TB Platforms for

Sustainable Detection, Care and Treatment

CLCHD Regional Memorandum No. 2019-066:

Guidelines on the Region-wide Implementation of Finding
TB Cases Actively, Separating Safely and Treating
Effectively (FAST) Strategy in all Public and Private
Hospitals and Rural/City Health Units (R/CHUs) in
Central Luzon
Timeline of Development
• May 15, 2019: Development of the Policy Brief on Region-wide FAST
implementation
• June 3, 2019: Presentation of the Policy Brief to CLCHD and Consensus-
Building
• June 10–14, 2019: Drafting of the Regional Memorandum
(Policy and Guidelines)
• July 4-5, 2019: Consultative Workshop on the Draft Regional Memo
• July 8-12, 2019: Finalization of the memo based on inputs from the
consultative workshop
• October 9, 2019: Approval and signing by the CLCHD Regional Director

Dr Hansel John Ybanez, orienting the participants of the workshop
on the FAST strategy (Photographer: Algiene Yusi)
Participants during the first workshop, where representatives from the
FAST-implementing hospitals were asked to share their experiences and
challenges as they implemented FAST. Participants in each group were
asked to analyze possible causes of the loss of FAST patients along the
TB cascade of care. (Photographer: Roselle Dalupang)
Participants during the second workshop, where they were asked Participants during the second workshop, where they were asked to
to review and revise the presented draft of policy and guidelines. review and revise the presented draft of policy and guidelines. Ms
Mr Jonathan Yambao facilitated the group (Photographer: Roselle Christine Joy Candari facilitated the group (Photographer: Roselle
Dalupang) Dalupang)
Outline of Regional Memo
1. Rationale 9. Roles and Responsibilities
2. Objectives 10. Sustainability Mechanism
3. Scope and Coverage 11. Repealing Clause
4. Definition of Terms 12. Effectivity
5. General Guidelines 13. Annexes
6. Specific Guidelines
7. Recording and Reporting
8. Monitoring and Evaluation
1) Rationale
• Although Tuberculosis (TB) detection in the Philippines has continuously improved over the past
decade, a significant proportion of DSTB and DRTB cases remain missing.

• Specifically for Central Luzon, data shows that in 2018, there were estimated 64,000 TB cases. Of
these, only 51,919 (81%) were notified to the health system and enrolled to treatment. In terms of
DR-TB, there were estimated 2,760 cases in 2018, of which, only 794 (29%) were enrolled to
treatment.

• A key review of performance reveals that the main reasons for the current status of TB detection
and treatment in the region is that engagement of the private sector in TB detection and
treatment is not fully optimized and TB clients exhibit poor health-seeking behavior, as
manifested by late/delayed consultations and hesitations to enroll for treatment.
1) Rationale
• The 2019-2022 Central Luzon Strategic TB Elimination Plan (CLuSTEP) serves as the
roadmap of the Central Luzon Center for Health Development - National TB Control Program
(CLCHD-NTP) to address the problem of TB in region 3.

• One of the CLuSTEP strategies is to expand provision of expanded integrated patient-centered TB

services thru engagement of all providers of TB services. By 2022, it targets that 100% of public
and private hospitals and R/CHUs are participating in TB control efforts under the direction of the
NTP.

• It is against this background that this Administrative Order, entitled, ‘Guidelines on the Region-
wide Implementation of the FAST Strategy in All Public and Private Hospitals and R/CHUs
in Central Luzon’ is developed.
1) Rationale
• The FAST strategy is a focused TB transmission and infection control strategy, in which all
admitted and/or visiting patients at all entry points of the hospital or R/CHUS are assessed for TB
symptoms and risk factors. All patients found to have TB symptoms or are at risk, regardless of
their chief complaint, are separated from other patients, referred immediately for TB screening and
confirmatory diagnostic tests, and enrolled to treatment, if found positive.

• The strategy also requires healthcare providers to practice infection control measures from the
time of patient referral to treatment.

• Evaluation of the initial implementation of FAST in the region showed that within three months of
implementation, the number of TB cases registered and enrolled to treatment increased by
5%. This equates to 15-20% increase in the number of TB cases detected and enrolled to
treatment per year.
1) Rationale
• The strategy is also beneficial to reducing nosocomial infections, especially for healthcare
workers at high risk, due to routine patient care.

• Administratively, the FAST strategy serves to support the overall implementation of the DOTS
strategy, which warrants that all TB cases should receive patient-centered care and treatment
(based on DOH Administrative Order 2015-0029: Revised Policies and Guidelines on Hospital
TB-DOTS under the National TB Control Program).

