MODULE VIII- NATIONAL TUBERCULOSIS PROGRAM
Marvin John J. Singco, RMT, MLS (ASCPi)
BRENT College of Medical Technology/Medical Laboratory Science
marvinjohnsingco@[Link]
At the end of this module, the student can:
1. Explain the mission, vision, goals and objectives of
NTP;
2. Explain DOTS;
3. Define Tuberculosis; and
4. Discuss Tuberculosis mode of transmission, treatment,
and diagnosis.
High prevalence of tuberculosis has
economic repercussions for the patient, his family, and
the country. 80% of those afflicted with tuberculosis are
in the most economically productive years of their lives,
and the disease sends many self-sustaining families
into unemployment and poverty. The rise in the number
of cases of tuberculosis is due to the unavailability of
anti-TB drugs, insufficient laboratory networking, poor
health infrastructures, and the lack of trained health
personnel.
According to the WHO, the Philippines ranks 4th in the world for the number of cases of
tuberculosis and has the highest number of cases per head in SEA. Sadly, almost 2/3 of Filipinos have
tuberculosis, and up to five million people are infected yearly in our country.
THE NATIONAL TUBERCULOSIS PROGRAM
First implemented in 1978 by the DOH, the National TB Control Program (NTP) identified the following
vision, mission and goals
VISION
A Tuberculosis-free Philippines
Zero deaths, disease, and suffering due to tuberculosis
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
MISSION
Ensure that TB-DOTS services are available, accessible and affordable to TB Clients through the
health services provided by the government agencies, non-governmental organizations and the private
sector involved in TB Control.
GOAL
Long Term Goal (2035):
• Reduce TB burden by decreasing TB mortality by 95% and TB incidence by 90%.
Medium Term Goals (2022):
• Reduce TB burden by:
• Decreasing the number of TB deaths by 50% from 22,000 to 11,000
• Decreasing TB incidence rate by 15% from 554/100,000 to 470/100,000
• Reduce catastrophic costs incurred by TB-affected households from 35% to 0%.
• At least 90% of patients are satisfied with the services of the DOTS facilities.
OBJECTIVES:
Specific objectives by 2022:
1. Improve the utilization of TB care and prevention services by patients and communities.
2. Reduce catastrophic cost of TB-affected households accessing DOTS facilities to 0%.
3. Ensure adequate and competent human resources for TB elimination efforts.
4. Improve the use of TB data for effective TB elimination efforts.
5. Enhance quality of all TB care and prevention services.
6. Increase to at least 90% of DOTS facilities that are providing expanded integrated patient centered
TB care and prevention services.
7. Enhance the political stewardship through high-level political commitment of national government
agencies and LGUs to implement localized TB elimination plan in coordination with different sectors.
DOTS as a key strategy in the National Tuberculosis Program
Directly Observed Treatment, Short-course (DOTS) or Tutok Gamutan, which the WHO introduced in
1996, is a combination of technical and managerial components breaking the cycle of transmission
between the TB infectious to non-infectious cases
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
DOTS is the most effective strategy in controlling TB today. This strategy takes place in a health facility,
treatment partner’s house or the patient’s house. Under DOTS, a treatment partner watches the patient
take his drug daily, reports and traces the patient if he defaults, provides health education regularly and
motivates the patient on sputum follow-ups. This supervised treatment is recommended for all smears (+)
TB cases. Treatment partners can anyone who is willing, trained, responsible, acceptable to the patient
and accountable to the TB control services.
FIVE COMPONENTS OF THE DOTS
1. Political commitment- Government and private sector groups working together
2. Microscopy services- Good quality diagnosis through Sputum smear microscopy
3. Direct observation of treatment- Trained treatment partners directly observe TB treatment
4. Quality drugs and uninterrupted supplies
5. Monitoring System- Registering TB patients, recording standard treatment outcome and reporting
results to the central NTP office.
Standard Treatment with Directly Observed Treatment
DOTS utilizes a standardized treatment regimen of at least 6 to 8 months for all confirmed sputum
smear positive cases, with directly observed treatment for at least the initial two months.
The NTP makes sure of the following:
• High quality drugs
• Free drugs for all the patient must be present before treatment is started
• Fixed Dose combination is preferred to avoid monotherapy. This will help reduce the emergence of
drug-resistant TB. In particular, to reduce the risk of using Rifampicin for conditions other than TB.
TUBERCULOSIS
Tuberculosis is a highly infectious, chronic respiratory disease caused by Mycobacterium
tuberculosis. It is one of the 10 leading causes of morbidity and mortality in the Philippines, and is also
known as KOCH’S DISEASE.
“Tubercle”- Round nodule/swelling, “osis”- condition
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
ETIOLOGIC AGENT
Mycobacterium tuberculosis (MTb) isolated by Robert Koch in 1882. Characteristics include the
following:
1. MTb are acid-fast bacilli (AFB): Stain with difficulty but
once stained, they do not decolorize with acid alcohol
2. MTb grows on simple medium such as Lowenstein-Jensen
or BACYEC and is slow growing
3. MTb are obligates aerobes, meaning they cannot survive
without oxygen
4. Culturing of clinical specimens increase rate of case
detection due to the higher sensitivity of culture compared
to smear microscopy.
• Other Mycobacteria such as Mycobacterium bovis, Mycobacterium africanum, Mycobacterium
canetti, and Mycobacterium microti can also cause tuberculosis, but these species do not usually
infect healthy adults.
MODE OF TRANSMISSION
• TB bacilli are passed through the air when a person who is sick with TB disease coughs,
sings, sneezes or laughs speaks, or another person breathes the air into their lungs
containing the TB bacteria.
