National TB Control Program Pakistan

Tuberculosis Treatment Facility Card TB 01 (Front Side)

TB. Registration No. / / / /
BMU Name: ________________________________________________ TB Care Facility Name : _____________________________
Patient Name: _____________________________________________ CNIC No. Patient Family member if <18 yrs)
Father / Husband Name: _____________________________________
SEX M F DOB Age
Date of Registration / / DISEASE SITE:
Pulmonary Extra Pulmonary
Patient Address ____________________________________________
If EPTB Specify site
Occupation _______________Phone no 1: ______________________
Pleura Lymph Abdomen/ Bone / joint Menin Other
Phone No. 2: _______________________________________________ node Peritoneum ges

Treatment Supporter Name: __________________________________

Evidence of EPTB diagnosis (other than bacteriology)
Treatment supporter type / contact number Histology X-Ray U/Sound MRI Other
Family Community LHW Cell number

PATIENT IS REFERRED BY TYPE OF PATIENT (Based on TB Treatment History)

NEW Unknown
Self CW LHW PB- HF PVT-HF Pharmacy Camp Other previous
treatment
RETREATMENT If retreatment case tick appropriate
CW; community worker, LHW; lady health worker, PB-Public, PVT-Private box below
Relapse Treatment
RISK FACTORS YES/NO after
Failure
Diabetes
Malnutrition After loss to Other
HIV Infection / AIDS follow up previously
treated
Smoking
Bacteriology Clinically
Health care worker (HCW) confirmed “B+” diagnosed
Contact of B+ PTB cases B+ are positive on AFB smear and/or Xpert(MTB) and/or culture
Other specify
INITIAL PHASE
INVESTIGATIONS
Regimen Drug Dosage Tablets
M Date Examination Lab Result CXR Weight Type Regimen
Type No (KG) Regimen-1 2HRZE (75/150/400/275)
AFB Sm (Adult)
0 Xpert
HIV Regimen-2 2HRZ+E (50/75/150)+100
Other (Culture) (Child)
2 AFB Sm
Other Regimen-3*: 2HRZE+Lfx (75/150/400/275)
(Culture/Xpert) (Adult)-HrTB +500
5 AFB Sm
*only for TB cases who are laboratory confirmed
Other Rifampicin sensitive, INH-Resistant and FQ-susceptible.
(Culture/Xpert)
6 AFB Sm
Other
(Culture/Xpert)
Sm: Smear , X: Xpert , CXR- Chest X-ray, M-month of treatment
Use blank column to enter results of other test done (as per required)
National TB Control Program Pakistan TB 01 (Back Side)

M. Tuberculosis DST Result*

DATE RIFAMPICIN [Link] Date ISONIAZID [Link] DATE FQ [Link]

*Enter Results: R=resistant , S=Susceptible and NA =if not done, FQ – fluoroquinolone

Continuation Phase
Regimen Drug Regimen Dosage No. of Tablets Remarks
Regimen 1 (Adult): 4HR (75/150)
4RHZE* (75/150/400/275)
Regimen 2 (Child): 4HR (50/75)
Regimen-3; (Adult) 4HRZE + Lfx (75/150/400/275)+500
*for retreatment TB case if AFB smear positive at the end of two month, send sample for DST adjust treatment as per
national guideline

APPOINTMENTS FOR DRUG COLLECTION & FOLLOW UP

Date Patients visited Weight (kg) Next appointment date Remark (General Condition/Adverse Event)
1
2
3
4
5

TREATMENT OUTCOME Date :

c cured Died Transferred /moved to DRTB register
(DR TB No.______________________)
Treatment completed Treatment Failure Re-enrolled on HrTB regimen (Regimen3)
Not evaluated Lost to follow up

CONTACT SCREENING : Household Contacts

Name of Contact Symptomatic Date & Result of Screening TB If not TB Identifier
Relation

(Y/N) Y/N Code

Age

SEX

If yes describe (If TB, Reg No.

