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CRUMBS

AND
RUMBLE
VENTURES,
INC.
TUBERCULOSI
S
(TB)
POLICY
PROGRAM

Prepared by:

Atty. Neil Energyte G. Baldonado

What is Tuberculosis?
Tuberculosis (TB) has been a public health concern wherein millions have died
from it worldwide (with more mortality compared to SARS and the Avian Flu). But
even with the nationwide campaign against TB for decades now, it has remain
among the top 10 morbidity and mortality of Filipinos -with 75 Filipinos dying from
it everyday as based in the 2003 data from the Philippine Tuberculosis Initiatives
for the Private Sector (PhilTIPS).
On 2004, the DOH together with the support of DOLE and other government
agencies launched the Comprehensive and Unified Policy ( C.U.P. 2004) for
Tuberculosis Control in the Philippines. And on October 2005, the Department of
Labor and Employment (DOLE) Secretary Patricia Sto. Tomas issued Department
Order No. 73-05, Series of 2005 or the Guidelines for the implementation of Policy
and Program on Tuberculosis prevention and control in the workplace. The DOH
has been advocating the PPM-TB (Private Public Mix), private practitioners may
refer their patients to TB DOTS facilities for free treatment using a two-way
referral system. The referring MD has no worry to loss their patient, since the TB
DOTS facilities ask the referred patient to return for ff-up with their attending MD.
Please do not hesitate to refer TB patients to the TB DOTS treatment centers, TB
DOTS is an effective public health program against tuberculosis.

What is TB-DOTS?
Directly Observed Treatment Short Course or DOTS is a comprehensive strategy to
control TB.
Key difference of DOTS from Non-DOTS Treatment:

Free Medicines and Laboratory (Sputum microscopy)


Monitors patients compliance to TB Drugs
Monitors treatment outcomes
Assures that the patient is cured not just treated
Refer treatment failure to MDR facilities (Lung Center/LCP, Kasaka QI,
JNRMMC/Tala) MDR treatment also provides free therapeutic regimen.

Emerging threats like Multidrug resistant TB (MDR-TB) and the Extremely Resistant
variety (XDR-TB) is on the rise partly due to poor compliance and poor patient
follow-up especially those who are treated outside the TB DOTS Program. Most of
the Company Physicians either will start the patient on anti-Kochs with no regular
follow up and no assurance to treatment compliance (of the patient) or refer the
patient to a Pulmonologist rather than referring the employee to a TB DOTS
treatment Facility. TB Drugs are very costly but these drugs are available for free
in the TB DOTS Centers and follows the Direct Observed Treatment Strategies thus
improving the chances of being cured.

What is the incidence of Active TB in the workplace?


The incidence of Active TB in the workplace is generally lower compared to the
general population because of the Healthy Worker Effect, since almost all
employees have gone through Fit to Work evaluation and has their Annual
Physical Examinations (APE). In practice I usually see only around 2 to 3 cases per
year among the workers in the company, its very minute compared to the actual
number of cases in the community.

What should an employee with active TB do?


For employees with recent APE (Annual PE) result of CXR findings of PTB infection,
do first a sputum exam (DSSM) request or a referral to the TB DOTS facility near
the patients place of residence to do the free DSSM. Explain to the patient the
nature of the disease and the importance of DOTS. Provide ample time for sick
leave and tell the employee that he can file for Temporary Total Disability at the
ECC (Employees Compensation Commission). Reassure your patient that TB can
be cured and he can be able to return to work.

How long will be the sick leave?


It would be usually case to case basis but for Active TB Disease requiring DOTS
Category Treatment, the minimum is 2 months. Two months is the time it takes to
finish the Intensive Phase/Course of TB DOTS and by that time a repeat sputum
microscopy at the end of the intensive phase will determine the infectivity (if the
patient still sheds the TB bacilli) and the success of the treatment whether the
patient respond to the first line anti Koch medications. Category I patients (TB
disease) are sputum positive individuals.

How can TB be diagnosed?


Although it is fairly obvious (from their symptoms) when someone has active
tuberculosis, the protection of the general population requires the identification of
latent TB sufferers, so that they can be treated and monitored.
Skin testing
Tuberculin is a purified protein extracted from Mycobacterium (tuberculosis?)
which acts as an antigen, and if a person has been either active or latenr TB
infection, their immune system will have produced antibodies to tuberculin. An
exposure to tuberculin thus produces an allergy-like reaction.
This generally involves a skin test. There are two main techniques: the Heaf or
Mantoux tests. A liquid containing tuberculin is introduced using a needle (or set
of them!) under the skin of the arm. 2-3 days later the inoculation site is checked
to see if there is a reaction to the test. The result to the test is counted as positive
if a raised bump is visible. This signifies latent TB infection, although it is often
explained as showing that the patient has been exposed to TB infection in some
way.

