREATMENT
month, and at the end of treatment. 1. Patients who fail to follow-up as scheduled should be
a. If smear-positive at the end of the intensive phase, refer immediately traced through: telephone call, text message
to a DOTS facility with PMDT services for screening. or home/workplace visit. Assess the cause of interruption
Start continuation phase while waiting for PMDT and agree on solutions.
recommendations. 2. If patient interrupted treatment for <1 month, continue
If sputum-negative at the end of the intensive phase, the treatment and prolong it to compensate for missed doses.
repeat DSSM at the end of the 5th month. 3. If patient interrupted treatment for >1 month but <2
b. If smear-positive at the end of the 5th month, classify months, do the following:
outcome as treatment failed and refer to a DOTS facility a. Repeat the DSSM.
with PMDT services for screening. b. If the DSSM is negative, continue the treatment and
If smear-negative at 5th month, repeat DSSM at the end prolong it to compensate for missed doses.
of treatment. c. If the DSSM is positive, check how long the patient
c. If smear-positive at the end of treatment, classify has been treated.
outcome as treatment failed and refer to a DOTS facility i. If treatment received is <5 months, continue
with PMDT services for screening or to an Xpert MTB/RIF treatment and prolong it to compensate for missed
site for testing. doses.
If smear-negative at the end of treatment, classify ii. If treatment received is >5 months, close the
outcome as cured or treatment completed. treatment card, classify the patient as having a
 For EPTB patients and patients where DSSM was not done, treatment outcome of “Treatment Failed” and refer
treatment response will be assessed clinically (e.g., weight the patient to a PMDT Treatment Facility for DR
gain, resolution of symptoms). screening.
4. If patient interrupted treatment for >2 months, classify as
MANAGEMENT OF ADVERSE REACTIONS TO ANTI-TB having a treatment outcome of “Lost to Follow-up”. Close the
DRUGS previous registration, repeat DSSM and follow the case-
 MINOR ADR DRUG MANAGEMENT finding policies and procedures.
MINOR
Gastro-intestinal Give drugs at bedtime TREATMENT MODIFICATIONS FOR SPECIAL SITUATIONS
H/R/Z 1. PREGNANCY
intolerance or with small meals.
Mild or localized Any kind of  Ascertain whether or not a woman is pregnant before she
Give anti-histamines. starts TB treatment.
skin reactions drugs
Orange / red  Most anti-tuberculosis drugs are safe for pregnant women,
R Reassure the patient. except streptomycin, which is ototoxic to the fetus.
colored urine
 Advise a pregnant woman that successful treatment of TB
Apply warm compress.
Pain at the with the recommended standardized treatment regimen
Z Rotate sites of
injection site (i.e., 2HRZE/4HR) is important for a successful outcome
injection.
of pregnancy.
Give Pyridoxine
Burning sensation  Pregnant women taking isoniazid should be given
(Vitamin B6):50-100
in the feet due to pyridoxine (Vitamin B6) at 25mg/day.
H mg daily for
peripheral
treatment10 mg daily
neuropathy
for prevention.

