COLLEGE OF NURSING Silliman University Dumaguete City

Resource Unit on National Tuberculosis Control Program

Submitted by: Almero, Kyle L. Section: NCM 104 - G2 Submitted to: Asst. Prof. Lourdes L. Oliva Date: June 22, 2009

VISION:
A leading Christian institution committed to total human development for the well-being of society and environment.

MISSION:
In this regard, the University Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ. Provide an environment where Christian fellowship and relationship can be nurtured and promoted. Provide opportunities for growth and excellence in every dimension of the university life in order to strengthen character, competence and faith. Instill in all members of the university community an enlightened social consciousness and a deep sense of justice and compassion. Promote unity among peoples and contribute to national development.

COLLEGE OF NURSING Silliman University Dumaguete City

Resource Unit: National Tuberculosis Control Program

Topic: National Tuberculosis Control Program Placement: Level IV, First Semester COPAR Rotation Time Allotment: 1 hour 30 minutes Topic Description: This topic deals on the National Tuberculosis Control Program which also covers the discussion of tuberculosis, its epidemiology, pathology, sign and symptoms, its mode of transmission, period of communicability, susceptibility and resistance, and methods of control. Furthermore, the NTP will be discussed in details including its definition, vision and mission, goals, and targets; the NTP objectives and strategies; its key policies; and the DOTS strategy. Central Objective: At the end of the 1 -hour teaching-learning activity, students of section G2 shall gain and broaden their knowledge on the National Tuberculosis Control Program, further enhance their skills, and develop a positive attitude and value towards the care of clients under the National Tuberculosis Control Program. Specific Objectives
At the end of the 1-hour teaching learning activity, the learners shall:

Content I. II. Prayer Introduction As of present time, we cannot get away with the fact that indeed, a lot of people especially those belonging to the third world countries are faced with problems such as tuberculosis. With this, it is still considered as the worlds deadliest disease and remains as a major public health problem in the Philippines. We are already aware that this is primarily a respiratory disease but can also affect other organs of the body and is common among malnourished individuals living in crowded areas. With the resurgence of TB in many parts of the world, it was then declared in the year 1993 as global emergency by

Evaluation

Specific Objectives
1. Describe correctly at a 75% efficiency the epidemiology of tuberculosis.

Content the World Health Organization. II. Tuberculosis A. Epidemiology TB is the most common infectious disease in the world today. To date, TB ranks seventh as a global cause of death, and, unless more focused attention is given to the control of the disease, it is likely to remain a major killer through the following years to come. It has been considered a fact that about one-third of the total human population is infected with tuberculosis. About 5 years ago, cases of tuberculosis already started to decline and became stable but to date, the rise in global incidence is slowing but it is unclear when the global incidence rate will begin to decline again. The number of new cases roughly correlates with economic conditions. Of the reported new TB cases, 80% lived in African, South-East Asia and Western Pacific regions with the lowest gross national products. In the Philippines, tuberculosis ranks 6th in the leading cause of morbidity (2002) and mortality (2002). The estimated incidence rate of all TB cases in the Philippines is 243 / 100,000 population/year as stated by WHO Report 2006. The country ranks ninth among the 22 high burdened countries under the WHO watchlist.

Evaluation

2. Determine the cause of tuberculosis.

B. Infectious Agents Mycobacterium tuberculosis and M. Africanum primarily from humans, and M. bovis primarily from cattle. Other mycobacteria occasionally produce disease clinically indistinguishable from tuberculosis; the etiologic agents can be identified only by culture of the organisms. About 10 years ago, there were 23 new strains of the TB bacilli found in the United States. Therefore, TB is no longer considered to be a disease of the past but of the present.

3. Enumerate at least 4 signs of symptoms of tuberculosis.

C. Signs and Symptoms According to Niedermen & Sarosi( 2000); and Small & Fujiwara (2001, as cited in Smeltzer & Bare, 2004), the signs and symptoms of pulmonary TB are insidious. Most patients have a low-grade fever, cough, night sweats, fatigue, and weight loss. The cough may be nonproductive, or mucopurulent sputum may be expectorated. Hemoptysis or recurrent blood-streaked sputum also may occur. Both the systemic and pulmonary symptoms are usually chronic and may have been present for weeks to months.

