NPHCDA

MODULE 4: DIAGNOSIS AND

MANAGEMENT OF TUBERCULOSIS AND
INTRODUCTION
TO NTBLCP

17 February
September,
2024
2019

N AT I O N A L P R I M A RY H E A LT H C A R E D E V E L O P M E N T A G E N C Y1
OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 2

 Learning Objectives
The Federal Government of Nigeria established the National Tuberculosis Leprosy Control program
(NTBLCP) in 1988 and formally launched it in 1991

At the end of this session, Participants will be able to;

To give a general overview of National Tuberculosis and
1 Leprosy Control Program in Nigeria

2 To define Tuberculosis and the Causative organism

3 To know how Tuberculosis is transmitted

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 3

WHAT IS TB?

• Chronic, infectious bacterial disease

caused by mycobacterium
tuberculosis, that usually affects the
lungs. (pulmonary TB)

• Can also affect any other part of the

body (Extra Pulmonary TB)

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 4

 TRANSMISSION

Spread from person

to person through
2 Droplets are
produced when a
the air via droplet
nuclei
1 person coughs,
talks and sings

Droplet nuclei can 3 Transmission can

remain in air for hours
4 occur when another
person inhales
these droplets

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 5

Key messages

Tuberculosis is a chronic infection bacteria infection

1 that usually affects the lungs

2 It is spread trough droplets

3 It can also affect any other organ of the body

(extrapulmonary)

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 6

OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 7

Learning Objectives

At the end of this session, Participants will be able to;

Identify the signs and symptoms of PTB, EPTB and TB in
1 children and take appropriate actions.

Take accurate and appropriate history and conduct

2 physical examination from the presumptive TB case

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 8

INTRODUCTION

TB affects the lungs in 80% of cases,

but it can affect any organ in the body.

TB of the lungs is called Pulmonary

Tuberculosis (PTB), while that affecting
other organs is called Extra pulmonary
TB.

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 9

 IDENTIFYING PRESUMPTIVE PULMONARY TUBERCULOSIS
(PTB)
The commonest symptom of PTB is persistent cough lasting two weeks or more, which is usually
accompanied by one or more of the following symptoms:

Weight loss Coughing up blood Fever Chest pain

SYMPTOM SYMPTOM SYMPTOM SYMPTOM SYMPTOM SYMPTOM SYMPTOM SYMPTOM

1 2 3 4 5 6 7 8
Shortness of breath Tiredness Loss of appetite Night sweats

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IDENTIFYING PRESUMPTIVE PULMONARY TUBERCULOSIS
(PTB)
Any person coughing for 2
weeks or more, with or without
the above symptoms should be
suspected of PTB.

A person with extra pulmonary TB

may also have the following
A person with extra general symptoms:
pulmonary TB will show • Weight loss,
symptoms depending on • Fever
the affected organ. • Night sweats

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 11

ORGAN AFFECTED AND SYMPTOMS
Back pain, Painful urination, blood in Headache, fever, neck
swelling on spine urine, frequent urination, stiffness, vomiting,
lower back pain irritability,
convulsions

SPINE KIDNEY AND URINARY TRACT MENINGES OF THE BRAIN

Long standing Hoarseness of voice, pain Swelling of the node,

bone infection on swallowing draining pus

BONE UPPER RESPIRATORY TRACT LYMPH NODE

Painful joint Chest pain, difficulty in Longstanding ulcer

swelling, usually breathing, fever despite antibiotic
affecting one treatment, draining
joint pus

JOINT PLEURAL MEMBRANE OF LUNGS SKIN

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 12
Taking accurate and appropriate history from Presumptive
TB case
CHECK LIST FOR HISTORY TAKING AND PHYSICAL EXAMS OF TB PATIENT FOR
GENERAL HEALTH CARE WORKERS.
HISTORY TAKING: General Approach
Greet patient in a friendly relaxed way
Introduce yourself
Call patient by name
Maintain confidentiality and respect patient’s privacy
Try to see things from patient point of view
Understand patient underneath mental status (anxiety, irritation or depression)
Always exhibit neutral position
Listen carefully
Questioning: simple/clear/ avoid medical terms, open, leading interrupting, direct questions and summarizing.
Personal data of patient includes: Name, Address, Sex, Age(year of birth), Contact address, occupation, ethnicity, Marital status

