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Tuberculosis and Typhoid Fever

Tuberculosis(TB) is considered as the worlds deadliest disease and remains as a major public health problem in the Philippines. TB is a highly infectious chronic disease caused by the tubercle bacilli. It is primarily a respiratory disease but can also affect other organs of the body and is common among malnourished individuals living in crowded areas.

In 1993, TB was declared as global emergency by the World Health Organization because of the resurgence of TB in many parts of the world. In the Philippines, tuberculosis ranks sixth 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(WHO Report 2006).

Cough of two weeks or more Fever Chest or back pains not referable to any musculo-skeletal disorders Hemoptysis or recurrent blood-streaked sputum Significant weight loss Other signs and symptoms such as sweating, fatigue, body malaise, and shortness of breath

Mycobacterium tuberculosis and M. Africanum primarily from humas, and M. bovis primarily from the cattle. Other mycobacteria occasionally produce disease clinically indistinguishable from tuberculosis; the etiologic agents can be identified only by culture of the organisms.

Airborne droplet method through coughing, singing, or sneezing Direct invasion through mucous membranes or breaks in the skin may occur, but is extremely rare Bovine tuberculosis results from exposure to tuberculosis cattle, usually by ingestion of unpasteurized milk or dairy products.

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.

The most hazardous period for development of clinical disease is the first 6-12 months after infection. The risk of developing the 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.

Prompt diagnosis and treatment of infectious cases BCG vaccination of newborn, infants, and grade 1/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 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 caontacts.

Vision: Mission:


A country where TB is no longer a public health problem. Ensure that TB DOTS services are available, accessible, and affordable to the communities in collaboration with the LGUs and other programs. To reduce prevalence and mortality from TB by half by the year 2015(Millennium Development Goal) 1. Cure at least 85% of the sputum smear-positive TB patient discovered. 2. Detect at least 70% of the estimated new sputum smear-positive TB cases.

The NTPs four-pronged set of objectives calls for improvement of access to and quality of services, enhancement of stakeholders healthseeking behaviour, sustainability of support for TB control activities, and strengthening management of TB control services at all levels. Objective A: Improve access to and quality of services provided to TB patients, TB symptomatics, and communities by health care institutions and providers.

Strategies: 1. Enhance quality of TB diagnosis. 2. Ensure TB patients treatment compliance. 3. Ensure public and private health care providers adherence to the implementation of national standards of care for TB patients. 4. Improve access to services through innovative service delivery mechanisms for patients living in challenging areas.

Objective B: Enhance the health-seeking behaviour on TB by communities, especially the TB symptomatics. Strategies: 1. Develop effective, appropriate, and culturally-responsive IEC/communication materials. 2. Organize barangay advocacy groups.

Objective C: Increase and sustain support and financing for TB control activities. Strategies: 1. Facilitate implementation of TB-DOTS Center certification and accreditation. 2. Build TB coalitions among different sectors. 3. Advocate for counterpart input from local government units. 4. Mobilize/extend other resources to address program limitations.

Objective D: Strengthen management(technical and operational) of TB control services at all levels. Strategies: 1. Enhance managerial capability of all NTP program managers at all levels. 2. Establish an efficient data management system for both public and private sectors. 3. Implement a standardized recording and reporting system. 4. Conduct regular monitoring and evaluation at all levels. 5. Advocate for political support through effective local governance.

A. Case finding 1. Direct Sputum Smear Microscopy(DSSM) 2. All TB symptomatics identified shall be asked to undergo DSSM for diagnosis before start of treatment. 3. Pulmonary TB symptomatics shall be asked to undergo to other diagnostic test. 4. NO TB diagnosis shall be made based on the results of X-ray examination alone. 5. Passive case finding shall be implemented in all health stations. 6. Only trained medical technologists or microscopists shall perform DSSM.

B. Treatment 1. Aside from clinical findings, treatment of all TB cases shall be based on a reliable diagnostic technique, namely, DSSM. 2. Domiciliary treatment shall be the prefered 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 without complications.

D. All patients undergoing treatment shall be supervised(DOT). No patient shall initiate treatment unless the patient and DOTS facility staff 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. F. Quality of FCDs must be ensured. FDCs must be ordered from a source with a track record of producing FDCs according to WHO-prescribed strength and standard quality.

DOTS is the internationally-recommended TB control strategy and combines five elements. The five elements are the following: 1. Sustained political commitment 2. Access to quality-assured sputum microscopy 3. Standardized short-course chemotherapy for all cases of TB under proper case management conditions, including direct observation of treatment 4. Uninterrupted supply of quality-assured drugs 5. Recording and reporting system enabling outcome assessment of all patients and assessment of overall program performance.


2. 3. 4.


Together with other NTP staff/workers, manage the procedures for case-finding activities. Assign and supervise a treatment partner for patient who will undergo DOTS. Supervise rural health midwives(RHMs) to ensure proper implementation of DOTS. Maintain and update the TB Register. Facilitate requisition and distribution of drugs and other NTP supplies.

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.

1. 2.

Prevention Case-finding a. Cases of TB in children are reported and identified in two instances b. All TB symptomatic children 0-9 years old, except sputum positive child shall be subjected to Tuberculin testing c. A patient shall be suspected as having TB and will be considered as a TB symptomatic if with any of the three signs and symptoms appear d. A child shall be clinically diagnosed or confirmed of having TB if he has any three of the following conditions:

e. For children with exposure to TB f. For children with signs and symptoms of TB 3. Case holding and treatment a. Case holding mechanism b. Treatment

1. 2. 3.