Date Sm X CXR P/EP. TPT (Y/N)
Cough, fever, Weight loss if TPT, Reg No.)
H HP
1.
2.
3.
4.
5.
6.
7.
8.
9.
10

Comments: ____________________________________________________________________________________________
Registration No. / / / /
CNIC - -

Phone No. ____________

 TB TREATMENT - INITIAL PHASE
Regimen Drug
Dosage Tablets
Type Regimen TB TREATMENT - CONTINUATION PHASE
Regimen-1
2HRZE (75/150/400/275) Regimen Drug Regimen Dosage Tablets
(Adult)
Regimen-2 Regimen 1A (Adult) 4HR** (75/150)
2HRZ+E (50/75/150)+100
(Child)
Regimen 1B (Adult) 4HRZE* (75/150/400/275)
Regimen-3* 2HRZE+L (75/150/400/275)
(Adult)- fx Regimen 2 (Child) 4HR** (50/75)
HrTB +500
* only for TB cases who are laboratory confirmed Rifampicin sensitive, INH-Resistant Regimen 3 (Adult) 4HRZE + LFX (75/150/400/275)+500
andFQ-susceptible. *Only for retreatment TB cases, if patient is AFB smear positive at the end of two month. Send sample for DST
and adjust treatment when DST results are available as per national guideline. **Regimen 1A and Regimen 2 -
extended for 6 more months (+6 HR) in case of TB Meningitis/Bone TB)
Date of Appointment of Drugs Collection
INVESTIGATIONS
M Date Examination Lab No Result CXR Weight
Type (KG)
AFB Smear
Xpert
0
HIV

Appointment for follow up (Type of test) Other (Culture)

AFB Smear
2
Other
(Culture/Xpert)
AFB Smear
5
Other
(Culture/Xpert)
AFB Smear
6
Other
(Culture/Xpert)
 National TB Control Program Pakistan

(TB 03)

TB CARE FACILITY (BMU) / DISTRICT TB REGISTER

Province Code: _______ District Code: _______ Facility Code: _______

 Xpert MTB/Rif test result reported as follows:
Instructions
“MTB” Column; Det=MTB Detected
ND=MTB Not Detected
Smear results reported as follows:
INV=Invalid/Error/No Result
Grading - ZN Microscopy
“RR” Column Det=Rifampicin Resistance Detected
No. of AFB Observed Report ND=Rifampicin Resistance Not Detected
IND=Rifampicin Resistance Indeterminate
No AFB in 100 fields Negative
1-9 AFB in 100 fields
10-99 AFB in 100 fields 1+
1-10 AFB/fields in 50 fields 2+ Disease type Treatment outcome
More than 10 AFB/field in 20 field 3+ NEW: No previous history of ATT
C= CURED
Previously treated TC=Treatment completed
Grading - FM Microscopy RLP : Relapse D=Died
TAF : Treatment after failure F- Failure
200X 400X Report L2FUP : Lost to follow up NE= Not evaluated
H/O – History of L2FUP= Lost to follow up
No AFB in one length No AFB in one length Negative
ATT –Anti TB treatment
1-4 AFB in one length 1-2 AFB in one length Confirmation required* UK : Unknown
5-49 AFB in one length 3-24 AFB in one length Scanty (exact number)
3-24 AFB in one fields 1-6 AFB in one fields 1+
25-250 AFB in one INITIAL PHASE
HIV Status
fields 7-60 AFB in one fields 2+ Regimen Type Drug Dosage
R – Reactive
Regimen
>250 AFB in one NR – Non- Reactive Regimen-1 2HRZE (75/150/400/275)
fields >60 AFB in one fields 3+ UK : Unknown (Adult)
* confirmation required by another technician or prepare Regimen-2 2HRZ+E (50/75/150)+100
another smear, stain and read. (Child)
Regimen-3*: 2HRZE+Lfx (75/150/400/275)+500
(Adult)-HrTB
 Date of Registration

TB Registration no.