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 13

PRESENTING COMPLAINT

• History of the presenting symptom(s) e.g time of onset,

mode of progression (continuous or intermittent, nature,
odour, colour etc

• History of past medical illness

• Drug history

• Family history

• Social history (occupation, living situation, marital status,

social habits.

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 PHYSICAL EXAMINATION OF TB PATIENT
• The examination must be systematic i.e start from head to toe, compare sides, start inspection, then
palpation, percussion and auscultation (where necessary)

Site What to look for

1 Head Hair texture in child

2 Neck Cervical cold lymph node

3 Eyes Paleness of the conjunctiva and yellowish of the of the sclera

4 Nose Signs of breathlessness (flaring of alae nasi)

5 Feet Wasting of inter-costal muscles, respiration rate and dullness on

percussion Oedema
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 SUSPECTING TB IN CHILDREN
• Diagnosis of TB in children is difficult because sputum cannot often be obtained from, especially younger
children. Sputum samples are often negative. Stool sample is used for GeneXpert test
• Diagnosis rests largely on the results of;

Clinical history

Family Contact History

X-ray Examination

Laboratory investigation

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 16

 SYMPTOMS OF TB IN CHILDREN
Low grade fever not responding to malaria treatment
Night sweats
Persistent cough for 2 weeks or more
Loss of weight, loss of appetite
Failure to thrive
Lymph node swellings
Joint or bone swellings
Angle deformity of the spine
Listlessness
Neck stiffness, headache, vomiting (TB meningitis)
Any child suspected of having TB should be referred to a medical Officer for diagnosis.
NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 17
 PTB PRESUMPTIVE CASE
The most important test to diagnose pulmonary TB is GeneXpert.

WHO Recommended Tools to Improve Diagnosis of Active and Drug Resistant Tuberculosis - Scientific Figure on ResearchGate. Available from:
[Link] [accessed 29 Feb,
2024]

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 18

HOW TO COLLECT SPUTUM SAMPLE:

Ask patient to cough deeply (demonstration is necessary);

The patient should spit the sputum carefully into the container to
avoid contamination of the outside part;

If the specimen is not suitable, e.g. saliva, then repeat deep cough
to produce better sample

The volume of the sputum should be about 3 to 5ml (equivalent to

one tablespoonful

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 19

AFTER SPUTUM COLLECTION

The container should be firmly closed using the lid;

Hands should be washed with soap and water;

Sputum specimens should to be stored preferably in a refrigerator

or in a cool, dry and dark place e.g. a cupboard;

The specimens for microscopy should be sent to the laboratory as

soon as possible, not later than 24 hours after collection;

Sputum specimens for culture should be sent to the laboratory

within 5 days

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 20

 KEY MESSAGES

Detection of tuberculosis in a
patient starts with clinical history

The examination of a Diagnosis of TB in children is

suspected patient with difficult because sputum cannot
tuberculosis starts from head often be obtained from, especially
to toe younger children (Sputum samples
are often negative).

The most important test to diagnose pulmonary TB is

GeneXpert.

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 21

OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 22

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 23
NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 24
NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 25
Discussions on completing Clinic Register for Presumptive
TB cases and sputum request form

1 Explain how to use the flow chart for management of Presumptive Case to
make a diagnostic decision.

2 Define a TB case

3 Educate TB patients about the disease.

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INTRODUCTION

The diagnosis of tuberculosis rests mainly on the

identification of the tubercle bacilli by GeneXpert

The result of sputum can either be negative or

positive

The diagnosis of extra-pulmonary TB can only be

made by a medical officer or consultant

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 Interpretation of GeneXpert Results