• If implemented effectively, the FAST strategy offers potential to find and treat the missing TB
cases, while also safeguarding healthcare workers from nosocomial TB transmission.
2) Objectives
• This Order aims to:

2.1) Provide the policies and guidelines on implementing the FAST strategy in all
Public and Private Hospitals and R/CHUs in Central Luzon;
2.2) Highlight key technical policies in facilitating and improving infection
control measures, screening, diagnosis and treatment of TB, and establishment
and/or strengthening of referral linkages between DOTS- referring and DOTS-
providing facilities;
2.3) Describe the recording and reporting system for FAST implementation;
2.4) Define the roles and responsibilities of stakeholders.
3) Scope and Coverage
• This order covers all public and private hospitals, R/CHUs, offices of the
CLCHD, and health offices of the Local Government Units (LGUs) in Region
3.
4) Definition of Terms
‘Finding TB cases A focused TB transmission and infection control strategy, in which all
Actively, Separating admitted and visiting patients at all entry points of the hospital or R/CHU
safely and Treating are assessed for TB symptoms and risk factors. All patients found to have
effectively.’ (FAST) TB symptoms or are at risk, regardless of their chief complaint, are
Strategy separated from other patients, referred immediately for TB screening and
confirmatory diagnostic tests, and enrolled to treatment, if found positive.
The strategy also requires that healthcare staff practice infection control
measures from the time of patient referral to treatment.
4) Definition of Terms
Presumptive TB Any person, with at least one of the below four signs and symptoms lasting
2 weeks or more; or
 Cough
 Unexplained fever
 Unexplained weight loss
 Drenching night sweat
Any person with at least one of the below seven TB risk factors with or
without any of the above symptoms-
 Age >60 years old
 Diabetes
 Former or Current Smoker/Alcoholic
 4Ps Beneficiary / Urban / Rural Poor
 Contact of a person with TB
 Previously treated for TB
 With other immunosuppressive medical condition
Any person with chest x-ray findings suggestive of active TB.
4) Definition of Terms
Chest X-ray A fast and painless imaging test that uses certain electro-magnetic waves
to create pictures of the structures in and around the chest. This imaging
test is used as primary screening tool for TB.
Direct Sputum A method of diagnosing TB, where sputum from a Presumptive TB
Smear Microscopy individual is collected for microscopy examination. Two sputum samples
(DSSM) are collected, either by frontloading (one hour apart sputum collection) or
early morning - spot collection.
Xpert A cartridge-based nucleic acid amplification test (NAAT) for simultaneous
Mycobacterium rapid TB diagnosis and rapid antibiotic sensitivity test. It is an automated
TB/Rifampicin diagnostic test that can identify Mycobacterium tuberculosis (MTB) DNA
Resistance and resistance to rifampicin (RIF).
(MTB/Rif) test
4) Definition of Terms
TB disease/TB case A presumptive TB case, who, after clinical an diagnostic evaluation, is confirmed
to have TB: Based on the diagnostic method used, this may be one of the
following:
Bacteriologically confirmed TB (BCTB) – refers to a patient from whom a
biological specimen either sputum or non-sputum sample is positive by smear
microscopy, culture or WHO approved rapid diagnosed tests (such as Xpert
MTB/RIF, Xpert MTB/Rif Ultra, Line Probe Assay for TB, TB LAMP).
Clinically diagnosed TB (CDTB) – refers to a patient wherein the criterion
for bacteriological confirmation is not fulfilled but diagnosis is made by the
attending physicians on the basis of clinical findings, X-ray abnormalities,
suggestive histology and/or other biochemistry or imaging tests.
Drug-Resistant TB A person with active TB disease which is resistant to one or more anti TB drugs.
(DRTB)
Drug-Susceptible A person with active TB disease which is susceptible to all anti-TB drugs. 
TB (DSTB)
Delivery of TB A strategy which warrants that all TB cases should receive patient-centered care
Services (DOTS) and treatment.
Strategy
4) Definition of Terms
DOTS Facility A healthcare facility, whether public or private, that provides DOTS, in
accordance with the policies and guidelines of the NTP.
‘Programmatic A facility equipped with the equipment and logistics needed to diagnose and
Management of Drug- treat DR-TB cases, operated by PMDT-trained healthcare professionals.
Resistant TB –
Satellite Treatment
Center’ (PMDT-STC)
Internal Referral A system of referral within a hospital or clinics (e.g. a multi-specialty or
System polyclinic). This involves referral from the wards, outpatient department or
other departments to the hospital TB team.
External Referral A process of referral from one health facility to another facility or institution
System (e.g. hospital to health center, health center to PMDT facility, jail to health
center).
Integrated A web-based system and a tool for data collection, processing, reporting, and
Tuberculosis use of the information necessary for improving TB control effectiveness and
Information System efficiency.
(ITIS)
5) General Guidelines
5.1) All Hospitals and R/CHUs shall adopt and implement FAST strategy (as the
focused TB transmission and infection control policy) that aims to facilitate and improve
infection control measures, screening, diagnosis and treatment of TB, and establishment
and/or strengthening of referral linkages between DOTS-referring and DOTS-providing
facilities.
 
