operational guidelines - wpro
TRANSCRIPT
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Operational Guidelines
for the
Korea Foundation for International Healthcare
(KOFIH) Project
In
Palawan Province and Puerto Princesa City
May 2012
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ACKNOWLEDGEMENTS We would like to acknowledge the following for their support in the development of this operational guidelines and to the DetecTB Project: Infectious Disease Office of the Department of Health, Philippines:
Mario S. Baquilod, MD, MPH Rosalind R. Vianzon , MD, MPH Anna Marie Celina G. Garfin, MD, MPH
National TB Reference Laboratory: Remigio M. Olveda, MD, CESO III Noel G. Macalalad, MD, FPCP, FPSMID Ma. Cecilia G. Ama, MD
Center for Health Development 4B:
Gloria J. Balboa, MD, MPH, MHA, CEO VI, CESO III Emerose Moreno, MD, MPH
Palawan Provincial Health Office:
Louie R. Ocampo, MD, DFP, MPH Eduardo P. Cruz, MD, MPH Pamela L. Garcia, RN, MPA, MAN Cyrus Cecilio A. Caabay, RMT Herminio C. Bitara, Jr.
Puerto Princesa City Health Office: Juancho V. Monserate, MD, MMHA Janeth C. Reston, MD Dean L. Palanca, MD Mary Joy C. Tianchon, RN Jocelyn L. Calalin, RMT Walter P. Gonzales
Korean Institute of Tuberculosis
Hee Jin Kim, MD Sang Jae Kim, PhD Chang Ki Kim, MD Kyung Hyun Oh, MD Sung Won Choi
Korean Foundation for International Healthcare:
Hyun Kyong Kim, MPH Chan Hee Kim, MSc.
World Health Organization, STB-WR/PHL Woo Jin Lew, MD, MSc, PhD
Francisco T. Ogsimer, Jr., MD, MPH Lennie Madeleine A. Oriondo
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Table of Contents 1. Definition of Terms
2. Introduction
3. Objectives
4. Approach of DetecTB Project
5. Expected Outcome
6. Roles and Responsibilities of Collaborating Agencies
7. Steering and Technical Committees
8. Organizational Structure
9. Project Time Frame and Setting
10. Outline of Activities
11. Flow of Case Finding Activities
12. Diagnostic Protocols
Current Diagnostic Protocol of the NTP
DetecTB Diagnostic Procedures
Diagnosis of TB
13. Referral of Identified Cases
14. Recording and Reporting
15. Project Monitoring and Evaluation
16. Future Steps
Annexes
DetecTB Recording and Reporting Forms
Baseline Data Collection
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Definition of Terms
1. *TB suspect- person who has signs and symptoms of TB such as cough, productive or non-productive of sputum, fever, weight loss, chest/back pain, hemoptysis, dyspnea, night sweats, and/or has exposure to a known TB case and/or has previous TB disease and treatment with anti-TB drugs; and/or, has Chest X-Ray findings of lesion/s suggestive of Tuberculosis
2. *Exposure- a condition where a person has close contact with a known TB case
in any one of the following places: house, workplace, school, community, confined institutions such as prison, home for the elderly, orphanage, and others (Project Definition)
3. DOTS facility- facility that provides treatment with anti-TB drugs applying the
Directly Observed Treatment Strategy (DOTS). This may be an RHU, PPMD, hospital and others.
4. Rural Health Unit (RHU)- a facility under the Municipality that provides health
services including DOTS
5. Public-Private Mix DOTS (PPMD)- a privately or publicly initiated facility that provides DOTS services
6. MDR-TB- a condition which is resistant to both Rifampicin and Isoniazid
7. MDR-TB Treatment Center- a facility that provides treatment through Directly
Observed Treatment to cases diagnosed as MDR-TB
8. Passive Case Finding- finding TB cases among TB symptomatics who present themselves in a DOTS facility
9. Active Case Finding- a health workers purposive effort to find TB cases (among
TB symptomatics in the community) who do not consult with personnel in a DOTS facility
10. *Intensified Passive Case Finding - finding of TB cases through screening of all
person regardless of signs and symptoms for TB among those who come purposively in a DOTS facility
11. *Intensified Active Case Finding – active case finding mainly focus on high risk
and vulnerable population
12. Marginalized sector- a section of the society or group of people who have been ignored, diminished importance and have been excluded from decision making, power and influence. This includes in the Philippines, indigenous peoples and urban and rural poor who have also decreased access to health services due to financial constraints and discrimination.
13. High risk and vulnerable population- group of people who have the potential to develop TB disease after exposure to a TB case due to the nature of their health, lifestyle, and living condition (e.g., indigenous people, people living in congested or crowded community).
14. *Initial Defaulter- diagnosed TB case that was not included for treatment in a
DOTS facility or treatment center due to failure of the case to be subjected for treatment
15. Treatment Success Rate- combination of rates of new smear positives that are
declared cured and treatment completed * Definition applies only for KOFIH Project’s use
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Note: Several definitions have been derived from the Manual of Procedures (MOP) for the National Tuberculosis Control Program of the Philippines 4th Edition 2005. Other terms not found in the MOP are for the project’s purpose and does not intend to contradict any definitions stated in the current Philippine NTP guidelines. The intended users of this Manual of Procedures are the health workers who will implement the DetecTB Project in selected areas of the Philippines, as agreed upon by the Department of Health, World Health Organization and Korea Foundation for International Healthcare (KOFIH) as the donor agency. This manual has no intention of creating confusions among health workers of non-project sites with regards to program protocol and definitions indicated in the current Manual of Procedures (MOP) of the Philippine National Tuberculosis Control Program.
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I. Introduction
The effectiveness of control programs of communicable diseases can be measured by the reduction in morbidity and mortality of the disease. In Tuberculosis, the main sources of infection are those with pulmonary manifestations who cough out TB bacilli in the environment. Cutting transmission of tuberculosis can be achieved by early detection of active cases and stopping infectiousness with appropriate chemotherapy.