Patient name

Father / husband name

Gender M/F

Age

CNIC

Address

Contact #

Date Treatment Started

Site PTB / EPTB

NEW

Relapse
TB CARE FACILITY (BMU) / DISTRICT TB REGISTER

Treatment After
Failure
Treatment After lost
To Follow Up
Previously Treated

Other

H/O ATT Unknown

Transfer In
TB-03

HIV Test Result

(R / NR / UK)
AFB sm
Xpert

MTB RR

CXR
Investigations “O” Month

Remarks/any other
investigation
 TB CARE FACILITY (BMU) / DISTRICT TB REGISTER TB-03

Follow

Moved to second line treatment register

up Smear DST - RESULT Outcome Contact Tracing HH
results Remarks
(e.g. Adverse

Re-enrolled on HrTB Regimen

events, Referring
Facility)

Regimen 2M 5M 6M Other

Treatment Completed
End Treatment Date
No. of No. of Contacts
1,2,3 Test No. of ConfirmedTB

Lost to follow up
AFB AFB AFB No. ofHH put on preventive

Not Evaluated
R H FQ Contacts Cases
sm sm sm Contact Treatment
Screened Detected
a

(Date)
Failure
Cured
Result Result Result Result Result Result

Died
5- 15+ 5- 15+ 5- 5- 15+
Lab Lab Lab 0-4 0-4 0-4 15+ 0-4
Lab No./Date Lab No./Date Lab No./Date 14 14 14 14
No./Date No./Date No./Date
 TB LABORATORY REQUEST FORM (TB05)
XPERT MTB/RIF AND/OR AFB MICROSCOPY TESTING FOR TB DIAGNOSIS

PATIENT IDENTIFICATION (ID): Patient CNIC #: --

Name of Patient: ____________________________________________________________Age__________ (yrs): Sex: M /F__________
Address: _____________________________________City ______________District_____________________ Contact #: ______________

Referring Health Facility Name: -----------------------------------------------------------------OPD/  “In-Patient” Ward# --------Bed# ------------

Name of Physician: _________________________Designation: _______________Contact#_____________ _Email:______________
Reason for Laboratory request  Diagnosis  Follow-up - If yes F-up Month_____ TB Reg#:

Clinical history
Disease site  Pulmonary  Extrapulmonary If Extra pulmonary specify
HIV +ve  YES  NO  Unknown
Previous TB treatment  YES  NO  Unknown
Contact of B+ve TB Patient  YES  NO  Unknown
Previous Laboratory results
AFB microscopy  Yes  No Date  Positive  Negative
Xpert MTB/RIF  Yes  No Date MTB- RR- ________

Laboratory Request
Specimen Origin  Pulmonary  Extra Pulmonary If yes specify
Specimen type:  Sputum  Gastric aspirate  BAL  Fluid _______
 Tissue Biopsy  FNA________  Pus_________  other _______
Test request  Xpert MTB/RIF  AFB microscopy
*Lymph node, pleura, Bone/ spine, Brian/meninges, kidney, Pericardium/heart
Date specimen collected: : ____/______/20_____
Date (If) specimen sent to Xpert Testing laboratory  through courier or  Other mean) : ____/______/20_____
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
LABORATORY REPORT: & XPERT MTB/RIF ASSAY & AFB MICROSCOPY (To be completed in laboratory)

Laboratory Name: ______________________________ Laboratory Registration No: _________________

Patient CNIC #: --

Name of Patient :_______________________________________________________( Yrs):_____________ Sex: __________
Address: _____________________________________ _____________District_____ ______Contact #: __________________

Referring Health Facility Name: ________________________________________ OPD ________ Ward/Bed# ______

Reason for Laboratory request :  Diagnosis  Follow-up - If yes F-up Month_____ TB Reg#:_________________
Specimen collection date: ___/___/20_____ Date specimen received __/___/20_____

RESULT: Date report

Specimen: Gross Appearance: Quantity
Test Results
AFB smear Lab#  Positive Sm grade  Negative
MTB/RIF-ultra Lab # MTB  Detected  High  Med  Low  V. Low  Trace

 Not detected  No results

Rifampicin  Not detected  Detected  Indeterminate

Resistance

Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------

Report prepared by: Name_________________________________________ Signature________________________

Revised 2023
 Name of District TB Coordinator / Facility In charge:

Previous Treatment Previously Treated (Excluding Relapse)

All TB Cases Registered New (N) Relapse (R) History Unknown N+R+ UK Total
Treatment Treatment after Other previously
(UK) after Failure lost to follow-up treated