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 6 of 9

 NATIONAL TB CONTROL PRGRAM
2. BREASTFEEDING
 A breastfeeding woman afflicted with TB should receive a
full course of TB treatment.
 Timely and properly applied chemotherapy is the
best way to prevent transmission of tubercle bacilli to the
baby.
 In lactating mothers on treatment, most anti-tuberculosis
drugs will be found in the breast milk in concentrations
that would equal only in small fraction of the therapeutic
dose used in infants.
 However, any effects on infants of such exposure have not
been established. If resources are available, provide infant
formula. If it is not possible, it is recommended that
lactating mothers feed their infants before taking
medications.
o To further protect against infection, give a baby with
no signs and symptoms prophylactic isoniazid for
at least 3 months then perform Tuberculin Skin
Testing (TST).
o If the TST is negative, stop the IPT. If the TST is
positive and the baby remains well, continue IPT for
another 3 months. Defer BCG vaccination of the
newborn until the end of isoniazid prophylaxis.
o Supplemental pyridoxine should be given to the
infant who is taking INH or whose breastfeeding
mother is taking INH.
3. ORAL CONTRACEPTIVES
 Rifampicin interacts with oral contraceptive
medications with a risk of decreased protective efficacy
against pregnancy.
 Advise a woman receiving oral contraceptives while on
rifampicin treatment that she has the following options:
a. Take an oral contraceptive pill containing a higher
dose of estrogen (50), following consultation with
a clinician
b. Use another form of contraception.
4. LIVER DISEASE OR HISTORY OF LIVER DISEASE
 H, R, Z are all associated with hepatitis. Of the three drugs
o Rifampicin is least likely to cause hepatocellular
damage, although it is associated with cholestatic
jaundice.
o Pyrazinamide is the most hepatotoxic.
 Treatment should be interrupted and, generally, a
modified or alternative regimen used for those with ALT
elevation more than 3x the upper limit of normal (ULN) in
the presence of hepatitis symptoms and/or jaundice, or 5x
the ULN in the absence of symptoms. Refer to appropriate
specialist if needed.
 Wait for the liver function tests to revert to normal
and clinical symptoms (e.g., nausea, abdominal
pain) to resolve before reintroducing the anti-TB
drugs.
 If it is not possible to perform liver function tests, it is
advisable to wait an extra 2 weeks after resolution of
jaundice and upper abdominal tenderness before
restarting TB treatment.
 Once drug-induced hepatitis has resolved, the drugs
are reintroduced one at a time, beginning with
rifampicin.
 After 3–7 days, isoniazid may be reintroduced.
 In patients who have experienced jaundice but tolerate
the reintroduction of rifampicin and isoniazid, it is
advisable to avoid pyrazinamide.
 If symptoms recur or liver function tests become abnormal
as the drugs are reintroduced, the last drug added should
be stopped.
 Patients with the following conditions can receive the usual
short course chemotherapy regimens provided there is no
clinical evidence of chronic liver disease:
o Hepatitis virus carriage
o Past history of acute hepatitis
o Excessive alcohol consumption.
5. ESTABLISHED CHRONIC LIVER DISEASE
 Patients with liver disease should not receive
pyrazinamide. Alternative regimens are 2SHRE/6HR,
9RE, or 2SHE/10HE.
6. ACUTE HEPATITIS (e.g., ACUTE VIRAL HEPATITIS)
 In some cases, it is possible to defer TB treatment until
the acute hepatitis has been resolved.
 When it is necessary to treat TB during acute hepatitis,
the safest options is the combination of SE for 3
Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS
1.9
months and, once the hepatitis has resolved, a
maintenance phase of 6 months isoniazid and
rifampicin (i.e., 3SE/6HR). If the hepatitis has not been
resolved, SE should be continued for a total of 12 months
(i.e., 12SE).
7. RENAL FAILURE
 HRZ are either eliminated almost entirely by biliary
excretion or metabolized into non-toxic compounds.
These drugs, therefore, can be given in normal dosages to
patients with renal failure.
 Patients with severe renal failure should receive H with Z
to prevent peripheral neuropathy.
 SE are excreted by the kidney. Where facilities are
available to monitor renal function closely, streptomycin
and ethambutol may be given in reduced doses.
DOSING RECOMMENDATIONS FOR PATIENTS WITH
REDUCED RENAL FUNCTION OR RECEIVING
HEMODIALYSIS
Recommended dose and
frequency for patients with
Change in
Drug creatinine clearance
frequency?
<30mL/min or for patients
receiving hemodialysis
300mg once daily; or 900mg three
H No change
times per week
600mg once daily; or 600mg three
R No change
times per week
25-35mg/kg per dose three times
Z Yes
per week (not daily)
15-25mg/kg per dose three times
E Yes
per week (not daily)
12-15mg/kg per dose two or three
S Yes
times per week
 Noting the above recommendations, it would therefore be
possible to give FDC-A (HRZE) three times per week and then
give FDC-B (HR) for the rest of the week during the intensive
phase.
 Continuation phase may proceed with 4HR. Otherwise, another
safe option is 2HRZ/4HR.
 It is recommended that anti-TB medications be taken after
hemodialysis.
8. TB/HIV CO-INFECTION
 In patients with HIV-related TB, the priority is to treat
TB, especially smear-positive PTB to stop
transmission.
 Patients with HIV-related TB can have Anti-
Retroviral Therapy (ART) and anti-TB treatment at
the same time, if managed carefully.
 For a patient with a high risk of death during the period
of TB treatment (i.e. disseminated TB and/or CD4count
<200/mm3), it may be necessary to start ART
concomitantly with TB treatment.
 For a patient with smear-positive PTB as the first
manifestation of HIV infection, who does not appear to
be at risk of dying, it may be safer to defer ART until
the initial phase of TB treatment has been completed.
o This decreases the risk of immune reconstitution
syndrome and avoids the risk of drug interaction
between R and a protease inhibitor (PI). Possible
options include the following:
a. Defer ART until completion of TB treatment.
b. Defer ART until the completion of the initial phase
of TB treatment and then useE and H in the
continuation phase.
c. Treat TB with a Rifampicin-containing regimen
and use efavirenz + two Nucleoside Reverse
Transcriptase Inhibitors (NsRTIs).
 Patients with TB/HIV co-infection should also receive
co-trimoxazole as prophylaxis for other infections.
 Persons with HIV infection who, after careful evaluation,
do not have active tuberculosis should be treated for
presumed latent tuberculosis infection with H for 6
months.
Page 7 of 9
 NATIONAL TB CONTROL PRGRAM 1.9

TREATMENT OUTCOMES
1. Determine the treatment outcome of patients based on
completion of treatment regimen, DSSM follow-up results
and clinical improvement or lack of clinical deterioration.
2. Record the treatment outcome in the NTP Treatment Card
and the TB Register.
3. Using the completely filled-out NTP ID Card, issue a
Certificate of Treatment Completion/Cure as a form of
recognition for the patient’s achievement.