5.2) CLCHD-NTP strongly encourages all hospitals to be DOTS-providing to
strengthen the implementation of FAST. Provincial/Highly Urbanized City Health
Offices (P/HUCHO) and Provincial DOH Offices (PDOHO) shall facilitate adoption by
the local government units.
 
5.3) All Hospitals and R/CHUs shall organize and support the FAST team, composed
of at least a trained medical doctor and nurse, who will oversee, coordinate and
manage the FAST Implementation.
5) General Guidelines
5.4) The designated FAST team shall operate a TB symptom and risk factor surveillance  system at all
possible entry points of the hospital (e.g. OPD, ER,) and R/CHU. All clients (and accompanying persons)
seen, regardless of their primary reason for seeking care, shall be screened for the presence of cardinal
signs and symptoms or risk factors of TB and/or Chest X-ray (if available), diagnosed and managed in
accordance with the policies and guidelines contained in the NTP Manual of Procedures.

5.5) All FAST-implementing health facilities shall ensure that a functional internal referral and
external referral system is in place. The referral system shall facilitate the following:
a. Linking high risk clients for TB to an X-ray facility for Chest X-ray;
b. Linking identified presumptive TB clients to a TB Microscopy Laboratory for DSSM or Rapid TB
Diagnostic Laboratory for Xpert MTB/Rif test; and
c. Linking diagnosed TB patients for proper TB treatment.
 
5.6) All TB cases  diagnosed and/or treated shall be reported to the NTP thru ITIS.

5.7) All FAST-implementing health facilities shall keep and maintain an updated FAST-prescribed
recording forms and submit reports to the Provincial/ Highly Urbanized City Health Office.
6) Specific Guidelines
6.1) Advocacy
 
6.1.1) The CLCHD-NTP, PDOHO and P/HUCHO shall provide an orientation on the
concept of FAST strategy to public and private hospitals and R/CHUs. It shall contain the
following salient points: infection control measures, screening algorithm, diagnostic and
treatment protocol, recording and reporting which are aligned with the national guidelines of
NTP.
 
6.1.2) An advocacy conference of Local Chief Executives (LCEs) and different
stakeholders will be conducted by CLCHD-NTP in collaboration with PDOHO and
P/HUCHO to be the platform in engaging public and private hospitals and R/CHUs. A pledge
of commitment shall be obtained from this cause.

6.1.3) As part of compliance to the licensing requirement of each hospital, the Medical
Director/ Chief of Hospital shall ensure that there is an existing local policy and procedures
that suggests the implementation of FAST Strategy.
6) Specific Guidelines
 
6.2) Setting up FAST Strategy in the Health Facility
 
6.2.1) The CLCHD-NTP, PDOHO, and P/HUCHO shall:
a) Conduct baseline assessment using the FAST Readiness Assessment Form (Annex
A) 
b) Assist the facility in organizing FAST team
c) Assist in developing health facility policies, procedures and plan for FAST strategy
implementation
d) Assist the FAST team in conducting internal advocacy or orientation to health
facility personnel
e) Provide needed capability building activities such as integrated TB-DOTS and
Direct Sputum Smear Microscopy (DSSM), Xpert MTB/Rif, TB Clinical
Management
f) Assist in establishing an effective and efficient information system (records and
reports)
 
6) Specific Guidelines
 
6.3) Implementation of the FAST Strategy
 
6.3.1) Nurses or designated personnel at all entry points, shall screen the client for the
following signs and symptoms lasting for >2 weeks:
a) Cough
b) Unexplained fever
c) Unexplained weight loss
d) Drenching night-sweat
 
Note: For screening of clients aged <15, please refer to the screening guidelines stipulated in the
latest edition of the NTP-MOP. All identified presumptive TB patients shall be recorded in the
Presumptive TB Masterlist and/or Hospital TB DOTS Referral Logbook.
6) Specific Guidelines
 
6.3) Implementation of the FAST Strategy
 
6.3.2) If the client is WITH any one of the signs and symptoms, the patient assessment form
shall be marked with the FAST screening stamp, with the appropriate signs and symptoms
ticked. All presumptive TB patient shall be given a face mask and shall be asked to sit in the
cough center waiting area (separate from non-coughing patients). Patient shall be referred to
the doctor for sputum test.  The order for sputum test shall be stamped with the FAST logo.
 