Result Interpretation Action

MTB (Mycobacterium
Negative result for TB Evaluate further
tuberculosis) not detected
MTB detected & Rifampicin
Positive result for TB with no resistance to Rifampicin Treat for drug susceptible TB
(RIF) resistance not detected

MTB detected & Rifampicin resistance Treat for drug resistant TB

Positive result for TB with resistance to Rifampicin
detected
Positive result for TB with inconclusive result on
MTB detected & Rifampicin resistance Obtain another sample and
Rifampicin
indeterminate repeat the test

Invalid result Result not valid Obtain another sample and

repeat the test
Error occurred in the sample processing Obtain another sample and
Error
repeat the test
No result Insufficient information for the machine to generate Obtain another sample and
result repeat the test

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 28

Flow chart on the management of Presumptive TB case
ALL PERSONS WITH SYMPTOMS OF TB
(cough of 2 weeks or more +/ - weight loss, night sweats, swelling in any part of the body etc)
-
For PLHIV current cough

Do the following:

i. Collect1 biological specimen (sputum, body tissues or other body fluids) and send to the Lab. For Xpert MTB/Rif test

ii. Provide *to those with unknown HIV Status

If Xpert result is: If Xpert result is : If Xpert result is :

MTB not detected detected MTB detected
Rif resistance Not detected Rif Resistance detected

Classify as: Drug Resistance

Classify as: Drug TB (DR -TB)
Refer patient to the Medical
Officer for further evaluation susceptible TB (DS -TB)
case

TREAT AS DRUG - Manage as DRTB case:

SUSCEPTIBLE TB: see DRTB section of the
Start first -line anti TB guideline
treatment

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 29

WHO IS A CASE TB

A TB case is a person who has been

diagnosed to have TB disease. It could
be classified as either bacteriologically
diagnosed or clinically diagnosed TB
case.

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ROLE PLAY
Counselling session for a patient with Tuberculosis

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 Guidelines and procedures for educating TB Patients and their
family at time of diagnosis
Greet and establish proper relationship with the patient and their family (Inform patient/family about:)

The disease is curable provided the correct drugs are taken for 8months without break

The nature and how the nature of the treatment will be at (DOTA) Hospital/clinic/home

The number and type of drugs to take

He need to bring symptomatic contacts for screening & children < 6 yrs
The sputum result and the type of disease diagnosed

The sputum result and the type of disease diagnosed

The need to bring symtomatic contacts for screening and children less than 6years

The cause of TB and how it is transmitted

The patient is no longer infectious if he takes his drugs regularly

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 Guidelines and procedures for educating TB Patients and their
family at time of diagnosis CONTD
Greet and establish proper relationship with the patient and their family (Inform patient/family about:)

Signs and symptoms of possible side effects of drugs and what to do(skin rash, poor vision, discolouration of urine

Obtain feed back from patient at the end of the health talk

Patient recall facts

Identify possible problems and deal with them appropriately

sputum will disappear but he must continue to take drugs as directed, if not the disease will come back in worse form

How to collect drugs on work free days and incessable times

Important of family support to ensure compliance of the patient

sputum examination will be conducted at the end of months 2,5 and 6 to know the effect of the drugs taken. if it
shows symtoms of the germ, treatment may change

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 33

Key messages

Counselling tuberculosis patients on DOTS and need for

1
compliance is very important.

TB case is a person who has been diagnosed to have TB

2 disease. It could be classified as either bacteriologically
diagnosed or clinically diagnosed TB case.