TREATMENT OUTCOMES FOR DRUG-SUSCEPTIBLE TB

CASES
OUTCOME DEFINITION
A patient who was bacteriologically-confirmed
to have TB at the beginning of treatment and
who was smear- or culture-negative in the last
Cured month of treatment and on at least 1 previous
occasion in the continuation phase.

A patient who completes treatment without

evidence of failure but with no record to show
that sputum smear or culture results in the last
month of treatment and on at least one
previous occasion were negative, either
because tests were not done or because results
are unavailable
Treatment
completed This group includes:
 A bacteriologically-confirmed patient who
has completed treatment but without
DSSM follow-up in the last month of
treatment and on at least one previous
occasion
 A clinically diagnosed patient who has
completed treatment
A patient whose sputum smear or culture is
positive at 5 months or later during treatment.
OR
Treatment
A clinically-diagnosed patient (child or EPTB)
failed
for whom sputum examination cannot be done
and who does not show clinical improvement
anytime during treatment
A patient who dies for any reason during the
Died
course of treatment.
Lost to A patient whose treatment was interrupted for
follow-up ≥2 consecutive months.
A patient for whom no treatment outcome is
Not assigned. This includes cases transferred to
Evaluated another DOTS facility and whose treatment
outcome is unknown.

PREVENTION OF TB
Specific measures and work practices
TB Infection
that reduce the likelihood of spreading
Control (TB IC)
the TB bacteria to others.
Measures that will reduce risk of TB
transmission by preventing the
Administrative generation of droplet nuclei or reducing
control exposure to droplet nuclei. This type of
control has the greatest impact on
preventing the spread of TB.
Measures that will reduce the
Environmental concentration of infectious droplets in
control the air especially in areas where
contamination of air is likely.
Respiratory Measures that involve selection and
protection proper use of respirators to protect one
controls from inhaling droplet nuclei.
A special type of closely-fitted mask with
the capacity to filter particles to protect
Respirator
users from inhaling infectious droplet
nuclei.
Essential separate set of measures to
facilitate the smooth implementation of
Managerial
the three (3) components of TB IC:
activities
administrative, environmental and
respiratory protection controls.

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 8 of 9

 NATIONAL TB CONTROL PRGRAM 1.9

CASES

PROCEDURE OF TB PROCEDURE ON
CASE MANAGEMENT
DIAGNOSIS CLASSIFICATION FOLLOW-UP
Presumptive TB
DSSM
1. A 25-year-old male comes to your clinic with 3 weeks history of productive 2nd-5th-6th month
CXRAY If (+) PTB in DSSM: 2HRZE/2HR
cough, given 2 courses of antibiotics by another doctor without improvement. DSSM
CATEGORY I
New case
2. 35-year-old female diagnosed to have PTB in 2012 (in Samar), who improved DSSM CATEGORY II
3rd-5th-8th month
symptoms and stopped medications after 3 months. She is now residing in CXRAY After lost to follow- 2HRZES/1HRZE/4HRE
DSSM
Manila. up
3. 60-year-old female diagnosed to have PTB in 2010, completed the treatment of DSSM
CATEGORY II 3rd-5th-8th month
6 months, presently having symptoms of fever, cough, and back pain of one CXRAY 2HRZES/1HRZE/4HRE
Relapse DSSM
month duration.
4. 60-year-old female diagnosed to have PTB in 2014, completed treatment of 6 DSSM
CATEGORY II 3rd-5th-8th month
months. She is now complaining again of afternoon fever, productive cough, and CXRAY 2HRZES/1HRZE/4HRE
Relapse DSSM
hemoptysis.
5. 45-year-old female diagnosed to have PTB in 1996, completed the treatment of DSSM
CATEGORY II 3rd-5th-8th month
6 months, presently complaining of draining pus, non-healing wound, on the CXRAY 2HRZES/1HRZE/5HRE
Extrapulmonary TB DSSM
lateral side of the neck.
DSSM
2HRZE/4HR
6. 23-year-old male call center agent is on his second month of TB treatment. CXRAY
CATEGORY I 2nd-5th-6th month
However, he is still complaining of fever and cough, and a mass was noted on XPERT MTB/RIF
Extrapulmonary TB Start or defer ART depending on DSSM
the right side of his neck. ASSAY
HIV status of px
HIV-TEST
Presumptive TB
2HRZE/4HR
DSSM
7. 25-year-old G2P1. AOG: 34-35 weeks consulted because of one month duration If (+) PTB in DSSM: 2nd-5th-6th month
CXRAY *Take Vit B6 at 25mg/day
of productive cough and afternoon fever. CATEGORY I DSSM
*Streptomycin is
New case
contraindicated

Transcribers: BLANCO, CAHANDING, CINCO ♥ FARILLAS, SOLIS Page 9 of 9