In the Philippines, the current diagnostic procedure1 being followed is passive and
active case finding. Passive case finding are for patients having signs and symptoms of TB who come purposively to the health facilities for consultation while active case finding is done among household contacts of identified TB cases. The passive and active case finding approaches are limited only to subjects who are TB symptomatics defined as having cough of two weeks or more. The Korea Foundation for International Healthcare (KOFIH) in collaboration with NTP and NTRL of DOH, CHD4B, Palawan PHO, Puerto Princesa CHO, the Korean Institute of TB (KIT) and World Health Organization, will implement the DetecTB Project to gather and provide data and information on the different approaches in detecting TB. With the KOFIH DetecTB Project, several diagnostic procedures and algorithms for both passive and intensified case findings will be introduced. Case finding will not be limited to subjects having cough of two weeks or more but other signs and symptoms of TB as well. This will also include history of exposure to a TB case and previous treatment with anti-Tb drugs. The project will also employ active case finding in detecting TB cases among the marginalized sector and high risks and vulnerable groups. These include the urban and rural poor, indigenous population, prison inmates, high school students and teachers and congested population in the selected project sites. The project will be mainly focused on case finding, thus identified TB cases will be referred to Rural Health Units for new cases and MDRTB Treatment Center for Rifampicin resistant cases for treatment. Although the main focus is case finding, the project will also provide effort to ensure that cases reach the necessary facility for inclusion to the DOTS or MDR-TB program. The project’s approaches in case finding will utilize cost-effective, modern diagnostic procedures both for screening and confirming TB cases which is suitable for national TB programs in developing countries like the Philippines. Based on the Philippine Plan of Action to Control TB (PhilPACT), the national target was set at 85% case detection rate for all forms of TB and 90% treatment success rate. One of the challenges for TB control in this country is enhancing case detection not only for smear positives but also other types of TB. The project’s approaches are set to identify all forms of TB which can help the Philippine NTP achieve its target of 85%. Further improvement of CDR for all forms in selected project sites can be possible because of the intensified case finding (ICF) activities that will be conducted where TB cases might have been missed by the current diagnostic protocol. The project aims to increase the detection of TB in project sites through the following approaches; i) intensified passive case finding for clients 15 y/o and above, but not limited to the current TB symptomatics, who present themselves in selected RHUs using digital X-ray, LED-FM smear microscopy and Genexpert and ii) active case finding among all 15 year old and above in identified areas with marginalized sector, high risk and vulnerable population using the same diagnostic tools. Results of analysis and interpretation of data and information collected through the project will be presented to the Philippine NTP. Good practices and success stories will be properly documented to provide evidence of the project’s cost effectiveness.
1 Based on the latest NTP MOP, passive case finding is the suggested approach. During the development of this manual, revision of the MOP is currently in progress and this will include modifications to include active case finding among household contacts.
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Successful models of these approaches if proven to be effective can be replicated and may contribute to effective case finding in the local set-up.
II. Objectives General Objective: The main objective of the project is to increase case detection by improving accessibility to TB services in high risk populations such as people living in slum/poor or marginalized areas, indigenous peoples and prisoners, and by introducing higher sensitive diagnostic tools such as digital X-ray, Xpert MTB/RIF and LED-FM. Specific Objectives:
Pre-implementation phase: 1) To capacitate selected local health workers of Palawan Province and Puerto
Princesa City in the conduct of intensified case finding and use of modern diagnostic tools for detection of TB cases
2) To collaborate with relevant agencies in identifying high risk and vulnerable population where intensified case finding activities will be conducted
Implementation Phase: 3) To increase by 10 % or more the number of TB cases through the intensified
case finding approach 4) To make a TB diagnosis on the same day by utilizing digital radiography,
florescent microscopy and Xpert MTB/RIF 5) To refer all identified active PTB cases to the local NTP for appropriate
management 6) To compare the project case-finding strategy with current NTP case finding
strategy in terms of yield of cases detected and to provide sound data and evidence to the NTP.
III. Approach of DETECTB project
1. A team of local health workers from Palawan PHO and Puerto Princesa CHO will be identified and trained on the use of a mobile clinic equipped with diagnostic tools to be used for the intensified passive and active case finding. The team will also be trained on the maintenance of records and reports on the output and details of the monthly operations of the project.
2. The project will conduct collaborative activities with the DOH, CHD 4B, Palawan
Province, Puerto Princesa City, and other relevant agencies in identifying target population and organizing the proper flow of the case finding activities. All the activities of the mobile and project support teams will be properly coordinated with the partners and relevant agencies to establish a harmonious working relationship among each other. Major activities to be conducted are advocacy, health education and information dissemination in the selected project sites or target population. Health workers of projects of project sites will either be trained or oriented depending on the need.
Since the project will employ an intensified approach to case finding, proper authorities will be involved and necessary procedures should be followed and utilize to ensure that the desired number of targets subjects are acquired. The project will conduct all activities based on the prescribed guidelines set by the Philippine NTP.
3. The trained teams of Palawan Province and Puerto Princesa City will be mobilized
in the project sites identified by partners to conduct ICF activities for TB cases. They will utilize a mobile clinic equipped with digital X-ray, LED-FM microscope, and Genexpert, and if necessary, culture examination as diagnostic tools. The
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team may refer diagnostic procedures such as culture to the authorized agency if needed. The team will also follow a diagnostic protocol in identifying TB cases in accordance with the Philippine NTP guidelines.
4. All cases identified by the team will be referred to a TB DOTS facility most
accessible to the patient. Proper referral procedures will be followed to ensure that the patient reach the DOTS facilities for appropriate management.
5. Follow-up activities will be done by the project support team to the treatment
facilities for all the cases detected by the mobile team to ensure minimal default and high treatment success rate. The project will also provide the technical committee with results of treatment outcomes of cases identified through the mobile clinic.
IV. Expected Outcome
1) Increase the number of detected PTB cases by 10% or more after implementation of DetecTB project in the project sites (Indicator; No. of registered cases in the project sites from September 2012 to December 2013 / No. of registered cases in the project sites from September 2010 to December 2011).
2) Decrease diagnostic delay by making diagnosis of tuberculosis on the same day 3) Decrease initial default rate (IDR is the rate of TB cases who were not registered
for treatment in the TB DOTS clinic or PMDT treatment centers among diagnosed as TB cases by the mobile clinic) to 5% or less for the radiographically diagnosed and 0% for the bacteriologically2 confirmed.
4) Achieve the treatment success rate of registered new cases through DETECTB
project of 90% or more. This can be achieved through proper patients’ counseling and continuous health education.
Table 1. Major Project Indicators
2 Bacteriology refers to the smear status of pulmonary cases and the identification of M. tuberculosis for any case by culture or newer methods. (WHO Treatment of Tuberculosis Guidelines, fourth edition 2010)
Indicators Baseline Target
Case Finding No. Rate No. Rate
Case Notification Rate: New Smear (+) TB
Case Notification Rate: New Smear (-) TB
Case Notification Rate: Extrapulmonary TB
Case Notification Rate: All Forms of TB
Initial Default Rate
Treatment Outcome for New Smear (+) No. Rate No. Rate
Cure Rate
Treatment Completion Rate
Treatment Success Rate
Failure Rate
Death Rate
Default Rate
Tranferred Out Rate
The project does not intend to create different definitions and diagnostic procedures to the current national TB program. The intention of the DetecTB Project is to provide sound evidence to the Philippine NTP regarding the application of the term TB suspects as target population for NTP case finding and to test diagnostic algorithms that are cost-effective in detecting all forms of TB.