6.3.2.1) If the sputum test (Xpert MTB/Rif or DSSM) is POSITIVE, the patient shall be
enrolled to treatment under appropriate regimen. If patient is to be referred to an outside
DOTS facility for treatment, the duly accomplished referral form shall be stamped with
the FAST logo. The nurse shall follow-up and ensure patient receives treatment at the
R/CHU referral site.
 
6.3.2.2) If the sputum test is NEGATIVE, patient shall be assessed for other diseases.
6) Specific Guidelines
 
6.3) Implementation of the FAST Strategy
 
6.3.3) The nurse should also check the client for the following risk factors:  
a) Age >60 years old
b) Diabetes
c) Smoker/Alcoholic (Former or Current)
d) 4Ps Beneficiary / urban/rural poor
e) Contact of a person with TB
f) Previously treated for TB
g) With other immunosuppressive condition
 
6.3.4) If the client has ANY ONE of the risk factors, the nurse should mark the patient assessment form
with the FAST screening stamp. Appropriate risk factors shall be ticked. Patient shall be referred to the
doctor for an order for chest x-ray. The order shall be stamped with the FAST logo.
 
Note: A separate logbook in the Radiology Department shall be kept and maintained in tracking patients referred
for CXR. (See Annex E)
6) Specific Guidelines
 
6.3) Implementation of the FAST Strategy
 
6.3.5) The nurse shall coordinate with the radiology department for the x-ray results. If the
patient has POSITIVE x-ray findings, the nurse shall refer the client to the doctor for an order
for sputum test. The order shall be stamped with the FAST logo.
 
6.3.5.1) If the sputum test (GeneXpert of DSSM) is POSITIVE, the patient shall be
enrolled to treatment under appropriate regimen. If patient is to be referred to an outside
facility for treatment, the referral form shall be stamped with the FAST logo. The nurse
shall follow-up and ensure patient receives treatment at the R/CHU referral site.
 
6.3.5.2) If the sputum test is NEGATIVE, patient shall be assessed for other diseases.
6) Specific Guidelines
 
6.3) Implementation of the FAST Strategy
 
6.3.6) If the chest x-ray is NEGATIVE, the nurse shall inform the doctor who shall assess the
patient for other diseases.
 
Note: if CXR is inaccessible, but the client is with cough of any duration, with or without other
TB signs and symptoms and with risk factors, COLLECT SPUTUM SAMPLE for Xpert
MTB/Rif or DSSM. Get consent for CXR in pregnant women.
 
6.3.7) If the client has NO risk factors, the nurse shall assess the patient for other diseases.
 
6.3.8) All TB cases diagnosed and/or treated shall be reported to the NTP thru ITIS.
7)
 
Recording and Reporting
7.1) All Public and Private Hospitals and R/CHUs shall maintain the following records and submit the
following reports to the P/HUCHO on approved timeline:
 
7.1.1) TB DOTS Referring Facilities WITHOUT TB microscopy laboratory
a) Presumptive TB Masterlist or Hospital TB Referral Logbook
b) Quarterly report on FAST Implementation (Paper-based)
c) Chest X-ray Logbook at Radiology Department (if applicable)
d) Notification of TB cases detected thru Integrated Tuberculosis Information System (ITIS)
 
7.1.2) TB DOTS Referring Facilities WITH TB microscopy laboratory
e) Presumptive TB Masterlist or Hospital TB Referral Logbook
f) NTP Laboratory Request Form
g) NTP Laboratory Register
h) Chest X-ray Logbook at Radiology Department (if applicable)
i) Quarterly report on FAST Implementation (Paper-based)
j) Notification of TB cases detected thru Integrated Tuberculosis Information System (ITIS)
 
7)
  
Recording and Reporting
7.1.3) TB DOTS Providing Facilities
a) Presumptive TB Masterlist or Hospital TB Referral Logbook
b) NTP Laboratory Request Form
c) NTP Laboratory Register
d) Drug susceptible TB Register
e) Chest X-ray Logbook at Radiology Department (if applicable)
f) Quarterly report on FAST Implementation (Paper-based)
g) Notification of TB cases detected thru Integrated Tuberculosis Information System (ITIS)
 
7)
 
Recording and Reporting
7.2) Timetable for the submission of reports
 
8) Monitoring and Evaluation
 
8.1) FAST implementing health facilities shall be included in the NTP monitoring, conduct of
program implementing review and periodic evaluation.
 
