Tuberculosis

Signs and Symptoms

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

Infectious Agent
Mycobacterium tuberculosis and M. Africanum

primarily from humans, and M. bovis primarily from cattle.

Mode of Transmission
Airborne droplet method through coughing, singing

or sneezing. Direct invasion through mucous membrane or breaks in the skin may occur, but is extremely rare. Bovine tuberculosis result from exposure to tuberculosis cattle, usually by ingestion of unpasteurized milk or dairy products. Extrapulmonary tuberculosis, other than laryngeal, is generally not communicable, even if there is a draining sinus.

Period of Communicability

Susceptibility and Resistance

Method of Control

Preventive Measures
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 eamination 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 prevent treatment of contacts.

The National Tuberculosis Program

Vision: A country where TB is no longer a public health problem Mission: Ensure that TB DOTS services are available, accessible, and affordable to the communities in collaboration with the LGUs and other partners Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millennium Developmental Goal)

Targets: Cure at least 85% of the sputum smear- positive TB patient discovered Detect at least 70% of the estimated new sputum smear- positive TB cases

 NTP Objectives and Strategies

The NTPs four- pronged set of objectives calls for improvement of access to and quality of services, enhancement of stakeholders health- seeking behavior, sustainability of support for TB control activities, and strengthening management of TB control services at all levels.

Objective A: improve access to and quality of servies provided to TB patients, TB symptomatics, and communities by health care institutions and providers

Strategies:
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 (geographically isolated communities with peace and order problem, culturally- different, and those in institutions like prisons)
1.

Objective B: Enhance the health- seeking behaviors on TB by communities, especially the TB symptomatics

Strategies:
Develop effective, appropriate, and culturally-

responsive IEC/ communication materials. Organize barangay advocacy groups

Objective C: Increase and sustain support and financing for TB control activities

Strategies:
Facilitate implementation of TB- DOTS Center

certification and accrediatation. Build TB coalitions among different sectors. Advocate for counterpart input from local government units. Mobilize/extend other resources to address program limitations

Objective D: Strengthen management (technical and operational) of TB control services at all levels.

Strategies:
Enhance managerial capability of all NTP program

managers at all levels. Establish an efficient data management system for both public and private sectors. Implement a standardized recording and reporting system. Conduct regular monitoring and evaluation at all levels. Advocate for political support through effective local governance.

Key Policies

Category I

Type of TB patient New smear- positive PTB New smear- negative PTB with extensive parenchymal lesions on CXR as assessed by th TBDC EPTB Severe concomitant HIV disease

Treatment Regimen Intensive phase Continuation Phase

2HRZE

4 HR

II

Treatment failure Relapse Return after Default Other New smear- negative PTB with minimal parenchymal lesions on CXR as assessed by the TBDC

2HRZE/ 1HRZE

5HRE

III

2HRZE

4HR

IV

Chronic (still smear- positive after supervised treatment)

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

Body weight (kg)

No. of tablets per day Intensive Phase (2 months) FDA (HRZE) 2 3 4 5

No. of tablets per day Continuation Phase (4 months) FDC- B (HR) 2 3 4 5

30- 37 38- 54 55- 70 >70

Body weight (kg)

Intensive Phase First two months FDC- A (HRZE) Streptomycin Third mo. FDC- A (HRZE) 2 3 4 5

Continuation Phase FDC- B (HR) E 400mg

30- 37 38-54 55- 70 >70

2 3 4 5

0.75 g 0.75 g 0.75 g 0.75 g

2 3 4 5

1 2 3 3

Anti- TB Drugs

No. of tablets per day Intensive Phase (3 months)

No. of tablets per day Continuation Phase (4 months)

Isoniazid (H) Rifampicin Pyrazinamide (Z)

1 1 2

1 1

Ethambutol (E)

Anti- TB Drugs

No. of tablets/vial per day Intensive Phase (3 months)

No. of tablets per day Continuation Phase (5 months)

