Disease : Tuberculosis

• “Primary Complex” is less than 3 years old
• Any child who does not return to normal health after measles or whooping cough.
• Most hazardous period: first 6-12 months after infection
• Highest in risk of developing: under 3 years old

Causative Agent

Mycobacterium Tuberculosis

Mode of Transmission

Droplet Infection ( inhalation of bacilli from patient who coughs and sneeze). Degree of Communicability Depends upon:

• Number of bacilli
• virulence of bacilli
• environmental conditions

Clinical Manifestation

• General weakness
• Loss of weight, cough and wheeze which does not respond to antibiotic therapy.
• Ever and night sweat
• Abdominal swelling with a hard painless mass and free fluid
• Hemoptysis and chest pain
• Painful firm or soft swelling in a group of superficial lymph nodes. Note: In young children the only sign of pulmonary TB may be stunted growth or failure to thrive.

Reservoir

Man And Diseased Cattle (Bovine TB)

Diagnostic Exam

• Sputum Exam 3 sample are taken with 24 hrs:
• Spot sample (1st visit)
• Early morning specimen
• Spot sample (2nd visit) Note: at least 2 sample are positive.
• Chest Xray
• Mantoux Test
• - .1 cc injection of PDD and 48- 72 hours reading * 10 mm + 5 mm + (HIV pt.)

Treatment

DOTS - patient is required to take the Ant-Tb drugs in the presence of a health care provider to ensure compliance to treatment regimen.

Anti-TB drugs: (RIPES)

• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol
• Streptomycin

Nursing Implication

Pointers for teaching on Anti- TB drugs:

• Rifampicin: taken befor meals, causes red urine urine
• Isoniazide: causes peripheral neuritis, given with Vit.B6
• Pyrazinamide: cause hyperurucemia
• Ethambutol: causes optic neuritis/ blurring of vision
• Streptomycin: cause tinnitus, loss of hearing balance, damage to 8th cranial nerve

Note: After 2-4 weeks of treatment, patient is no longer contagious.

The National Tuberculosis Control 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 LGU’s and other partners.

Goal: To reduce prevalence and mortality from TB by half the year 2015 ( Millennium Development 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

Objective A: Improve access to and quality of services provided to TB patients, TB symptomatics and communities by health care institutions and providers.

Strategies:

• Enhance quality of TB diagnosis.
• Ensure TN patient’s treatment compliance.
• Ensure public and private health care providers adherence to the implementation of national standards of care for TB patients.
• Improve access to services through innovative service delivery mechanisms for patients living in challenging areas.

Objective B: Enhance the health-seeking behavior 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 accreditation
• 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

1. DSSM ( Direct Sputum Smear Microscopy ) shall be the primary diagnostic tool in NTP case finding. Note: No TB diagnosis shall be made based on Xray result alone likewise result of PDD skin test (Mantoux Test).
2. All TB symptomatic identified shall undergo DSSM for diagnosis before start of treatment. Note: Only contraindication for sputum collection is hemoptysis.
3. After three sputum specimen yielding negative result X-ray and culture are necessary. Note: Diagnosis based on Xray shall be made by the TB Diagnostic Committee.
4. Only trained medical technologist or microscopist shall perform DSSM.

Patients with the following conditions shall be recommended for hospitalization:

• massive hemoptysis
• pleural effusion
• military TB ( TB of the Spine “Pot’s Disease”)
• TB meningitis
• TB pneumonia
• and those requiring surgical intervention

Anti-TB drugs: (RIPES)

• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol
• Streptomycin

Two Formulation of Anti-TB Drugs

1. Fixed-Dose Combination ( FDCs) – two or more first line anti-TB drugs are combined in one tablet. There are 2,3, or 4 drug fixed dose combinations.
2. Single Drug Formulation (SDF) – each drug is prepared individually. Isoniazid, Pyrazinamide and Ethambuto are in tablet form while Rifampicin is in capsule form and streptomycin is injectable.

RECOMMENDED CATEGORY OF TREATMENT REGIMEN

1. Category I (Type of TB Patient)
• New smear positive PTB
• New smear positive PTB with extensive parenchymal lesion
• EPTB and Severe concomitant HIV disease
• TREATMENT REGIMEN
• IntensivePhase
• - 2 RIPE
• ContinuationPhase
• - 4 RI
• TOTAL PERIOD
• - 6 mos.
2. Category II (Type of TB Patient)
• Treatment Failure
• Relapse
• Return after default
• TREATMENT REGIMEN
• IntensivePhase
• - 2 RIPES / 1 RIPE
• ContinuationPhase
• - 5 RIE
• TOTAL PERIOD
• - 8 mos.
3. Category III (Type of TB Patient)
• New smear-negative PTB
• With minimal parenchymal lesion
• TREATMENT REGIMEN
• IntensivePhase
• - 2 RIP
• ContinuationPhase
• - 4 RI
• TOTAL PERIOD
• - 6 mos.
4. Category 1 (Type of TB Patient)
• Chronic ( still smear-positive after supervised re-treatment )
• TREATMENT REGIMEN
• IntensivePhase
• - Refer to or DOTS to City
• ContinuationPhase
• - Specialized Plus Center Provincial Coordinator
• TOTAL PERIOD
• - facility refer NTP