4. Identify correctly the mode of transmission of tuberculosis.

Specific Objectives D. Mode of Transmission

Content TB spreads from person to person by airborne transmission. An infected person releases droplet nuclei (generally particles 1 to 5 micrometers in diameter) through talking, coughing, sneezing, laughing, or singing. Larger droplets settle; smaller droplets remain suspended in the air and are inhaled by the susceptible person (Smeltzer & Bare, 2004). Also, direct invasion through mucous membranes or breaks in the skin may also occur. And lastly, with bovine tuberculosis, it can result from exposure to tuberculosis cattle, usually by ingestion of unpasteurized milk or dairy products. E. Period of Communicability Tuberculosis is communicable as long as viable tubercle bacilli are being discharged in the sputum. Some untreated or inadequately treated patients may be sputum-positive intermittently for years. The degree of communicability depends on the number of the bacilli discharged, the virulence of the bacilli, adequacy of ventilation, exposure of the bacilli to sun or UV light and opportunities for their aerosolization by coughing, sneezing, talking or singing. Effective antimicrobial chemotherapy usually reduces communicability to insignificant levels within days to a few weeks. Children with primary tuberculosis are generally not infectious (Cuevas, 2007). F. Susceptibility and Resistance The most hazardous period for development of clinical disease is the first 6-12 months after infection. The risk of developing disease is highest in children under 3 years old, lower in later childhood and high again among adolescents, young adults, and the very old. Reactivation of long latent infections account for a large proportion of cases of clinical disease in older persons. For those infected, susceptibility to disease is markedly increased in those with HIV infection and other forms of immunosuppression and also increased among underweight and undernourished persons with silicosis, diabetes or gastrectomies and among substance abusers (Reyala et. al, 2000). G. Methods of Control Preventive Measures Prompt diagnosis and treatment of infectious cases BCG vaccination of newborn, infants and grade I/school entrants Educate the public in mode of spread and methods of control and the importance of early diagnosis. Improve social conditions, which increase the risk of becoming infected, such as overcrowding. Make available medical, laboratory and x-ray facilities for examination of patients, contacts and suspects, and facilities for early treatment of cases and persons at high risk of infection and beds for

Evaluation

5. Appropriately identify the length of period of communicability of tuberculosis.

6. Compare and contrast the different methods of control on tuberculosis.

Specific Objectives

Content those needing hospitalization. Provide public health nursing and outreach services for home supervision of patients to supervise therapy directly and to arrange for examination and preventive treatment of contacts (Cuevas, 2007).

Evaluation

7. Correctly define the National Tuberculosis Control Program

III. National Tuberculosis Control Program A. Definition The National TB Program (NTP) is the Government's commitment to address the TB problem in the country. The NTP is being implemented nationwide in all government health centers and government hospitals. Its objectives are to detect active TB cases (at least 70%) and cure them (at least 85%). Achieving and sustaining targets will eventually result to the decline of the TB problem in the Philippines. B. Vision, Mission, Goals, and Targets Vision: A country where TB is no longer a public health problem Mission: Ensure that TB DOTS services are available, accessible, and affordable to the communities in collaboration with the LGUs and other partners Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millennium Development Goal) Targets: 1. Cure at least 85 per cent of the sputum smear-positive TB patient discovered 2. Detect at least 70 per cent of the estimated new sputum smear-positive TB cases

8. State correctly the vision, mission, goals, and targets of the NTP.

9. Compare and contrast the 4 objectives of NTP and each of their strategies.

C. NTP Objectives and Strategies The NTPs four-prolonged set of objectives calls for improvement of access to and quality of services, enhancement of stakeholders health-seeking behavior, sustainability of support for TB control activities, and strengthening management of TB control services at all levels. 1. Objective A and its strategies Objective A: Improve access to and quality of services provided to TB patients, TB symptomatics, and

Specific Objectives

Content communities by health care institutions and providers Strategies: a. Enhance quality of TB diagnosis. Adopt a quality assurance system for direct sputum smear examination, including external quality assurance. Establish more TB Diagnostic Committees and expand their functions to include TB in children Strengthen the network of quality laboratory services in accordance with National TB Reference Laboratory roles/functions. b. Ensure TB patients treatment compliance. Implement an efficient drug supply management system. Adopt directly observed treatment (DOT) through treatment partners. c. Ensure public and private health care providers adherence to the implementation of national standards of care for TB patients. Establish and sustain public-private mix DOTS, including the public-public mix DOTS. Expand hospital-based DOTS. Advocate for the widespread adoption of a comprehensive and unified policy on TB. d. Improve access to services through innovative service delivery mechanisms for patients living in challenging areas (geographically isolated communities, with peace and order problem, culturally different, and those in institutions like prisons). 2. Objective B and its strategies Objective B: Enhance the health-seeking behavior on TB by communities, especially the TB symptomatic

Evaluation

Specific Objectives

Content Strategies: a. Develop effective, appropriate, and culturally-responsive IEC/ communication materials. b. Organize barangay advocacy groups. 3. Objective C and its strategies Objective C: Increase and sustain support and financing for TB control activities Strategies: a. Facilitate implementation of TB-DOTS Center certification and accreditation. b. Build TB coalitions among different sectors. c. Advocate for counterpart input from local government units. d. Mobilize/extend other resources to address program limitations. 4. Objective D and its strategies Objective D: Strengthen management (technical and operational) of TB control services at all levels. Strategies: a. Enhance managerial capability of all NTP program managers at all levels. b. Establish an efficient data management system for both public and private sectors. c. Implement a standardized recording and reporting system. d. Conduct regular monitoring and evaluation at all levels. e. Advocate for political support through effective local governance. 5. Key Policies a. Case finding Direst Sputum Smear Microscopy (DSSM) shall be the primary diagnostic tool in NTP case finding. All TB symtomatics identified shall be asked to undergo DSSM for diagnosis before start of treatment, regardless of whether or not they have available X-ray results or whether or not they are suspected of having exta-pulmonary TB. The only contraindication for sputum collection is hemoptysis; in which case, DSSM will be requested after control of hemoptysis.