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 34

OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 35

Learning Objectives

At the end of this session, Participants will be able to;

1 Describe criteria for TB patients classification

2 Classify a TB patient appropriately

3 Fill in the relevant portion of the TB treatment card

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 36

CRITERIA FOR CLASSIFICATION

Anatomical site of disease

Bacteriological results (including drug resistance)

History of previous treatment

HIV status

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 37

 DETERMINANTS OF CASE DEFINITIONS OF TB
HIV status
Identification Previous
Site of disease
of [Link] TB treatment
HIV-positive
Culture
Positive TB HIV negative
Expert
Smear positive TB
positive PTB HIV unknown

Pulmonary
Bact No New Case
confirmed
TB CASES
TX after loss
to follow up
Yes
Clin. Extra-
Relapse
confirmed pulmonary
Tx after
Failure
Unknown Others

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 38

SPUTUM RESULTS

Enter sputum results in the appropriate sections of the TB treatment/appointment cards

bearing the patient’s full name, sex, Age, Address, Diagnosis, date of collection, date
sputum result was released, AFB result and the LGA TB registration number

Enter type/category of patient in the appropriate sections of the TB treatment

/appointment cards

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 39

OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 40

 Learning Objectives
At the end of this session, Participants will be able to;

Explain the aims and strategies of importance of adherence and the

1 TB treatment 5 consequences of poor adherence

Identify the drugs used for treating Describe procedure for engagement
2 6
TB of treatment supporter

Explain the regimens and criteria Administer INH prophylaxis for

3 7
used in TB treatment children

Fill in the relevant portion of the TB

4
treatment card

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 41

AIMS OF TB TREATMENT

To cure the patient of TB and prevent death from

active disease or its complications

To prevent transmission of TB to others

To prevent emergence of Multi Drug Resistant-TB and

other forms of drug resistant-TB

To prevent relapse

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 STRATEGY FOR ADMINISTERING TB TREATMENT

Direct Observation of Treatment

1 Direct observation of drug intake (DOT) by health worker or treatment

supporter at least in the intensive phase

2 Standardized treatment regimens

3 Standardized treatment regimens

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 IMPORTANCE OF DOT

Direct observation of treatment is the process of observing the patient swallow anti TB drugs

Monitors possible problems during treatment

Provides opportunities for continuous health education

Ensures that the patient is cured

Avoids TB complication

Limit spread of TB germs

Avoid the growth of stubborn TB germs

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DRUGS USED IN TB TREATMENT

Drugs Picture

Rifampicin (R)

Isoniazid (H)

Ethambutol (E)

Pyrazinamide (Z)

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 45

TYPES OF TREATMENT REGIMENS

Regimen 1 Adult: (2RHZE /4RH)

Regimen 1 Adult: (2RHZE /4RH)

Regimen 2 Adult: (2RHZE/10RH)

Regimen 2 Children: (2RHZ+E/10RH

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 PHASES OF TB TREATMENT

Phases of
treatment

Intensive Phase Continuation Phase

▪ Daily supervised treatment ▪ Daily supervised treatment
▪ In adults and children: ▪ In adults and children
▪ Regimen 1 : first 2months ▪ Regimen 1: last four months
▪ Regimen 2: first 2 months ▪ Regimen 2: last10 months

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CRITERIA FOR ASSIGNING TREATMENT

Age

History of previous anti-TB exposure

Other medical conditions like pregnancy, HIV status,

and other contra indications

Pre-treatment weight

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 48

 DRUG REGIMEN

Recommended Regimen Length of

Type of TB Disease
treatment
Intensive Phase Continuation Phase

PTB and all forms of EPTB except TB meningitis

2 RHZE 4 RH 6 months
& Osteo-articular TB (spine, joints) in adults

TB meningitis and Osteo-articular TB (spine,

2 RHZE 10 RH 12 months
joints) in adults

PTB and all forms of EPTB except TB meningitis

2 RHZ+E 4 RH 6 months
& Osteo-articular TB (spine, joints) in children

TB meningitis and Osteo-articular TB (spine,

2 RHZ+E 10 RH 12 months
joints) in children

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 49

 ADULTS- Regimen 1 for susceptible PTB/EPTB cases: 2RHZE
/4RH

Pre-treatment weight
Regimen 19-37 kg 38-54 kg 55-70 kg > 70 kg

Intensive phase (2 months):

Combined tablet of RHZE 2 3 4 5
(150mg+75mg+400mg+ 275mg)

Continuation phase (4 months):