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V. Role and Responsibilities of Collaborating Agencies
1) NTP/NTRL/Department of Health
Supervise the overall implementation of the KOFIH project
Provide overall supervision regarding technical matters
Provide administrative support at the national level
Participate as member of the steering and technical committee
Monitor and evaluate the project implementation 2) Center for Health Development 4B
Implement and supervise the project implementation
Provide administrative support at the regional level
Regulate temporary transfer of mobile team (e.g., schedule and facilitation)
Co-manage the mobile unit transferred from KOFIH
Provide an office space for the project support team
Participate as member of the steering & technical committee
Collaborate / coordinate with the local government units and local health authorities regarding the project implementation
Participate in advocacy, training, and health education activities of health workers and the target community
Provide technical assistance in the development of IEC and other materials needed to mobilize the community
Participate in the preparation of ‘activity and budget plan’ 3) Palawan Province and Puerto Princesa City
Function as the main implementers of the project
Provide administrative support
Conduct biweekly-based operation of mobile team
Mobilize health workers and communities in the catchment area
Prepare schedule of mobile team – annual, monthly, and weekly bases
Participate as member of the technical & steering committee
Conduct advocacy, training, and health education activities to health workers and community
Participate in the development of leaflets, banners, posters and other materials needed to mobilize community
Assist in the preparation of ‘activity and budget plan’
Provide maintenance of mobile clinic during the project (i.e., together with Region 4B with support from KOFIH)
Maintain and submit records and reports of project’s output 4) BIHC
Participate as member of steering committee
Provide administrative support
Collaborate with all project partners 5) WHO Philippines Office
Oversee the implementation of the project
Hire and dispatch a project coordinator who will be part of the project support team
Supervise the project support team
Provide administrative support
Coordinate the project through the project support team
Manage transfer of budget from KOFIH
Participate as member of the steering and technical committee
Provide technical support including data collection and analysis 6) Project Support Team
Coordinate all activities related to the implementation of the project with KOFIH and all partners
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Provide technical support to the Provincial and City mobile teams
Provide financial and logistics support
Provide administrative support
Participate in planning and budget preparation activities
Organize technical and steering committee
Attend to meetings of the committees
Other unspecified services
7) KOFIH
Manage the project budget
Set up mobile unit: bus + digital X-ray + LED microscope + Genexpert
Participate as member of steering and technical committees
Monitor, supervise, and evaluate the implementation of the project 8) KIT
Provide technical support and advice including data analysis and other technical matters related to the project.
Participate as member of technical committee
VI. Steering and Technical Committees
Steering Committee
The Steering Committee will be composed of the higher level representatives. Meetings will be conducted on an annual or semi-annual basis depending on the need. The committee shall approve the budget, schedule of activities, and future decision regarding the need to extend the project, including coordination regarding issues and concerns that may arise during the project implementation. Members shall consist of representatives from KOFIH, NCDPC of the Philippines, BIHC, WHO, Region 4B, Palawan PHO, Puerto Princesa CHO, Local Chief Executives of Municipalities of Project Sites.
Technical Committee The committee will be composed of representatives from the DOH-NTP, NTRL, KOFIH, WHO, KIT, CHD 4B, Palawan PHO, and Puerto Princesa CHO. Meetings will be conducted on a quarterly basis which will be held in Region 4B or any place in Manila. The committee will review and analyze the quarterly reports, and provide technical supervision and administrative support to the project.
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VII. Organizational Structure
Figure 1. Organization structure of the DETECTB project
The project implementation team will be composed of Physician, Nurse, Medical Technologist, Radiology Technologist and Driver of the mobile unit. Two mobile teams will function for the project: one from Palawan PHO and another from Puerto Princesa CHO. The teams will be mobilized in the project sites to conduct case finding activities alternately and will be responsible for the daily operations of the mobile clinic. The Project Support team will be composed of the Medical Officer of the WHO-STB of WR-Philippines, Project Administrative Staff, Project Coordinator and the Assistant Project Coordinator. The last two will be hired by WHO, under the supervision of the WHO-STB Medical Officer. The project support team will be responsible to ensure the smooth flow of the mobile teams’ operations and provide, technical, financial, logistics, and administrative support to the mobile teams.
VIII. Project Time Frame and Setting Project duration for the first phase will be up to December 2013 with possible extension. Pilot project for the first phase will be implemented in region 4B (Palawan province and Puerto Princesa city) up to 2013. Seven municipalities will be covered for the province of Palawan which includes Aborlan, Narra, Espanola, Brooke’s Point, Bataraza and Rizal in the southern part and Taytay in the north. For the city of Puerto Princesa, nine barangays will comprise the project sites namely: Iwahig, Montible, Sta. Lucia, Inagawan, Bagong Silang, Pagkakaisa, Mabuhay, Tanabag and Concepcion. Extension of the project will be decided upon after the result of the evalution of the first phase of the project.
Steering Committee
Technical Committee
DOH / IDO / NTP
CHD 4B
KOFIH / KIT WHO
Project Support Team
Puerto Princesa CHO
Project Implementation Team of Palawan
Province
Project Implementation Team of Puerto Princesa City
Palawan PHO
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IX. Outline of Activities
1. Preparatory activities Initial discussion with the different level health offices and other relevant partners need to be done prior to the start of the project. This will help the project identify the needs and priorities of the partners.
2. Selection of target areas Meetings with partners will be conducted to help the project identify ideal target population and areas where the ICF will be implemented. The project will only select 6 municipalities from Palawan Province and 9 barangays from Puerto Princesa City. TB high risk and vulnerable population will be identified after discussion with partners.
3. Training of the mobile team and volunteers The identified team will be sent to Korea to undergo training on the use of the mobile clinic and maintenance and management of records and reports. They will also be trained on the protocol of the diagnostic procedure for case finding. The project coordinator will organize trainings and orientations of other health workers and volunteers who may assist in the operations of the mobile clinic.
4. Baseline data and information gathering Baseline data and information on the TB control program of selected municipalities of Palawan province and Puerto Princesa City will be collected and analyzed from NTP recording and reporting forms between September 2010 and December 2011. Identified agencies and point persons will be requested to participate in meetings to be called by the project coordinators to provide necessary data and information needed for the purpose. Collected data and information will be the basis of program monitoring and evaluation.
5. Launching and implementation of the project Heads and representatives of the different partner agencies will be invited to attend the launching of the mobile teams. The launching formally starts the implementation of the project. After the launching, the provincial and city teams will be mobilized to the project sites to conduct the ICF activities and perform recording and reporting of their routine activities.
6. Project implementation monitoring and evaluation Several project indicators will be used to monitor and evaluate the success of the project. DOH and CHD 4B will be requested to assist in the conduct of monitoring of project implementation based on the agreed frequency and schedule. Internal and external evaluation of the project will be done in cooperation with partners and other development agencies to be invited. Regular monitoring and evaluation will be conducted on a quarterly basis and PIR (Project Implementation Review) will be carried out every 6 months.
Table 2: Gantt chart for the project activities
Activity 2012 2013
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
1. Preparatory activities
2. Selection of target areas
3. Training of mobile team
4. Baseline data and information
gathering
5. Launching and
implementation
6. Project monitoring and
evaluation
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X. Flow of Case Finding Activities
Figure 2. Flow Diagram of Case Finding
All subjects aged 15 y/o and above will be interviewed by the nurse or designated assistant/s of the nurse using the DetecTB Screening Form (Form 1) designed for the purpose.
Exclusion from case finding:
Cases that have ongoing treatment with the National TB Program (either DOTS facility or PMDT treatment center/site)
MDR-TB suspects (especially treatment failures and defaulters. kindly explain and refer them to MDR-TB center/satellite/site. However previously cured cases and close contacts of MDR-TB cases should not be excluded from screening )
those who refuse to fill up the consent form
1. All information should be asked and recorded. If upon interview and the subject is identified as an rifampicin-resistant MDR-TB case, he/she should be advised to go the RHU for proper referral to the PMDT.