Evaluation

10. Correctly Indentify the methods for case finding and treatment used in NTP.

Specific Objectives

Content Pulmonary TB symptomatic shall be asked to undergo diagnostic tests (X-ray and culture), if necessary, only after they have undergone DSSM for diagnosis with three sputum specimens yielding negative results. Diagnosis based on x-ray shall be made by the TB Diagnostic Committee (TBDC). Since DSSM is the primary diagnostic tool no TB diagnosis shall be made based on the results of X-ray examinations alone. Likewise, results of the skin test for TB injection (PPD skin test) should not be used as bases for TB diagnosis in adults. Passive case finding shall be implemented in all health stations. Concomitant active case finding shall be encouraged only in areas where a cure rate of 85 per cent or higher has been achieved, or in areas where no sputum-smear positive case has been reported in the last three months. Only trained medical technologists or microscopists shall perform DSSM (smearing, fixing, and staining of sputum specimens, as well as reading, recording, and reporting of results). However, in far flung areas, BHWs may be allowed to do smearing and fixing of specimens, as long as they have been trained and are supervised by their respective NTP medical technologists/ microscopists. b. Treatment Aside from clinical findings, treatment of all TB cases shall be based on a reliable diagnostic technique namely, DSSM. Domiciliary treatment shall be preferred mode of care. c. Patients with the following conditions shall be recommended for hospitalization: 1. massive hemoptysis; 2. Pleural effusion obliterating more than one-half of a lung field; 3. Miliary TB; 4. TB meningitis; 5. TB Pneumonia; and 6. Those requiring surgical intervention or with complications.

Evaluation

Specific Objectives

Content d. All patients undergoing treatment shall be supervised (DOT). No patient shall initiate treatment unless the patient and DOTS facility staff shall have agreed upon a case holding mechanism for treatment compliance. e. The national and local government units shall ensure provision of drugs to all smear-positive TB cases. There are two formulations of anti-TB drugs: 1). Fixed-dose combination (FDCs)- Two or more first-line anti-TB drugs are combined in one tablet. There are 2-, 3-, or 4-drug fixed dose combinations. 2). Single drug formulation (SDF)- Each drug is prepared individually. IHN, Ethambutol, and pyrazinamide are in tablet form while Rifampicin is in capsule form. f. Quality of FDCs must be ensured. FDCs must be ordered from a source with a tract record of producing FDCs according to WHO-prescribed strength and standard of quality. g. Treatment shall be based on recommended category of treatment regimen RECOMMENDED CATEGORY OF TREATMENT REGIMEN Category I Type of TB patient New smear-positive PTB New smear-negative PTB with extensive parenchymal lesions on CXR as assessed by the TBDC, EPTB, and severe concomitant HIV disease Treatment failure Relapse Return after default Treatment Regimen Continuation Intensive Phase Phase

Evaluation

2HRZE

4 HR

II

2HRZES/1 HRZE

5HRE

Specific Objectives

Content Other New smear-negative PTB with minimal parenchymal lesions on CXR as assessed by the TBDC Chronic (still smear-positive after supervised re-treatment)

Evaluation

III

2HRZE

4 HR

IV

Refer to specialized facility or DOTS Plus Center Refer to Provincial/ City NTP coordinator

Dosage per Category of Treatment Regimen a. Fixed-Dose Formulation (FDC) The number of tablets of FDCs per patient will depend on the body weight. Hence, all patients must be weighed (using kilogram as a unit) before treatment is started. Treatment regimen for categories I & II: 2HRZE/ 4 HR (FDC) No. of tablets per day Intensive Phase (2 months) FDC-A (HRZE) 2 3 4 5 No. of tablets per day Continuation Phase (4 months) FDC-B (HR) 2 3 4 5

Body Weight (Kg) 30-37 38-54 55-70 > 70

Treatment regimen for Category II: 2HRZES/HRZE/ 4HRE (FDC) Intensive Phase Continuation Phase Body First two months Third month FDC-A E FDC-A FDC-A Weight (kg) Streptomycin (HRZE) 400mg (HRZE) (HRZE) 30-37 2 0.75 g 2 2 1 38-54 3 o.75 g 3 3 2 55-70 4 0.75 g 4 4 3