DOSAGE PER CATEGORY OF TRATMENT REGIMEN

1. Fixed-Dose Combination Formulation : The number of tablets of FDCs per patient will depend on the body weight.
• Categories I and III : 2 RIPE / 4 RI ( FDC)
• - No.of tablets per day Intensive Phase ( 2 months ) FDC-A ( RIPE)
• Body Weight (kg) : 30 – 37 / No. of tablets : 2
• Body Weight (kg) : 38 – 54 / No. of tablets : 3
• Body Weight (kg) : 55 – 70 / No. of tablets : 4
• Body Weight (kg) : more than 70 / No. of tablets : 5
• - No. of tablets per day Continuation Phase ( 4 months ) FDC-B (RI)
• Body Weight (kg) : 30 – 37 / No. of tablets : 2
• Body Weight (kg) : 38 – 54 / No. of tablets : 3
• Body Weight (kg) : 55 – 70 / No. of tablets : 4
• Body Weight (kg) : more than 70 / No. of tablets : 5
• Categories II : 2 RIPES / RIPE / 4RIE (FDC)
• - Intensive Phase
• Body Weight (kg) : 30 – 37 / First 2 Months FDC-A (RIPE) : 2 / Streptomycin : 0.75 g / 3rd Month FDC-A (RIPE) : 2
• Body Weight (kg) : 38 – 54 / First 2 Months FDC-A (RIPE) : 3 / Streptomycin : 0.75 g / 3rd Month FDC-A (RIPE) : 3
• Body Weight (kg) : 55 – 70 / First 2 Months FDC-A (RIPE) : 4 / Streptomycin : 0.75 g / 3rd Month FDC-A (RIPE) : 4
• Body Weight (kg) : more than 70/ First 2 Months FDC-A (RIPE) : 5 / Streptomycin : 0.75 g / 3rd Month FDC-A (RIPE) : 5
• - Continuation Phase
• Body Weight (kg) : 30 – 37 / FDC-B (RI) : 2 / E 400 MG : 1
• Body Weight (kg) : 38 – 54 / FDC-B (RI) : 3 / E 400 MG : 2
• Body Weight (kg) : 55 – 70 / FDC-B (RI) : 4 / E 400 MG : 3
• Body Weight (kg) : more than 70 / FDC-B (RI) : 5 / E 400 MG : 3
2. Single Dose Formulation ( SDF ) : Simply add 1 tablet of Isoniazid ( 100mg) , Pyrazinamide (500mg) and Ethambutol ( 400mg) each for the patient weighing more than 50kg before treatment initiation. Modify drug dosage within acceptable limits according to patient’s body weight, particularly those weighing less than 30 kg at the time of diagnosis.
• Categories I and III: 2 RIPE / 4 RI (SDF)
• - Anti-TB Drugs
• Rifampicin
• No. of tablets per day (Intensive phase 2 months) : 1
• No. of tablets per day (Continuation phase 4 months) : 1
• Isoniazid
• No. of tablets per day (Intensive phase 2 months) : 1
• No. of tablets per day (Continuation phase 4 months) : 1
• Pyrazinamide
• No. of tablets per day (Intensive phase 2 months) : 2
• No. of tablets per day (Continuation phase 4 months) : 0
• Ethambutol
• No. of tablets per day (Intensive phase 2 months) : 2
• No. of tablets per day (Continuation phase 4 months) : 0
• Categories II: 2 RIPES / 1 RIPE / 5 RIE
• - Anti-TB Drugs
• Rifampicin
• No. of tablets per day / vial per day (Intensive phase first 2 months) : 1
• No. of tablets per day / vial per day (Intensive phase 3rd months) : 1
• No. of tablets per day (Continuation phase 5 months) : 1
• Isoniazid
• No. of tablets per day / vial per day (Intensive phase first 2 months) : 1
• No. of tablets per day / vial per day (Intensive phase 3rd months) : 1
• No. of tablets per day (Continuation phase 5 months) : 1
• Pyrazinamide
• No. of tablets per day / vial per day (Intensive phase first 2 months) : 2
• No. of tablets per day / vial per day (Intensive phase 3rd months) : 2
• No. of tablets per day (Continuation phase 5 months) : 0
• Ethambutol
• No. of tablets per day / vial per day (Intensive phase first 2 months) : 2
• No. of tablets per day / vial per day (Intensive phase 3rd months) : 2
• No. of tablets per day (Continuation phase 5 months) : 2
• Streptomycin
• No. of tablets per day / vial per day (Intensive phase first 2 months) : 1
• No. of tablets per day / vial per day (Intensive phase 3rd months) : 1