Combined tablet of RH (150mg + 75mg) 2 3 4 5

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 Regimen 1 for susceptible PTB/EPTB cases:
2RHZ+E/4RH

Maximum dose
Drug Dosage (mg/kg) Range (mg/kg)
(mg/day)
Isoniazid (H) 10 7 – 15 300

Rifampicin (R) 15 10 – 20 600

Pyrazinamide (Z) 35 30 – 40 2000

Ethambutol (E) 20 15 – 25 1200

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 Children: Regimen 1 for susceptible PTB/EPTB cases*:
2RHZ+E/4RH
Weight
Daily Regimen
< 5 kg 5 - 9 kg >9 - 13 kg >13 - 18 kg

Intensive phase (2 months)

▪ Combined tablets of RHZ (60
mg+30 mg+150 mg) 1 2 3 4
▪ Ethambutol tablet (100mg)

Continuation phase:(4 months)

Combined tablets of RH (60 mg + 60 1 2 3 4
mg)

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 ADULTS: Regimen 2 for adults with TB meningitis and
Osteo-articular TB: 2RHZE/10RH

Pre-treatment weight
Regimen
19-37 kg 38-54 kg 55-70 kg > 70 kg
Intensive phase (2 months):
▪ Combined tablet of RHZE
2 3 4 5
(150mg+75mg+400mg+275mg)

Continuation phase (10 months):

▪ Combined tablet of RH (150mg + 2 3 4 5
75mg )

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 53

 CHILDREN: Regimen 2 for children with TB meningitis and
Osteo-articular TB: 2RHZ+E/10RH
Weight
Daily Regimen
< 5 kg 5 - 9 kg >9 - 13 kg >13 - 18 kg

Intensive phase (2 months)

▪ Combined tablets of RHZ (60 mg+30
mg+150 mg) 1 2 3 4
▪ Ethambutol tablet (100mg)

Continuation phase: (10 months)

▪ Combined tablets of RH (60 mg + 60 1 2 3 4
mg)

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 TUBERCULOSIS TREATMENT CARDS
▪ A ‘TB treatment card’ and a ‘TB appointment card’ should be filled for every diagnosed patient according to
the NTBLCP guidelines
▪ For smear negative and extra-pulmonary patients the Medical Officer’s report should be attached to the
treatment card.
▪ It is very important for the hospital or health unit where the patient is receiving treatment to maintain a
Tuberculosis Treatment Card for every patient started on treatment

Treatment Card helps us make sure that the patients;

Were correctly classified as either pulmonary or extra-pulmonary tuberculosis

Were correctly classified as either New, Relapse, Transferred-in, Failures, Return

after default or others

Were prescribed the correct regimen and dosages

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SNAPSHOT OF THE TUBERCULOSIS PATIENT TREATMENT CARD
(1/2)

▪ These cards will serve as the medical record to document and track important information related to the diagnosis, treatment, and
management of patients with tuberculosis
▪ They will be used by healthcare providers involved in the diagnosis and treatment of tuberculosis patients at the health facilities

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 56

SNAPSHOT OF THE TUBERCULOSIS PATIENT TREATMENT CARD
(2/2)

▪ These cards will serve as the medical record to document and track important information related to the diagnosis, treatment, and
management of patients with tuberculosis
▪ They will be used by healthcare providers involved in the diagnosis and treatment of tuberculosis patients at the health facilities

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 57

 Adherence involves partnership between the patient,
health care worker and treatment
Adherence is the term used to describe the patient’s behavior of taking drugs correctly – the
Definition
right drugs, in the right dose, with the right, frequency, and at the right time

Adherence

2 1
Health care
worker

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 There are five major importance of adhering to tuberculosis
treatment

Reduces the risk of developing resistance to the drug (s)

1
2 Enhances curability

3 Improves social stability of a TB patient

4 It builds the patient confidence in getting treatment

ADHERENCE
5 It builds a strong and trusting patient - provider relationship

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 59

Brainstorming

Discuss with the participants on factors affecting poor adherence using their
experience
Discuss interventions