The upper portion of Form 1 will be filled up by the nurse while the middle portion is for the mobile team physician’s use. All subjects interviewed should be sent to the X-Ray room for the procedure. The Screening form (Form 1) should not be given to the patient after the interview. There is the possibility of missing a TB suspect identified through the interview if the TB suspect decides not to proceed with the X-ray. In case there are lost TB suspects identified through the interview, the local health workers should be informed for possible tracking of the subject. The Screening form should be brought to the X-Ray room by one of the mobile team members or a designated volunteer.
2. After all information has been recorded in Form 1, the subject is directed to the X-ray room. The Radiology Technician should check if all information in the upper portion is recorded. If not, he/she should ask the subject and fill up the blank space. The Radiology Technician then enters all the information in the Screening form into the DetecTB Screening Masterlist (Form 2). In case there are subjects identified as TB suspects through interview but did not proceed for Chest X-Ray, they should also be included in the Screening Masterlist (Form 2)
3. The Physician reads the Chest X-ray result on spot and reviews interview portion
(1) Interview of all subjects 15 years old and above (Output: Screening form)
(2) Chest X-ray (Output:
CXR result)
(3) Assessment of Subject for Laboratory Exam (Output: MD’s decision if subject needs to undergo Laboratory Exams)
(4) Laboratory Examinations (Output: Genexpert and Sputum Exam result)
(7) Refer Subject (Output: DetecTB
Referral form)
(6) Inform Result to Subject
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of the Screening form. He/She then writes the result of the Chest X-Ray in the middle portion of Form 1 and assesses the subject if he/she should be subjected to Genexpert and sputum microscopy. The Radiology Technician should make sure that all the information on the upper and middle portion of the Screening Form (Form 1) is logged in the Screening Masterlist (Form 2).
4. After the X-Ray Examination, all those identified as TB suspects will be subjected to Genexpert and sputum microscopy. The Rad Tech then brings the Screening form (Form 1) to the Medical Technologist and the patient is instructed to proceed to the Laboratory. There may be some clients who may decide not to proceed with the laboratory procedures thus, it is advised that the Rad Tech brings the Screening form to the Med Tech. In case there are lost TB suspects in this stage, the local health workers should be also be informed and advised to track these TB suspects that have been identified through interview and/or Chest X-Ray.
Sputum collection should be done with utmost precaution to prevent spread of infection. If the vicinity does not have a sputum induction area, the team should decide on where sputum collection can be done. In case a sputum induction area should be installed, the team should provide soap and clean water to ensure proper safety precautions for infection control. The Med/Lab Tech or his/her designate should properly instruct the subject on how to properly expectorate and the amount that should be collected.
Subjects should also be informed of the need to collect two specimens and the interval of one hour at least from the first collection to the second. After two specimens have been collected, the Med/Lab Tech should check whether the amount / quality of the two specimens are enough before accepting these. The Med/Lab Tech must put the specimen inside a refrigerator in case he/she can not perform smearing at once.
The Med Tech should determine the cut-off time for accepting specimens since there is an interval of at least one hour between the two specimens considering the mobile unit’s closing time.
Example: If the mobile unit closes at 4:00PM, it is advisable to make the cut-off time for the collection of the first specimen at 2:30pm. This will allow the second specimen for microscopy to be collected at 3:30pm providing time to still perform smearing, staining and reading.
The Med Tech then fills up the lower portion of Screening form (Form 1) for the result of the sputum microscopy. The Med Tech is also responsible for registering the case into the TB Suspect Masterlist (Form 3). The Med Tech should immediately inform the Physician on the results of tests.
5. The physician will be in charge of informing the subjects on the result of their tests. The physician may provide counseling and should be able to convince subject on the need to undergo treatment at the designated health facility (this may be at the RHU / DOTS facility or MDR-TB treatment center). In case all results are negative, the patient may be allowed to go home. If there are findings other than TB, the physician should refer the subject to the health center physician or to the necessary specialist/s.
For TB suspects with smear negative and Genexpert negative result but have suspicious lesion on Chest X-Ray as identified by the mobile Physician, it is advised that a referral to the TBDC be done.
In case the result is invalid or registered as an error, the mobile Physician will decide on next step he/she thinks is necessary.
6. After all the results are available, and the mobile team Physician has decided that the patient needs to be referred for treatment with anti-TB drugs, the mobile team Nurse is informed. It will be the mobile team nurse who fills up the DetecTB Referral form (Form 4). A health volunteers from the Community Health Team or BHW will accompany the patient to the RHU together with the referral form and photocopy of the results of tests. There may be some patients who will be reluctant to treatment due to several factors, thus it is advisable that detected
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cases are accompanied by a health worker. The project support team may assist in this procedure.
The Nurse should record all cases referred in the TB Case Referral Masterlist (Form 5)
XI. Diagnostic Protocols
A. Current Diagnostic Procedure of Philippine NTP
Figure 3. Flow diagram of current NTP diagnostic procedure
If all smears are negative
Abnormal findings on CXR
Refer to Physician (Symptomatic treatment for 2-3 weeks)
Classify as Smear Negative TB
If symptoms persist, request for CXR)
No abnormal findings on CXR
TBDC Observation/ further exam
Consistent with active TB
Not Consistent with active TB
Observation/ further exam
TB symptomatic- cough of two weeks or more
Sputum Exam (3 specimens)
2 or more Positive
All 3 smears -Negative
Repeat Sputum Exam
If 1 at least one positive
Negative
Only 1 Positive
Classify as Smear (+) For TB Treatment
Symptomatic treatment for 2-3 weeks, but if symptom persist
Chest X-Ray
If consistent with active TB
If not consistent with active TB, observation/further exams if necessary
Refer to table below for continuation
Although the main objective of the project is to increase the case detection, the project will exert effort to ensure that cases detected by the mobile unit are referred to the RHUs or PMDT Treatment Centers. The project assistant coordinator has the role to follow-up the cases referred and provide counseling, if necessary, to those who have not approached and enrolled for treatment in RHUs or PMDT Treatment Centers.
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The current diagnostic protocol of the Philippine NTP applies passive case finding among TB symptomatics defined as having cough of two weeks or more. Once TB symptomatics present themselves to the health facility, they are subjected to three sputum specimen examination (1st spot upon coming to the health facility, early morning specimen on day 2, and 2nd spot also on day 2). The patient has to wait on the average, about one week, before the results are released. Two positive results out of three specimen means that patient is positive and immediately started on treatment. Only one positive would mean a doubtful result which necessitates another set of specimen within one week. One positive from the second set is considered positive and treatment is already initiated. If all the second set specimens are negative, Chest X-Ray is done and if result shows lesions suggestive of TB, patient is considered as a smear positive case and patient is included to the program.
If sputum exam results are negative, symptomatic treatment is prescribed first for 2-3 weeks. If symptoms persist, they are then subjected to Chest X-ray examination and if the CXR result shows lesions suggestive of TB, they will be referred to a TBDC for decision if treatment is necessary. On the average Philippine setting, TBDC decisions are acquired after two weeks.