Dose per Kg Body Weight and Maximum Dose

• - Anti-TB Drugs
• Rifampicin
• 5 ( 4 – 6 ) mg/kg and not to exceed 400 mg daily
• Isoniazid
• 10 ( 8 – 12 ) mg/kg and not to exceed 600 mg daily
• Pyrazinamide
• 25 ( 20 – 30 ) mg/kg and not to exceed 2 mg daily
• Ethambutol
• 15 ( 15 – 20 ) mg/kg and not to exceed 1.2 g daily
• Streptomycin
• 15 ( 12 – 18 ) mg/kg and not to exceed 1 g daily

D.O.T.S ( Directly-Observed Treatment Shortcourse ) “TuTok Gamutan”

5 Elements of D.O.T.S

• Sustained political commitment
• Access to quality-assured sputum microscopy
• Standardized short-course chemotherapy for all cases of TB
• Uninterrupted supply of essential drugs
• Recording and reporting system enabling outcome assessment of all patients and assessment of overall program performance.

MANAGEMENT OF CHILDREN WITH TB

Prevention

• BCG vaccination shall be given to all infants.
• BCG vaccine is moderately effective. It has a protective efficacy of:

• 50 % against any TB disease
• 64 % against TB meningitis
• 74 % against death from TB

Case Finding

• Cases of TB in children are reported and identified in two instances:
• - The patient sought consultation.
• - The patient was reported to have been exposed to an adult with TB
• All TB symptomatic children 0-9 years old, except sputum positive child shall subject to PDD testing
• - Only trained nurse and midwife shall do the PDD test and recording
• - Testing and reading shall be conducted once a week either on Monday or Tuesday. Note: 10 children shall be gathered for testing to avoid wastage.

A child shall be suspected as having TB and considered symptomatic if with any three (3) of the following sign and symptoms:

• cough and wheezing for 2 weeks or more
• unexplained fever for 2 weeks or more loss of appetite,
• loss of weight, failure to gain weight
• failure to respond to a 2 weeks of appropriate antibiotic therapy
• failure to regain state of health 2 weeks after a viral infection or after having measles.

A child shall be clinically diagnosed or confirmed of having TB if he has any three (3) of the following condition:

• positive history of exposure to an adult/ adolescent TB case
• presence of sign and symptoms suggestive of TB
• positive Mantoux Test
• abnormal chest radiograph suggestive of TB

Management

For children with exposure to TB

• Should undergo physical examination and PDD testing (Mantoux Test)
• A child with productive cough shall be referred for DSSM, if found positive, treatment shall be started immediately. PDD testing shall no longer needed.
• Children without sign/symptoms of TB but with positive Mantoux Test and those with symptoms of TB but negative Mantoux Test shall referred for chest x-ray examination.

For children with signs and symptoms of TB

• A child to have signs and symptoms of TB with either known or unknown exposure shall be referred for Mantoux test.
• For children with known contact but with negative Mantoux and those unknown contact but with positive Mantoux shall be referred for chest x-ray examination.
• For a negative x-ray report, Mantoux test shall be repeated after 3 months.
• Chemoprophylaxis of Isoniazid for 3 months shall be given to children less than 5 years old with negative chest x-ray after which Mantoux test shall be repeated.

Treatment

• D.O.T.S will still be followed just like in adult
• Short course regimen:
• - at least 3 anti-TB drugs for 2 months ( intensive phase )
• - 2 anti-TB drugs for 4 months ( continuation phase )
• *For Extra Pulmonary TB Cases:
• - 4 anti-TB drugs for 2 months ( intensive phase )
• - 2 anti-TB drugs for 10 months ( continuation phase )
• Domiciliary treatment shall be the preferred mode of care
• No treatment shall be initiated unless the patient and health worker has agreed upon a caseholding mechanism for treatment compliance.

Treatment Regimen

1. Pulmonary TB
• Rifampicin (Intensive Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 2 months
• Isoniazid (Intensive Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 2 months
• Pyrazinamide (Intensive Phase)
• Daily Dose : 20-30 mg/kg body weight
• Duration : 2 months
• Rifampicin (Continuation Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 4 months
• Isoniazid (Continuation Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 4 months
2. Extra Pulmonary TB
• Rifampicin (Intensive Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 2 months
• Isoniazid (Intensive Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 2 months
• Pyrazinamide (Intensive Phase)
• Daily Dose : 20-30 mg/kg body weight
• Duration : 2 months
• Ethambutol (Intensive Phase)
• Daily Dose : 15-25 mg/kg body weight
• Duration : 2 months
• Streptomycin (Intensive Phase)
• Daily Dose : 20-30 mg/kg body weight
• Duration : 2 months
• Rifampicin (Continuation Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 10 months
• Isoniazid (Continuation Phase)
• Daily Dose : 10-15 mg/kg body weight
• Duration : 10 months

Public Health Nurse Responsibilities ( Childhood TB )

1. Interview and open treatment cards for identified TB children.
2. Perform Mantoux testing and reading to eligible children
3. Maintain NTP records
4. Manage requisition and distribution of drugs
5. 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.
6. Assist in the training of other health workers on Mantoux testing and reading.