8.2) The following indicators shall be analyzed: Incidence Rate of Health Workers with TB, X-
ray Positivity Rate, Testing Rate, Xpert MTB/Rif Positivity Rate, DSSM Positivity Rate,
BC/CD Ratio, Percentage of TB cases detected among all people screened, Treatment
Enrollment Rate, TB Notification Rate.
9) Roles and Responsibilities
 
9.1) Public and Private Hospitals and Rural Health Units
 
a) Organize and support a FAST team to facilitate FAST strategy implementation;
b) Develop and implement plans and policies on FAST Strategy;
c) Establish and maintain an internal and external TB referral system;
d) Provide services to TB patients according to the FAST strategy recommendations, and in
line with the DOH-NTP policies and international standards;
e) Coordinate with the CLCHD, PDOHO, P/HUCHO in case technical or logistical
assistance is needed;
f) Identify and provide all equipment and logistics needed to implement FAST Strategy, and
ensure effective storage, operating and maintenance procedures;
g) Maintain NTP records and submit reports periodically;
h) Participate during FAST monitoring and supervisory visits & strategy implementation
review.
9) Roles and Responsibilities
 
9.2) Department of Health – Central Luzon Center for Health Development
 
a) Oversee the implementation of FAST Strategy in the hospitals and R/CHUs;
b) Formulate and issue relevant policies and guidelines that would further support
implementation of FAST;
c) Provide technical support, including relevant training, to the staff of hospitals and R/CHUs;
d) Provide logistical support such as anti-TB drugs, laboratory supplies and basic NTP forms;
e) Conduct monitoring, supervisory visits, strategy review and planning;
f) Coordinate with LGUs and program partners.

9.3) Local Government Units (Provincial/Municipal/City Health Office)

 
g) Oversee the implementation of FAST Strategy in the hospitals and R/CHUs;
h) Provide technical assistance to the hospitals and R/CHUs;
i) Conduct EQA of DSSM;
j) Receive, allocate and distribute TB logistics from DOH;
9) Roles and Responsibilities
 
e) Procure TB logistics to augment supply from DOH;
f) Facilitate participation of hospitals and R/CHUs in the referral systems;
g) Conduct or participate in monitoring and mentoring visits, strategy review and planning;
h) Coordinate with the DOH-CLCHD and program partners;
i) Submit quarterly reports to CLCHD on approved timeline.

9.4) Development Partners

a) Provide technical assistance to hospitals and R/CHUs from the initiation to the
institutionalization of the FAST strategy;
b) Provide training for hospital and R/CHU staff relevant to FAST implementation;
c) Collect data on FAST implementation on a periodic basis, and do analysis on FAST indicators to
assist in improving the strategy;
d) Participate in monitoring and supervisory visits, strategy review and planning;
e) Provide stamps for all FAST implementers;
f) Coordinate with the DOH-CHD Region 3, LGUs, FAST-implementing hospitals and R/CHUs
and other partners.
10) Sustainability Mechanism
 
To facilitate sustainability mechanism, it is recommended that the provisions of this issuance, along
with the FAST Standard of Procedures of the hospital/R/CHU, be integrated into the facility’s
existing infection control procedures.
11) Repealing Clause
 
All issuances that are inconsistent with the provisions of this RO are repealed or modified accordingly.
12) Effectivity
 
The issuance shall take effect immediately following release by the DOH-CLCHD, using the official
publication medium.
 

Annexes
Annex A. FAST Implementation Readiness Assessment Form
 
Annex A. FAST Implementation Readiness Assessment Form
 
Annex A. FAST Implementation Readiness Assessment Form
 
Annex A. FAST Implementation Readiness Assessment Form
 
Annex B. Algorithm for Implementation of the FAST Strategy

 
Annex C.FAST Implementation Quarterly Report
 
Annex C.FAST Implementation Quarterly Report
 
Annex C.FAST Implementation Quarterly Report
 
Annex D.FAST Implementation Monitoring Tool
 
Annex D.FAST Implementation Monitoring Tool
 
Annex D.FAST Implementation Monitoring Tool
 
Annex E. Format of Radiology Department Logbook for FAST