Pulmonary, Bacteriologically Confirmed

Pulmonary, Clinically Diagnosed
EPTB -Bacteriologically confirmed
EPTB- Clinical diagnosed
Total

Block 2: All New, Relapse and Previous treatment history unknown Cases registered during the period by Age Group and Gender
0-4 5-14 15-24 25-34 35-44 45-54 55-64 65 & above Grand Total
M F M F M F M F M F M F M F M F
Pulmonary, Bacteriologically Confirmed
Pulmonary, Clinically Diagnosed
EPTB -Bacteriologically confirmed
EPTB- Clinical diagnosed
Total

Block 3: Presumptive TB case Identification, Laboratory Diagnosis and use of WRD Block 4: TB HIV Activities

No. of Presumptive TB No. of T B Among Presumptive Among all Among All No. of TB patients TB Patients tested HIV PositiveTB Patients put on ART
Cases identified Presumptive TB cases tested tested for HIV positive for HIV
Total New tested using number reported B+
OPD in Through registered (N+R+UK),
Quarter Community number of number tested
Total Referrals B+ TB by Gene Xpert
Xp & XP
(LHWs) AFB AFB AFB +
Xpert Xpert [Link] Cases
HIV patients tested for HIV patients tested TB positive HIV patients HIV positive TB naegative
AFB TB positive for TB put on TB Tx patients on TPT
0-4 5-14 15 +
6H
3 HR
3 HP

Block 5: Bacteriologically Confirmed TB Cases with DST Result

Block 6 : Contact Tracing HH
Rifampicin Isoniazid Fluoroquinolone
Total No. of HH No. of HH Among HH No. of HH contacts HIV negative
Sensitive Resistant Sensitive Resistant Sensitive Resistant of B+ PTB contacts of contact initiated on TPT Immuno-
B+ PTBCases screened, No. compromised on
New + UK screened of TB Cases TPT
diagnosed
Relapse
0-4 5-14 15+ 0-4 5-14 15+ 0-4 5-14 15+
0-4 5-14 15+ 0-4 5-14 15+
Previously Treated 6H
3 HR
Total
3 HP
NATIONAL TB CONTROL PROGRAM PAKISTAN

(TB 09)

QUARTERLY REPORT ON TREATMENT OUTCOMES

INDIVIDUAL BMU / CONSOLIDATED (TICK ONE)

Revised 2023
 QUARTERLY REPORT ON TREATMENT OUTCOMES
INDIVIDUAL BMU / CONSOLIDATED (TICK ONE)

Block-1: All TB cases registered during the quarter

Number ofTB TREATMENT OUTCOMES Moved/

Re-enrolledon Total
Transferred
Cases HrTB
TB Patient Type to the DR-TB Evaluate
registered Treatment Treatment Loss to Treatment
Cured Died Not evaluated register d
completed failed follow-up
Age /
(X) <15 >=15 <15 >=15 <15 >=15 <15 >=15 <15 >=15 <15 >=15 (Y) (Z) (X-Y-Z)
Gender
A. Pulmonary TB Male
Bacteriologically confirmed
(N+R+UK) Female

B. Pulmonary TB Clinically Male

Diagnosed (N+R+UK) Female
C. Extra Pulmonary TB case Male
(N+R+UK) Female

Treatment outcome of subset of patients

D. Retreatment (Excluding Relapse)

A-1: HIV - Positive PTB and EPTB (N+R+UK)

Block 3: No. of Patient Put On Each Treatment

Block 2: Bacteriologically Confirmed TB Cases with DST Result Block 4: No. of Patient Put On Preventive Treatment Regimen
Regimen
Regimen Regimen Lost to Diagnose
Rifampicin Isoniazid Fluoroquinolone Regimen 3: Regimen Total Completed Refused Died
1: 2: follow up TB
2HRZE 2HRZ+E / 6HRZE +
Sens Resist Sens Resist Sens Resist 6H
/ 4HR 4HR LFX
New + UK New +UK 3HR

Relapse Relapse 3HP

Previously Previously
Treated Treated