• Spread occurs most often among household or
other close contacts with infected person’s sputum
• Several factors- genetic susceptibility, age, stress,
nutrition-influence the outcome of infection
• Droplet infection; 1-5 microns in diameter and
remains suspended in the air for 30 minutes
Spread of Droplet infection
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
Common Symptoms of TB Disease
• Cough (2-3 weeks or more)
• Coughing up blood
• Chest pains
• Fever
• Night sweats
• Feeling weak and tired
• Losing weight without trying
• Decreased or no appetite
Diagnosis
1. Bacteriological test
a. Ziehl-Neelsen stain
b. Auramine stain (Fluorescence microscopy)
2. Sputum culture test
a. Lowenstein-Jensen (LJ) solid medium: 4-18 weeks
b. Liquid medium: 8-14 days
c. Agar medium: 7 to 14 days
3. Radiography: Chest X-ray (CXR)
4. Nucleic acid amplification
5. Tuberculin skin test
Direct Sputum Smear Microscopy
Direct sputum smear microscopy or DSSM is the
primary diagnostic tool in NTP case finding. Sputum
microscopy is a more specific test than chest x-ray for TB
diagnosis. Based on the NTP, no diagnosis of PTB shall be
made based on the chest x-ray result alone to avoid over
diagnosis. In fact, to avail of the free TB drugs, sputum smear
result is required.
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
Collection and Transport of Sputum Specimens
• Explain to the TB symptomatic the purpose of sputum examination
• Demonstrate how to produce good sputum so that sputum is produced from deep down in the chest:
o Instruct patient to rinse mouth with water to remove food remnants prior to coughing out.
Brushing the teeth and rinsing mouth with an antiseptic is not recommended
o Ask the patient to breathe in deeply two times and then exhale through pursed lips
o At the height of the third inspiration, ask client to cough out strongly and spit the sputum in
the container.
• Seal the sputum specimen containers. Label the body of the container with the patient’s complete
name, date and time of collection and the referring unit
o Recommended specimen containers:
▪ Clean and preferably sterile
▪ Wide-mouthed
▪ Leak proof
▪ Disposable
▪ Transparent
▪ Durable
▪ Easily labeled on outer surface
• Transport the specimen containers to a laboratory as soon as possible or not later than 4 days from
collection together with the laboratory request form. Otherwise, the specimen should be stored in a
cool, dark and safe place. Freezing of the specimen may decrease yield
• Collect three sputum specimens within 2 days from each patient with respiratory symptoms of more
than 3 weeks duration according to the following procedure
o Spot Specimen (1st) – at the time of consultation or as soon as TB suspect is identified
o Early morning Specimen (2nd)- very first sputum produced in the morning collected by the
patient himself as per instruction of the health worker
o Spot specimen (3rd)- at the time the patient comes back to the health facility to submit the
second specimen
Interpretation of Smear examination
• if at least 2 sputum specimens are smear positive for AFB= pulmonary smear positive case
• if all 3 specimens are negative, refer to Medical Health officer for further assessment if symptoms
persist
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
• if only one sputum specimen is positive for AFB= doubtful, advise TB suspect to undergo another
sputum examination of 3 specimens
Treatment
• Treatment for TB uses antibiotics to kill the bacteria. The two antibiotics most commonly used are
rifampicin and isoniazid
• However, instead of the short course of antibiotics typically used to cure other bacterial infections,
TB requires much longer periods of treatment (around 6 to 12 months) to entirely eliminate
mycobacteria from the body
• Multiple-drug therapy to treat TB means taking several different antitubercular drugs at the same
time
• The standard treatment is to take isoniazid, rifampin, ethambutol, and pyrazinamide for 12 months.
• Directly Observed Treatment (DOT)
ANTI-TUBERCULAR DRUGS
1st line Drug 2nd Line drug Newer Drug
1. Isoniazid 1. Thiacetazone 1. Ciprofloxacin
2. Rifampin 2. Paraaminosalicylic acid 2. Oflaxacine
3. Pyrazinamide 3. Ethionamide 3. Clarithromycine
4. Ethambutol 4. Cycloserine 4. Azithromycine
5. Streptomycine 5. Kanamycine 5. Rifabutine
6. Capriomycine 6. Bedaquiline
Prevention
• For the prevention of TB, general measures such as adequate nutrition, health education, cover
the mouth and wear mask, wash your hands frequently are important measures.
• Intradermal injection of live attenuated vaccine BCG (Bacille Calmette-Guerin)
• Immunity lasts for 10-15 years
Tuberculosis and HIV
• Worldwide the number of people infected with both HIV and TB is rising
• The HIV virus damages the body’s immune system and accelerates the speed at which TB
progresses from a harmless infection to a life threatening condition
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
• The estimated 10% activation of dormant TB infection over the life span of an infected person,
is increased to 10% activation in one year, if HIV infection is superimposed.
• It is opportunistic infection that most frequently kills HIV-positive people
References:
1. Gesmundo, Moniha H., The Basics of Community Health Nursing, 2010
2. [Link]: The official website of the Department of Health of the Republic of the Philippines
3. [Link]: the official website of the World Health Organization
Disclaimer:
This module contains copyrighted materials. The use of which has not been specifically authorized by the
copyright owner. We are developing this Module in our efforts to provide printed and e-copy learning resources
available for our students in reference to the learning continuity plan of this college in this time of pandemic.
This Module is not intended for uploading nor for commercial use. This will be utilized for educational
purposes only by Brent Hospital and Colleges, Inc.
Writer:
MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)
Clinical Instructor
Approved by:
MA ERMA P. DORMIDO, MSMT
Dean, College of Medical Technology
BRENT HOSPITAL & COLLEGES, INC.
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MARVIN JOHN J. SINGCO, RMT, MLS (ASCPi)