Interview and Open treatment cards for identified tuberculous children Perform tuberculin testing and reading to eligible children Maintain NTP records(treatment cards, TB register for children and quarterly reports) Manage requisition and distribution of drugs Assist the physician in supervising the other health workers of the RHU in the proper implementation of the policies and guidelines on TB in children. Assist in the training of other health workers on Tuberculin testing and reading.

Etiologic Agent:

Salmonella typhosa, typhoid bacillus Source of Infection: Feces and urine of infected persons. Description: A systematic infection characterized by continued fever, malaria, anorexia, slow pulse, involvement of lymphoid tissues, especially ulceration of Peyers patches, enlargement of spleen, rose spots on trunk and diarrhea. Many mild typical infections are often unrecognized. A usual fatality of 10% is reduced to 2 or 3% by antibiotic therapy.

Mode of Transmission: Direct or indirect contact with patient or carrier. Principal vehicles are food and water. Contamination is usually by hands of carrier. Flies are vectors. Incubation Period: Variable; average 2 weeks, usual range 1 to 3 weeks.

Period of Communicability: As long as typhoid bacilli appear in excreta; usually from appearance of prodromal symptoms from first week throughout convalescence. Susceptibility, Resistance, and Occurrence: Susceptibility is general although many adults appear to acquire immunity through unrecognized infections. Attack rates decline with age after second or third decades. A high degree of resistance usually follows recovery.

Methods of Prevention and Control Same preventive and control measures as in Dysentery and in addition, immunization with a vaccine of high antigenicity. Education of the general public and particularly the food handlers.

The program covers diseases of a parasitic, fungal, viral, and bacteria in nature, usually acquired through the ingestion of contaminated drinking water or food. The more common of these diseases are bacterial in nature, the most common of which are typhoid fever and cholera. These two organisms had been the cause of major outbreaks in the Philippines in the last two years. Parasitic organisms are also an important factor, among them capillariasis, Heterophydiasis, and paragonimiasis, which are endemic in Luzon, Visayas, and Mindanao. Cysticercosis is also a major problem since it has a neurologic component to the illness. The approaches to control and prevention is centered on public health awareness regarding food safety as well as strengthening treatment guidelines.

The program aims to: 1. Prevent the occurrence of food and waterborne outbreaks through strategic placement of water purification solutions and tablets at the regional level so that the area coordinators could respond in time if the situation warrants; 2. Procure Intravenous Fluid solutions, venosets and IV cannula for adult and pediatric patients in diarrheal outbreaks and to be stockpiles at the 17 Centers for Health Development (CHD) and the Central Office for emergency response to complement the stocks of HEMS; 3. Place first line and second line antimicrobial and anti-parasitic medicines such as albendazole and praziquantel at selected CHDs for outbreak mitigation as well as emergency stocks at the DOH warehouse located at the Quirino Memorial Medical Center (QMMC) compound; 4. Increase public awareness in preventable food-borne illnesses such as capillaria, which is centered on unsafe cultural practices like eating raw aquatic products;

5. Increase coordination between the National Epidemiology Center (NEC) and Regional epidemiology surveillance Unit (RESU) to adequately respond to outbreaks and provide technical support; 6. Procure Typhidot-M diagnostic kits for the early detection and treatment of typhoid patients; 7. Procure Typhoid vaccine and oral cholera vaccine to reduce the number of cases seen after severe flooding; 8. Provide training to local government unit (LGU) laboratory and allied medical personnel on the Accurate laboratory diagnosis of common parasites and proper culture techniques in the isolation of bacterial food pathogens; and 9. Provide guidance to field medical personnel with regard to the correct treatment protocols vis--vis various parasitic, bacterial, and viral pathogens involved in food and waterborne diseases.

The Food and Waterborne Disease Control Program targets individuals, families, and communities residing in affected areas nationwide. For parasitic infections, endemic areas are more common.

Case monitoring is maintained through the Philippine Integrated Disease Surveillance and Response (PIDSR) framework of NEC and the sentinel sites of the RESU. To add to that, quarterly reports of the regional coordinators supplement the data and the regular updating from NEC Outbreak Surveillance. Outbreaks are being prevented though public education in print and radio stations. The need for safe food and water intake by adequate cooking and boiling of drinking water is inculcated to the public. Multi-drug resistant cases of typhoid are monitored through reports from the hospital sentinel site and the data from the Research Institute of Tropical Medicines Antibiotic Resistance & Surveillance Program.

The following organizations and agencies take part in the achievement of program objectives: University of the Philippines-National Institutes of Health (UP-NIH) Department of Agriculture-National Meat Inspection Service (DA-NMIS) Asia Centric Disease Bureau World Health Organization-Western Pacific Regional Office (WHO-WPRO) World Health Organization-Southeast Asia Regional Office (WHO-SEARO)

Teach members of the family how to report all symptoms to the attending physician especially when patient is being cared for at home. Teach, guide, and supervise members of the family on nursing techniques which will contribute to the patients recovery. Interpret to family the nature of the disease and need for practicing preventive and control measures.

Demonstrate to family how to give bedside cares, such as tepid sponge bath, feeding, changing of bed linens, use of bedpan and mouth care. Any bleeding from the rectum, blood in stools, sudden acute abdominal pain, restlessness, falling of temperature should be reported at once to the physician or the patient should be brought at once to the hospital. Take vital signs and teach family member how to take and record same.