Note: The current MOP (4th edition 2005) employs the 3 sputum specimen but the NTP is in the process of revising the MOP which will be based on the WHO guidelines of two sputum collection for diagnosis.
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B. DetecTB Diagnostic Procedures
Figure 4. Flow Diagram of DetecTB Diagnostic Procedure
The following procedures will be followed during the ICF activities of the mobile clinic:
1) Interview The nurses of mobile clinic and/or his/her designate/s will interview subjects 15 years old and above using a screening form and record information which may help the Physician decide on whether further diagnostic tests may be necessary. Very importantly, the following information should be elicited:
A. signs and symptoms of TB B. history of exposure to a TB case C. previous treatment with anti-TB drugs
Cases that will be identified as MDR-TB suspects (especially treatment failures, defaulters) will be referred to the RHU with jurisdiction over the subject for the necessary referral to the PMDT.
Interview: Information gathering
Chest X-ray
(+) SSx or Exp or Hx of Dse /Tx and (+) CXR
(-)SSx or Exp or Hx of Dse/Tx but (+) CXR
(-)SSx/Exp/Hx; (-) CXR
(+)SSx or Exp or Hx of dse/Tx but (-) CXR
Label as non-TB
Refer to RHU Physician or qualified specialty field, possibility of Non-TB Mycobacterium
Refer to MDRTB Treatment Center (Cat IV) Suspect for
other disease/s
Refer to RHU (Category 1 or 3 for new; Category II for retreatment)
(-) SSx/Exp/Hx; (-) CXR for TB (+) Other disease/s
Label as non-TB and refer to a Physician or authorized specialty field
Strong suspicion of TB due to CXR as decided upon by mobile physician
Refer to TBDC
Genexpert and Sputum Exam
Genexpert (+) Rifam Susceptible
Genexpert (MTB not detected); SpSm(-), CXR (-)
Genexpert (+) Rifam Resistant
Genexpert Invalid/Error, Sputum Exam (+)
Genexpert (MTB not detected); Sputum Exam (-); CXR (+)
Note: For invalid Genexpert results with both negative sputum microscopy and Chest XRay, the Mobile Team Physician will decide on next step.
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2) Chest X-ray Examination
All subjects 15 years old and above will be subjected to Chest radiography. Reminder: Exceptions for case findings are: 1. Cases that are currently undergoing treatment with NTP; and 2. MDR-TB suspects (failures and defaulters) After chest radiography, the following will have to undergo laboratory exams:
a. All subjects having TB sign/s and symptom/s or history of exposure or previous TB disease and treatment
and/or
b. All subjects with Chest X-ray result showing lesions suggestive of
TB Those who do not fit the above criteria may be labeled non-TB and allowed to go home. Subject who do not fit the criteria but have lesions other that TB, as decided upon by the mobile team Physician should be referred to the health center or the needed specialist.
3) Genexpert and Sputum AFB smear examination Subjects having TB sign/s and/or symptom/s, exposure to a TB case and previous TB treatment and/or lesions suggestive of TB on Chest X-Ray will be subjected to Genexpert examination simultaneously with two spot sputum examination collected with at least one hour interval taking into consideration the quality and amount of sputum collected. Amount and quality of sputum, collection method and storage of specimen will follow the guidelines set by the Philippine NTP. The Medical Technologist of the mobile team will perform the Genexpert Exam and smearing, fixing and reading for the sputum microscopy and recording of both examination results. In case of high workload, a Laboratory Technician or a smearer may be trained to perform smearing procedures only.
TB suspects identified through Chest X-Ray who have negative sputum microscopy and Genexpert result of MTB not detected but have strong evidence to be considered as active TB as decided by the mobile team Physician will be referred to the TBDC. If the TBDC has decided to treat the subject, the patient will be included as a case of TB even without confirmation through the Laboratory procedures.
Table 3. Comparison between current NTP protocol and KOFIH Project protocol
Current Philippine NTP Protocol
KOFIH Project Protocol
1. Subject for case finding
TB symptomatics with cough of 2 weeks or more
*TB suspects and 15 years old and above
2. Case finding approach
Passive case finding and active case finding of household contact
*Intensified Active and passive case finding for all TB suspects 15 y/o and above
3. Initial Diagnostic procedure
Sputum microscopy and Chest X-ray as needed for smear negative
Sputum microscopy, GeneXpert and Chest Radiography
4. Confirmatory test
None (other than PMDT) Culture if necessary
* refer to definitions
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Diagnosis of Tuberculosis Cases Diagnosis of active TB patients from the mobile clinic will be in accordance with the Philippine NTP guidelines. Diagnosis of TB will be confirmed by the result of Sputum Exam and Genexpert. The following will be the types of patient based on the given criteria: A. New Cases- These are cases that do not have previous anti-TB treatment or had treatment but less than one month. These cases will be treated with Category 1 or 3
1. Pulmonary a. Smear Positive i, Smear positive and GeneXpert positive II. Smear positive but GeneXpert negative b. Smear Negative
i. Sputum smear (-) but Genexpert (+) ii. Sputum smear (-); Genexpert (-); CXR suggestive
2. * Extrapulmonary (EPTB) * Intrathoracic lymphadnopathy and pleural effusion would be the most common forms of EPTB that are detected from the project
B. Retreatment Cases- These cases will be treated with Category 2
1. Pulmonary a. Relapse b. Failure c. Return After Default d. Other, Positive e. Other, Negative
2. Extra-Pulmonary C. Drug Resistant TB.
1. New- has no previous treatment with anti-TB drugs but has Genexpert result of Rifampicin-resistant MTB
2. Retreatment- has previous treatment with anti-TB drugs and has Genexpert result of Rifampicin-resistant MTB
XII. Referral of Identified Cases The mobile clinic does not provide treatment to identified cases. Patients diagnosed as active TB case should be referred to TB DOTS clinic or MDR treatment center. “DetecTB Referral form” will be used for this purpose. The mobile team nurse or physician should explain to the patient the need to undergo treatment particularly the asymptomatic cases who might be reluctant to treatment. The Community Health Team (CHT) of Palawan and the Barangay Health Workers will be utilized to accompany identified cases of the mobile teams to the RHU for inclusion to the NTP (either to a DOTS facility or PMDT treatment center). It will be the responsibility of the project support team to ensure that TB cases identified by the mobile team are properly referred to DOTS facilities or treatment centers for MDRTB. The team should monitor if referrals are received by the proper facilities. Referrals will also be provided to the Provincial/City TBDC if TB suspects have sputum smear and Genexpert negative results but with strong suspicion of active TB by the mobile team Physician through information derived from the interview and/or Chest X-Ray findings. It will be the role of the mobile team Nurse to fill-up an NTP TBDC referral form for this purpose. Cases that are referred to the TBDC should be followed up by the Project Assistant
20
Coordinator to determine the decision of the TBDC. This information should be relayed to the Nurse so the case can be recorded in the TB Case Referral Masterlist as a case of TB.