Further testing, such as a chest X-ray, may be necessary to determine if active TB


disease is present.
X-ray screening
From the 1950s there was a programme of mass X-ray testing in the UK and
America ; X-ray machines routinely visited cities and towns throughout the British
Isles and adults were persuaded to present themselves for testing; usually no
appointments were necessary. This was phased out in the 1970's, presumably due
to reductions in the incidence of TB, or because likely candidates did not present
themselves
for
testing.
X-ray testing is not particularly effective for the identification of latent
tuberculosis, but very useful to identify active TB and to monitor the progress of
control measures.
Sputum examination
Sputum is the dense mucus-like secretion coughed up from the lungs, although it
can be extracted by a vacuum method using a tube. A sample is sent to a
specialist laboratory for further processing.
Smear test
Sputum may be examined under the microscope, after being spread on a slide,
stained with special stain then treated with heat and acid. If Mycobacterium
shows up as acid fast bacilli (rod-shaped bacteria, still staining darkly), this is a
very direct diagnosis of active TB.
Culture test
Sputum may also be spread on the surface of a special microbiological medium
(an agar plate) and incubated under special conditions. Bacteria will grow into
colonies which are visible to the naked eye, but this takes some time - a matter of
weeks.
This technique can also be used to identify other lung infections such as
pneumonia, and to find out what antibiotics the bacteria are sensitive to, which
makes prescribing antibiotics more effective.

How can TB be treated?


Control (drug therapy) using antibiotics
Tuberculosis can usually be controlled using drugs called antibiotics to kill the
infecting bacteria. It is not susceptible to antibiotics like penicillin. From 1945 the
antibiotic streptomycin was used against TB; initially it was very successful and
quickly replaced the sanatoria which provided treatment based on fresh air and
isolation! However streptomycin has several unwelcome side-effects.
Nowadays, isoniazid is the main antibiotic of choice because (when activated by
bacterial catalase) it prevents the formation of the waxy component of cell walls
in Mycobacterium tuberculosis which are its main defence. Another antibiotic
often used is rifampicin which prevents bacteria from producing proteins.

Drug-resistant TB
Within a large population of any living organisms, there will be some individuals
that due to a mutation have a different feature which might (or might not)
possibly give its owner an advantage under certain circumstances.
The same is true of bacteria, although they reproduce asexually. They exist in very
large numbers and individual mutant bacteria will exist with features such as a
different cell wall structure or a different metabolism (way of working at a
chemical level), either due to a modified version of a gene, or an extra gene.
When these are challenged by being exposed to antibiotic taken by the patient
they survive and reproduce, passing on the gene responsible to their offspring - a
clone of themselves. As a result the other (antibiotic-sensitive) bacteria die and
are replaced by the offspring of the mutant form which make an antibioticresistant strain.
This situation has unfortunately developed with TB on a worldwide scale. Strains
which are resistant to one antibiotic can also develop resistance to other
antibiotics. Multiple drug resistant - MDR - strains are produced as a result,
and these are very difficult, if not impossible, to treat with antibiotics. There are
several categories of antibiotics, depending on their agreed role in treatment: first
line, second line, third line. Isoniazid and rifampicin are first line drugs.
Extensively (or extremely) drug-resistant tuberculosis (XDR-TB) is not treatable
using first and second line drugs.
The phenomenon of extensively drug resistant strains has a number of ethical
consequences. In some instances, many of which have attracted media attention,
sufferers have been forcibly excluded from exposure to the general public;
compulsory quarantine is not far removed from imprisonment!
TB treatment regimes
The treatment of TB is essentially quite different from that of other diseases:

it takes a long time, and must not be stopped if the sufferer feels some
improvement

it uses drugs (antibiotics etc) that are not cheap, especially in relation to
income in developing countries

treatment may involve a mixture of drugs and this is likely to change


during the treatment process

This depends on the sufferer being expected to be seen to take their medication
under the supervision of another qualified individual, who can check the drug
requirements and carry out the appropriate administration, as well as the
necessary backup arrangements. The main points of this programme are as
follows:

commitment by the local authorities/government,

diagnosis and monitoring using sputum smear microscopy

standardized treatment regimen with directly observed treatment for at


least the first two months

a regular drug supply

a standardized recording and reporting system that allows assessment of


treatment results

What are the policies of the Company towards TB?


The Company provides periodic tests for its employees to check for TB infections.
Further the Company ensures sanitary and healthy work conditions for its
employees to ensure that TB airborne particles shall not pose a threat to health.
The Company shall report all cases of TB to the DOLE and DOH, but shall not
discrimate or in any way oppress the employee.