First 2 months Isoniazid (H) 1

3rd months

Rifampicin (R)
Pyrazinamide (Z) Ethambutol (E) Streptomycin (S)

1
2 2 1 vial/day*

1
2 2

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

Public Health Nursing Responsibility (Adult TB)

Together with other NTP staffworker, manage the procedures for case-

finding activities Assign and supervise a treatment partner for patient whi 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. Provide continuous health education to all TB patients placed under treatment and encourage family and community participation in TB control. In coordination with the physician, conduct training of health workers. Prepare, analyse, and submit the quarterly reports to the Provincial Health Office or City Health Office.

Leprosy

Signs and Symptoms

1. Early Signs and Symptoms Change in skin color- either reddish or white Loss of sensation on the skin lesion Decrease/ loss of sweating and hair growth over the lesion Thickened and/ or painful nerves Muscle weakness or paralysis of extremities Pain and redness of the eyes Nasal obstruction or bleeding Ulcers that do not heal

2. Late Signs and Symptoms Loss of eyebrow- madarosis Inability to close eyelids- lagophthalmos Clawing of fingers and toes Contractures Shrinking of the nose bridge Enlargement of the breast in males or gynecomastia Chronic ulcers

Infectious Agent
Mycobacterium leprae an acid fast, rod- shaped

bacillus which can be detected by Silt Skin Smear (SSS)

Method of Transmission
Airborne- inhalation of droplet spray from coughin

and sneezing of untreated leprosy patient Prolonged skin-to-skin contact

 Diagnosis of leprosy is currently based on clinical signs

and symptoms especially if there is history of contact with person with leprosy (PWL). Only in rare instances is there really a need to use laboratory and other investigation to confirm a diagnosis. Silt Skin Smear (SSS) examination is an optional procedure. It is done only when clinical diagnosis is doubtful. The main objective is to prevent misclassification and wrong treatment. A ready referral facility must be recognized in the conduct of SSS procedures. Susceptibility - Children especially twelve years and below are more susceptible

Prevention Avoidance of prolonged skin-to-skin contact especially with a lepromatous case Children should avoid close contact with active, untreated leprosy case BCG vaccination Good Personal Hygiene Adequate Nutrition Health Education

Leprosy Control Program

Vision:

Empowered primary stakeholders in leprosy and eliminated leprosy as a public health problem by 2020 Mission: To ensure the provision of a comprehensive, integrated quality leprosy services at all levels of health care Goal: To maintain and sustain the elimination status

The National Leprosy Control Program aims to:

Ensure the availability of adequate anti-leprosy drugs or

multiple drug therapy (MDT). Prevent and reduce disabilities from leprosy by 35% through Rehabilitation and Prevention of Impairments and Disabilities (RPIOD) and Self Care. Improve case detection and post-elimination surveillance system using the WHO protocol in selected LGUs. Integration of leprosy control with other health services at the local level. Active participation of person affected by leprosy in leprosy control and human dignity program in collaboration with the National Program for Persons with Disability. Strengthen the collaboration with partners and other stakeholders in the provision of quality leprosy services for socio-economic mobilization and advocacy activities for leprosy.

Public Health Responsibilities

a. Prevention

Health education of patients, families and the

community on the nature of the disease, symptomatology and its transmission. Children who are more susceptible to the disease should not be exposed to untreated lepromatous cases. Advocate healthful living through proper nutrition, adequate rest, sleep and good personal hygiene. BCG vaccination especially of infants and children.

b. Casefinding Recognize early signs and symptoms of leprosy and refers suspects to the RHU physician or skin clinic for diagnosis and treatmen Takes patient and family history and files up patient records Conducts epidemiological investigation and report findings to MHO Assists physician in physical examination of patients in the clinic/ home. Assesses health of the family members and other household contacts. Performs/assists in examination of contacts Integrates casefinding of leprosy case in other activities such as MCH, EPI, inspection, examination of school children and other programs