XIII. Recording and Reporting
Management of documents by the mobile teams 1. The Nurse is the overall custodian of records and reports. He/she has the
responsibility to: a. Fill up the upper portion of the Screening Form (Form 1) b. Fill up the DetecTB Referral form (Form 4) c. Maintain the TB Case Referral Masterlist (Form 5) d. Fill up the Case Finding Data Form (Form 6) e. Fill up the Treatment Outcome Data Form (Form 7)
2. Radiology Technologist has the responsibility to: a. Maintain the Screening Masterlist (Form 2) b. Keep a storage file for electronic copies of the Chest X-Ray results of all
cases c. Provide electronic copies of X-Ray results of cases that need to be
referred to the TBDC 3. Medical Technologist has the responsibility to:
a. Maintain the TB Suspect Masterlist (Form 3) b. Fill up the lower portion of the Screening form (Form 1)
4. The Physician as the Mobile Team leader has the responsibility to: a. Ensure that all recording and reporting forms are properly filled up b. Fill up of the middle portion of the Screening form
Management of document by the project support team The project support team will be in charge of the overall management of recording and reporting. The team will be responsible for the preparation and submission of the “Quarterly Report” to the Technical Committee. The project assistant will be responsible for converting the paper-based data and information to electronic file. He/she will prepare the quarterly reports (monthly as needed) and the Project Coordinator should ensure that these reports are accurate, complete, and submitted on time.
XIV. Project Monitoring and Evaluation Several project evaluation indicators will be used to assess the performance of the mobile teams with regards to their routine operations. The project will employ intensified case finding thus, the number of target population subjected to screening will directly affect the number of TB cases that can be identified. The indicators listed in the tables below will be utilized in monitoring and evaluating the project. Significant improvement from the baseline data will serve as basis for the success in TB case finding among the project sites. Table 4 indicators are the operational target indicators which measures the monthly performance of the mobile clinic with regards to diagnostic tools performed to identify TB cases. The project has set targets based on the capacity of the mobile team and which were agreed upon by the implementing personnel. Different aspects will be monitored namely: the quantity of output, quality of work done, and timeliness of the output of the mobile clinic. The procedures performed during the ICF activities should not only be in high numbers but also of good quality to guarantee accuracy in diagnosis. Also, the turnaround time from registration to the release of the results should also be acceptable for clients’ satisfaction.
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Interview with subjects and observation of the health workers on their routine work may be done to ensure that NTP procedures are followed. Examples of these are how the health workers instruct clients on sputum collection and how laboratory technicians or microscopists perform the smearing, staining and microscope manipulation. Table 4. Operational Target Indicators Project Site:________________ Period Covered:___________
Operational Target Indicator Required Accomplishment
Quantity %
1. Chest X-Ray / month
City 800
Province 600
2. Sputum exam performed / month
City 160 cases
Province 120 cases
3. Genexpert / month
City 160 cases
Province 120 cases
4. Culture / month As needed
Table 2 indicators are dependent on the achievement of the targets during the routine operations of the mobile clinic. The quantity of clients screened and the quality of work performance on the diagnostic procedures will directly affect number of TB cases identified. The indicators to be used for monitoring will be the same indicators used by the Philippine NTP including some which may be useful for the project. The performance indicators will be divided into two categories namely case finding and case holding. Case finding indicators will focus mainly on the different types of TB cases identified while case holding is on the success of the referral system shown by the number of cases reaching the proper health units for treatment. Table 5. Project Performance Indicators Project Site:___________________ Period Covered:_____________
Project Performance Indicator Baseline (2011) Accomplished
Case Finding No. % No. %
1. No. of clients interviewed
2. No. of clients who consent to X-ray examination
3. No. of TB suspects by interview only
4. No. of TB suspects by X-ray only
5. No. of TB suspects by interview and/or X-ray
6. No. of TB suspects underwent sputum exam. only
7. No. of TB suspects underwent Xpert only
8. No. of TB suspects underwent Xpert and sputum
9. No. of new PTB cases identified
- Smear (+) and Xpert (+)
- Smear (+) but Xpert (-)
- Smear (-) but Xpert (+)
- Smear (-) and Xpert (-) but X-ray positive (by
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TBDC)
- pan-susceptible
- R-resistant
10. No. of EPTB cases identified
- New
- Retreatment
11. No of retreatment cases identified
- Relapse
- Failures
- Defaulters
- Others
- pan-susceptible
- R-resistant
Case Referral for treatment No % No %
12. No. of all forms of cases referred (= No. 9+10+11)
13. No. of cases successfully registered for treatment
Baseline (2011) Accomplished
Case Holding No. % No. %
14. Initial Defaulter
- Sm (+) Xpert (+)
- Sm (+) Xpert (-)
- Sm (-) Xpet (+)
- Sm (-) Xpet (-) X-ray positive (by TBDC)
15. Treatment outcomes for New Sm PTB (+)
- Cured
- Treatment Completed
- Died
- Failed
- Defaulted
- Transferred-out
XV. Future Steps It will be the decision of KOFIH if project extension and expansion to other provinces in the Philippines are feasible. After the project implementation, data and information generated from all the project sites will be analyzed by the Korean Institute of Tuberculosis (KIT) and World Health Organization. The result of the analysis will be circulated in international publications and submitted to the Philippine NTP for the program’s reference. Good practices will be documented and weaknesses of the project will be studied to identify the areas that need to be improved. Analysis of cost-effectiveness will be done to provide information to national TB control programs who may be interested in applying the project’s approaches in their case finding activities. Possibility of recognition and commendation of other national TB control program may help convince the Philippine NTP in adopting the project’s diagnostic protocol in detecting more TB cases.
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Form 1: DetecTB Screening Form Reg. No. ___________________ Name:__________________________ Age:____ Date of Birth (Mo/Day/Year):___________ Gender: ( )M ( )F Complete Address: __________________________________________________ Contact No: _____________________ Reg. No ________________________ Presence of Signs and Symptoms (check space provided):
1. Cough: ( )1-7 days ( )8-13 days ( )two weeks or more 2. ( )Sputum 3. ( )Weight loss of 10% or more in the past six month 4. ( )Chest pain 5. ( ) Back pain 6. Fever : ( )<4weeks ( )>4weeks
7. ( )Hemoptysis 8. ( )Dyspnea 9. ( )Night sweats 10. Others,____________________________ 11. ( )None
History of Exposure to a TB case (check space provided): Subject had close contact within the past two years ( )None ( )Yes, If yes 1. ( )Smear (+) 2. ( )Smear (-) 3. ( )MDR TB 4.( )Unknown History of previous TB treatment (check space provided): ( )None ( )Yes, if yes, ( )less than a month ( ) one month or more No. of previous treatment/s ( )1 ( )2 ( ) 3 or more
(Space below to be filled up by Mobile Team Physician) ---------------------------------------------------------------------------------------------------------------- Chest X-Ray Result Chest X-Ray Serial No:_____________ Chest X-Ray Result: ( )Normal ( )TB, active ( )TB, inactive ( )TB, activity undetermined ( )Other disease/s: __________________________________________ (Note: TB active and TB activity undetermined should be labeled as TB suspect) Based on the above information patient is classified as: ( )TB suspect ( )non TB Action taken:________________________________________________________ _______________________________________________ ________________ Signature over printed name of the Mobile Team Physician Date
(Space below to be filled up by the Medical Technologist) --------------------------------------------------------------------------------------------------------------------------- Laboratory Result Examination done: Genexpert( ) Sputum Microscopy( ) Date of sputum collection: _____________
Specimen No. Spot 1 Spot 2 Genexpert
Amount (in ml)
Visual Appearance
Reading
Diagnosis of Sputum Microscopy: ( )Positive ( )Negative Date of Release:________________ Diagnosis of Genexpert: ( )Rifampicin Susceptible MTB ( )Rifampicin Resistant MTB ( )MTB not detected ( )Invalid/Error Date of Release:__________________
____________________________________
Signature over printed name of Med. Tech.