Specific Objectives >70 5

Content 0.75 g

Evaluation 5 5 3

b. Single Drug Formulation (SDF) Simply as one tablet of INH (100mg), PZA (500mg), and E (400 mg) each for the patient weighing more than 50 kg before treatment initiation. Modify rug dosage within acceptable limits according to patients body weight, particularly those weighing less than 30 kg at the time of diagnosis. Treatment Regimen for Categories I & II: 2HRZE/ 4 HR (SDF) No. of tablets per day No. of tablets per day Anti-TB Drugs Intensive Phase Continuation Phase (2 months) (4 months) Isoniazid (H) 1 1 Rifampicin (R) 1 1 Pyrazinamide (Z) 2 Ethambutol (E) 2 Treatment Regimen for Category II: 2HRZES/ 1HRZE/ 5 HRE No. of tablets/ vial per day Intensive Phase (3 moths) Anti-TB Drugs First 2 months 3rd month Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) * 56 vials for two months 1 1 2 2 1 vial/day* 1 1 2 2

No. of tablets per day Continuation Phase (5 months 1 1 2

Specific Objectives Drug Dosage per Kg Body Weight

11. Define correctly the DOTS strategy

Content

Evaluation

Drug Isoniazid Rifampicin Pyrazinamide Ethambutol Streptomycin 6. DOTS Strategy

Dosage per kg body weight and maximum dose 5 (4-6) mg/kg, and not to exceed 400mg daily 10 (8-12) mg/kg, and not to exceed 600 mg daily 25 (20-30) mg/kg, and not to exceed 2 g daily 15 (15-20) mg/kg, and not to exceed 1.2g daily 15 (12-18) mg/kg, and not to exceed 1g daily

12. Enumerate correctly at least 4 out of 5 elements of DOTS strategy

a. Definition Directly observed therapy for tuberculosis is the practice of health care personnel observing or assisting clients as they take their prescribed medications for six months, or until a cure is achieved. In addition, it allows health care personnel to provide immediate information and support to clients who require it (Black, J. &, Hawks, J.,2005). b. Five Elements of DOTS Strategy

14. Discuss appropriately each of the public health nursing responsibilities.

1. Political commitment to effective TB control. 2. Case detection by sputum smear microscopy among symptomatic people. 3. Standardized treatment regimen of 6-8 months with first-line anti-TB drugs, administered under proper case management conditions, including direct observation for the first two months. 4. Uninterrupted supply of all essential anti-TB drugs. 5. Standardized recording and reporting system, allowing monitoring and evaluation of treatment results. c. Public Health Nursing Responsibilities 1. Together with other NTP staff/workers, manage the procedures for case finding activities. 2. Assign and supervise a treatment partner for patient who will undergo DOTS. 3. Supervise rural health midwives (RHMs) to ensure proper implementation of DOTS. 4. Maintain and update the TB Register. 5. Facilitate requisition and distribution of rugs and other NTP supplies.

Specific Objectives

Content 6. Provide continuous health education to all TB patients placed under treatment and encourage family and community participation in TB control. 7. In coordination with the physician, conduct training of health workers. 8. Prepare, analyze, and submit the quarterly reports to the Provincial Health Office or City Health Office (Cuevas, 2007). IV. Open Forum V. Evaluation Quiz: 1. What are the agents that cause tuberculosis? 2. Enumerate at least 4 signs and symptoms of tuberculosis. 3. What is the length of period of communicability of TB? 4. How is TB transmitted to other susceptible people? 5. How can TB be prevented? 6. Define the NTP program of the DOH. 7. What are the mission, vision, and goal of the NTP? 8. Identify the methods for case finding and treatment used in NTP. 9. Discuss the DOTS strategy. 10. What are the public health nursing responsibilities regarding the NTP?

Evaluation

Quiz at 75% level of competency

References: BOOK SOURCES: Black, J & Hawks, J. (2005). Medical-surgical nursing:Clinical management for positive outcomes.( 7th ed). Philippines: Elsevier. Cuevas, F. (Ed.).(2007). Public health nursing in the Philippines. (10th ed.). Philippines: National League of Philippine Government Nurses. Reyala, J. et al. (2000). Community health nursing services in the Department of Health Philippines . (9th ed.). Philippines: National League of Philippine Government Nurses. Smeltzer, S & Bare, B.(Ed.). (2004). Brunner & Suddarths textbook of medical-surgical nursing. (10th ed). Philippines: Lippincott Williams & Wilkins. Williams, G. (2008). TB guidelines for nurses in the care and control of tuberculosis and multi drug-resistant tuberculosis. (2nd ed.). Geneva, Switzerland: International Council of Nurses. INTERNET SOURCE: http://www.doh.gov.ph/programs/tb