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 MANAGEMENT OF CONTACTS OF TUBERCULOSIS PATIENTS

When patient is diagnosed a smear positive, he/she is

requested to bring the following persons to the Health
facility to screen for TB

All adult contacts that are Patient testing All children of the household
coughing for two (2) weeks or positive below 6 years (including children
more born while on treatment)

Hospital

N:B: Record should be kept of these contact persons in an exercise book

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 Contact Investigation
Contact investigation is important for detection of active TB as well as providing preventive therapy for
latent TB

This can be achieved by investigating the following;

History of contact with a person

with bacteriologically positive
pulmonary TB is a very important
component in the diagnosis of TB

Investigation of all household

contacts of diagnosed child TB
cases (reverse contact tracing)

All child contacts in the household

of bacteriologically confirmed
index TB cases should be screened
for TB.

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 There are three main priority groups for tuberculosis
patient treatment
1
People Living with
Human Immuno-
deficiency Virus
(PLHIV)

3 Under-5 2 Contacts of
contacts of bacteriologically positive
bacteriologica TB cases above 5 years of
lly positive TB age (Children,
cases Adolescents and Adults).

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 Priority Groups and Regimens

I. For six (6) months (6H)

Daily isoniazid (INH)

II. For three (3) months (3HP)

IV. For 1 month (1HP)
Weekly INH and Rifapentine
Daily INH and Rifapentine

III. For three (3) months (3HR)

Daily INH and Rifampicin

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 Key Considerations in TPT Administration

PLHIV should receive TPT at ART Line-listing and screening all

initiation after ruling out active TB household contacts of index TB cases
▪ Repeat course of TPT is no longer ▪ Evaluate presumptive TB cases
recommended in PLHIV
▪ Offer TB treatment for clients with active
▪ Ensure kitting of the medicines for TB
entire treatment duration at the
onset ▪ Offer TPT for TB infection in eligible
clients if no contraditctions
▪ Weigh client monthly and adjust
medicine dosage as necessary
▪ Align TPT appointment date with
other clinic visits

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 65

 Monitoring of Tuberculosis Patient Treatment

Review for ▪ Discontinue TPT

signs/ Evaluate If client ▪ Assess for active TB
symptoms of adherence develops ▪ Refer to medical
Ask for side officer/specialist if not
active TB and counsel symptoms
effects sure of diagnosis
during appropriately suggestive
monthly of active TB: ▪ If on ART, assess for
medicine adherence to ART/ART
refills failure

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 Contradictions to TPT

▪ Active Tuberculosis
General ▪ Active liver disease (check for jaundice, abdominal pain, nausea and vomiting)
contradictions ▪ Known or reported alcohol addiction (heavy alcohol consumption)
▪ Allergy to any of the TPT medicines

Contradictions ▪ PLHIV on protease inhibitors (Pis) NNRTIs and TAF

to Rifapentine
plus INH ▪ Pregnant women

Contradictions
to Rifapentine ▪ PLHIV on protease inhibitors and NNRTIs (except EFV)
plus INH

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY 67

KEY MESSAGES
Adherence is very important in Tuberculosis treatment
1 as it reduces the risk of drug resistance

PLHIV should receive TPT at ART initiation after ruling

2 active TB

Ensure kitting of the medicine for entire treatment

3 duration at the moment

Weigh client monthly and adjust medicine dosage as

4 necessary

Align TPT appointment date with other clinic visits

5

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OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 69

Learning Objectives

At the end of this session, Participants will be able to;

Discuss how and when to monitor TB treatment

1

Record drug intake/collection in the TB treatment

2
and appointment card during treatment

Record follow up sputum examination results and

3
act appropriately

Define treatment interruption and take appropriate

4
action

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IMPORTANCE OF MONITORING

To cure the patient of TB and prevent death from

active disease or its complications

To prevent transmission of TB to others

To prevent emergence of Multi Drug Resistant-TB and

other forms of drug resistant-TB

To prevent relapse

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IMPORTANCE OF MONITORING

Monitoring progress of a tuberculosis patient while on treatment is an essential part of

the case management.