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DetecTB Consent Form (Tagalog) Ito ay pagpapatunay na:
1. Ako ________________________________, nasa wastong edad na, ______ , nakatira sa ___________________________________________, ay kusang loob at buong pag-iisip na pumayag at hindi pinuwersa o pinilit o binigyan ng anumang kabayaran upang sumailalaim sa mga pagsusuring isasagawa sa akin ng DetecTB Project upang matukoy ang sakit na Tuberculosis.
2. Ako ay binigyan ng kaalaman sa lahat ng mga maaaring gawing pagsusuri sa
akin tulad ng Chest X-Ray at Sputum Examination.
3. Ang pamunuan ng DetecTB Project ay walang pananagutan sa anumang mangyari sa akin habang ako ay sumasailalim sa mga karaniwang pagsusuri para sa sakit na TB na hindi nagdudulot ng masasamang epekto sa aking kalusugan at alinsunod sa patakaran ng Kagawaran ng Kalusugan ng Pilipinas.
______________________
Lagda
DetecTB Consent Form (English) This is to certify that:
1. I, _____________________________, (age)_____ years old, residing at _________________________, willingly consent, without being forced and provided compensation, to undergo diagnostic procedures done by the DetecTB Project for the detection of Tuberculosis.
2. I was provided with enough information regarding the diagnostic procedures such as Chest X-Ray and Sputum Examinations.
3. The DetecTB team and other field assistants are not responsible to whatever untoward incidents that may occur while I am undergoing these safe procedures which are in accordance with the standards of the Department of Health of the Philippines.
___________________
Signature
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DetecTB Consent Form for Minors (Tagalog) Ito ay pagpapatunay na:
1. Ako ________________________________, ______ taong gulang , (pangalan ng magulang o nangangalaga) nakatira sa ___________________________________________, ay kusang loob at buong pag-iisip na pumayag at hindi pinuwersa o pinilit o binigyan ng anumang kabayaran upang sumailalaim sa mga pagsusuri para sa sakit na Tuberculosis na isasagawa ng DetecTB Project para sa aking _____________ (relasyon)
na si ______________________ , na may edad na _______. (pangalan ng susuriin)
2. Ako ay binigyan ng kaalaman sa lahat ng mga maaaring gawing pagsusuri sa
aking kasamang menor de edad tulad ng Chest X-Ray at Sputum Examination.
3. Ang pamunuan ng DetecTB Project ay walang pananagutan sa anumang mangyari habang ang aking sinamahang menor de edad ay sumasailalim sa mga karaniwang pagsusuri para sa sakit na TB na hindi nagdudulot ng masamang epekto sa kalusugan at alinsunod sa patakaran ng Kagawaran ng Kalusugan ng Pilipinas.
______________________
Lagda
DetecTB Consent Form for Minors (English) This is to certify that:
1. I, _____________________________, _____ years old, residing at ______________________________, hereby consent, without being forced and paid, to allow my ___________(relation to minor), _______________________ (name of minor) to undergo diagnostic procedures done by the DetecTB Project for the detection of Tuberculosis.
2. I was provided with enough information regarding the diagnostic procedures such as Chest X-Ray and Sputum Examinations.
3. The DetecTB team and other field assistants are not responsible to whatever untoward incidents that may occur on the minor I am accompanying while undergoing these safe procedures which are in accordance with the standards of the Department of Health of the Philippines.
___________________
Signature
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Form 2: Screening Masterlist
Date of Registrati
on Reg. No.
P Passive
CF
A Active
CF Name Age Sex Address
S / Sx
Hx of Exp
Hx of Prev Tx
*X-ray Result
TB susp Y/N
Action Taken
27
Form 3. TB Suspect Masterlist
Date of Reg.
Reg No.
A or P
Name Age Sex Address S E T X-ray
Result
Sputum exam
Genexpert Culture Result
Action Taken
+ - ND
TB
DR
TBND
INV
ND
+ - ND
TB
DR
N TB
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Form 4. DetecTB Referral Form To:__________________________ Date:____________________ Respectfully requesting further management of patient bearing this referral form. Name of Referring Unit: ( )Palawan Provincial DetecTB Mobile Team ( )Puerto Princesa City DetecTB Mobile Team Registration No._____________ Name of Patient:______________________ Age:_____ Gender: ( )M ( )F Address:___________________________________________________________ Contact No:________________________ Reason for referral: ( )For inclusion to DOTS / PMDT of patient based on the findings below:
1. ( )Pulmonary ( )EP 2. ( )New ( )Retreatment 3. ( )Sm+ ( )Sm- 4. CXR
( )TB, Active ( )TB, Inactive ( )TB, Activity Undetermined 5. Genexpert
( )Rif-Susp ( )Rif-Resistant ( )MTB not detected ( )Invalid/Error
( )Other reason/s: __________________________________________________________________
__________________________________________________________________
__________________________________________________________________ Name and Signature of referring official:___________________________________ ---------------------------------------------------------------------------------------------------------------
Reply Slip (Please return to sending unit) Registration No.___________ Date received:_____________ Name of receiving facility:______________________ Address of receiving facility:____________________________________________ Contact No. of receiving facility / officer:___________________/_______________ Name of patient:________________________ Age:_____ Gender:________ Action taken:________________________________________________________ Name, designation and signature of receiving officer:________________________ Date returned:_____________________________
29
Form 5. TB Case Referral Masterlist Date of
Reg. Reg No. A
or P
Name Age Sex Address Referred to (Name of Facility)
S E T CXR
SM GX prt
Cul-ture
*Type of TB
Cat Sputum follow-up **Tx Outcome
1 2
3 4 5 6 7 8 9
*Legend for Type of TB:
1- New Smear Positive; 2- New Smear(-), Xpert(+); 3- New Smear Negative, Xpert(-), CXR(+); 4- New Extrapulmonary; R-Relapse; F-Failure; RAD-
Return After Default; O(+)- Other positive; O(-)- Other negative; REP-Retreatment EP
** Treatment outcome:
C-Cured; CT-Completed Treatment; F-Failed; D-Died; DF-Defaulted; TO-Transferred-out
30
Form 6: Case Finding By Age and Gender
Mobile Clinic: ( ) Province ( ) City Period Covered: _________________ Project Site: _____________________
Prepared by: ________________________________ Designation: ___________________ Date Submitted: ___________________
Type 0-4 5-14 15-24 25-34 35-44 45-54 55-64 65&> Total
M F M F M F M F M F M F M F M F M F
New Sm(+)
Sm(-); Xpert+
Sm-; Xprt -
EP
SubTotal
Total
Retreat
ment
Relapse
Tx Failure
RAD
Other (+)
Other (-)
EP
Sub
Total
DR-TB New
Retreatment
Sub-Total
Total
31
Form 7: Treatment Outcomes of All Types Referred
Mobile Clinic: ( ) Province ( ) City For cases identified during:_________________ Project Site:_____________________
Prepared by:________________________________ Designation:__________________ Date Submitted:___________________
Type
No. registered
Cured Comp. Tx Tx Success Failed Died Defaulted Trans-Out Total
Evaluated
No % No. % No. % No. % No. % No. % No. % No. %
New Sm(+) Xpert(+)
Sm(+), Xpert(-)
Sm(-) Xpert(+) Sm-; Xpert(-) EP
Retreat
ment
Relapse
Tx Failure RAD Other (+) Other (-) EP
DR TB New Retreatment
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Baseline Data Collection The project will be monitored and evaluated based on baseline data and information of the project sites including NTP indicators collected before the project implementation. Baseline data will be collected from both Palawan PHO and Puerto Princesa CHO using the 2011 records and reports. Data and basic information on the target groups and Municipal for Palawan Province and Barangay for Puerto Princesa City project sites will also be collected. Sources for baseline data for NTP indicators are mainly the Laboratory and TB Registries of the project sites. Other records that may be used are TB Symptomatic Masterlist (if available), Treatment Cards, Quarterly and Annual Reports. Baseline data of other municipalities with the same characteristics to that of the target sites may also be collected for comparison. Due to limited capacities and funds at the provincial and city level, several baseline data will be based on the national figures that were generated during the National TB Prevalence Survey conducted in 2007. Coordination with Provincial and City NTP point persons, particularly the Nurse and the Medical Technologist, will be done to identify the schedule and venue for the data collection activity. The Nurse and the Med Tech will be requested to bring with them all the necessary recording and reporting documents as mentioned above. Other agencies that may be requested to provide data and information are the Provincial/Municipal Civil Registry, Provincial/Municipal Social Welfare Development Office, Provincial/Municipal Planning and Development Office and the Department of Education. The project will utilize several data and information collecting forms for this purpose. The target date of data collection is two weeks prior to the start of implementation.
33
Annex I. Epidemiological situation and TB control activities in the project site
X. General information of the project sites
Palawan province Puerto Princesa city
Data Year (2011)
Data Year (2011)
Total population
No. of 15 y/o and above
Population, urban area
Population, rural area
No. households
No. 3rd and 4th year high school students 3rd:
4th:
3rd:
4th:
No. of Secondary School Teachers
Land area in square kilometers
No. municipalities/cities
No. barangays
No. Rural Health Units / City Health Centers (or TB DOTS clinic)
No. of barangays/sitio/purok in remote area & population with difficult access to health centers under project area
No:
Pop:
No:
Pop:
34
Other vulnerable / high risk groups
1. Prison inmates
2. Congested areas like urban slums
3. Indigenous peoples
4. Fisherfolks / Farmers
2. Epidemiological situation of tuberculosis
Indicators Palawan province Puerto Princesa city
Data year Remark Data year Remark
Annual risk of infection
Prevalence rate of pulmonary TB
Prevalence rate of smear positive TB
Notification rate of pulmonary TB
Notification rate of smear positive TB
No. of TB deaths, annual
Primary drug resistance rate
Primary MDR rate
Acquired drug resistance rate
Acquired MDR rate
Prevalence of HIV infection among new cases
Some data may not be available.
35
3. All TB cases registered and detected: Palawan province, 2011
Sputum smear positive PTB New Smear negative PTB (not available)
Pulmonary sputum smear microscopy not
done / not available
New extrapulmonary
Other previously treated
3
TOTAL All cases
New cases
Previously treated
0-4 yrs
5-14 yrs
> 15 yrs
0-4 yrs
5-14 yrs
> 15 yrs
0-4 yrs
5-14 yrs
> 15 yrs Relapse
Treatment failure
Return After
Default
4. New smear positive pulmonary tuberculosis cases – Age group : Palawan province, 2011
Sex 0-4 10-14 15–24 25–34 35–44 45–54 55–64 > 65 Total
M
F
5. All TB cases registered and detected: Puerto Princesa city, 2011
Sputum smear positive PTB Smear negative new PTB (not available)
Pulmonary sputum smear microscopy not
done / not available
New extrapulmonary
Other previously treated
3
TOTAL All cases
New cases
Previously treated
0-4 yrs
5-14 yrs
> 15 yrs
0-4 yrs
5-14 yrs
> 15 yrs
0-4 yrs
5-14 yrs
> 15 yrs Relapse
Treatment failure
Return After
default
36
6. New smear positive pulmonary tuberculosis cases – Age group: Puerto Princesa city, 2011
Sex 0-9 10-14 15–24 25–34 35–44 45–54 55–64 > 65 Total
M
F
7. NTP activities
Palawan province Puerto Princesa city
2008 2009 2010 2008 2009 2010
No. of new cases
No. of new smear (+) cases
Treatment outcomes of new smear (+) cases
Cure rate
Success rate
Treatment Completion Rate
Default rate
Transfer out rate
Death rate
Failure rate
No. of relapse cases
No. of MDR cases
(Some data may not be available)
37
8. Case finding activities in 2011
Name of TB DOTS facility
Population covered
No. of TB suspects examined
Pulmonary TB
All types Remarks New cases Retreatment cases (smear positives)
Smear + Smear – Relapse Others
Palawan province
1.
2.
3.
4.
Puerto Princesa city
1.
2.
3.
4.
Total
Add more rows if needed
38
9. Sputum positivity rates among TB suspect in 2011
Name of microscopy center No. of TB suspects examined by sputum smear microscopy
No. of TB suspects with positive sputum smear microscopy result
Positivity Rate
Registered cases among smear positive cases
Palawan province
1.
2.
3.
Puerto Princesa city
1.
2.
3.
Add more rows if needed 10. Culture results of the diagnostic specimens in 2011 (No data)
Smear results
Palawan province Puerto Princesa city
Positives Negatives Contaminant Total Positives Negatives Contaminant Total
Positives
Negatives
Total
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11. Baseline ICF activities, Palawan province
Name of site Date
Total Pop
TB suspects Others (Non-TB suspects) Genexpert
No. X-ray screend
No. smear exam
No. smear positives
No. clinical TB
No. Non-TB
No. X-ray screen
No. smear exam
No. smear positives
No. clinical TB
No. Non-TB
No. exam
No. +ives
Clinical TB; Bacteriologically negative, but radiologically active TB. ※ Duplicate the form, if needed
40
12. Baseline ICF activities, Puerto Princesa city
Name of site Date
Total Pop
TB suspects Others (Non-TB suspects) Genexpert
No. X-ray screen
No. smear exam
No. smear positives
No. clinical TB
No. Non-TB
No. X-ray screen
No. smear exam
No. smear positives
No. clinical TB
No. Non-TB
No. exam
No. +ives
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