This is to ascertain the effectiveness of treatment in killing M. Tuberculosis as well as

assessing improvement in the patient’s clinical state

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METHODS OF MONITORING
Monitoring is done through the following methods;
Clinical assessment: This involves regular
clinical assessment including weight
assessment

Drug intake: This is done

through assessment of
patient’s records for regularity

AFB microscopy: It involves

looking for AFB in sputum at
specified intervals

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CLINICAL ASSESSMENT

Most TB patients will start to show signs of improvement after 2 to 4 weeks of anti-TB
treatment. However few patients may not improve and would show the below signs and
symptoms

No symptom resolution, or symptoms are getting worse, Continuous weight loss

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 FOLLOW UP USING DRUG INTAKE

Follow up

Phase 1 Phase 2
▪ Ensure that patient drug records ▪ Ensure that patient treatment card is
are regularly updated to avoid updated during each patient visit.
treatment interruption and to
▪ Indicate on the treatment card
allow for proper follow up
whether DOT was observed or
whether patient missed their drugs
while at home

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Key messages

All sputum samples are to be collected one week prior

1 to the end of the month specified above

If a patient can no longer produce sputum, but produces

2 saliva instead, the laboratory should examine these
materials for AFB

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 TREATMENT PROCESS

When? What do I do? Result? Conclusion? Action!

Positive TB case Start DOTS!
1st patient’s visit 2 sputum
(diagnosis) specimen May be not TB
Negative Not sure what to do REFER!

Start Continuation and repeat

Positive Intensive Rx not AFB at end of 3months
1 sputum enough
End of 2 months specimen
Negative Intensive Rx enough Start Continuation

▪ Gene expert. If MTB detected and Rif

Positive Intensive Rx not Sensitive - continue Rx
1 sputum enough ▪ If RIF resist inform LGTBLS
End of 3 months specimen
Negative Patient improving Continue Rx

▪ Send one sample for gene expert. If MTB

Positive Treatment failed detected and Rif sesnsitive-start reg. 1
1 sputum ▪ If RIF Resist- Inform LGTBLS
End of 5/ 6 months specimen
Negative Excellent! Give last Rx
DECLARE CURED!

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OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 78

Learning Objectives

At the end of this session, Participants will be able to;

1 Case Holding

2 Management of treatment interruption

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 CASE HOLDING AND MANAGEMENT OF TREATMENT
INTERRUPTION (1/2)

▪ Health Workers should do all that is humanly possible to ensure that patients complete treatment in the
Case holding required time
and
management ▪ Adherence to treatment of every patient is absolutely essential in order to cure the patient and prevent
Multiple Drug Resistant TB (MDR TB)

▪ Any TB patient who has not come to receive his/her treatment for two consecutive days either in the
Treatment
intensive or continuation phase should be regarded as having interrupted treatment and therefore be
interruption
trackeded

▪ Trace patient
▪ Find out the cause of interruption
Interruption ▪ Counsel on the essence or importance of adhering to treatment
for 1 – 2 ▪ Solve the cause of interruption where possible
months ▪ Continue treatment and prolong it to compensate for missed doses
▪ Do 2 sputum smears
▪ Continue treatment while you wait for results

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 CASE HOLDING AND MANAGEMENT OF TREATMENT
INTERRUPTION (2/2)

▪ Trace patient
▪ Find out the cause of interruption
Interruption ▪ Counsel on the essence or importance of adhering to treatment
for more than ▪ Solve the cause of interruption where possible
2 months ▪ Continue treatment and prolong it to compensate for missed doses
▪ Do 2 sputum smears
▪ No treatment while you wait for results

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 SOP on management of patients who interrupt treatment
Length of
Do a smear? Result of smear Length of treatment Action to be taken
interruption
▪ Continue Rx and prolong to compensate for missed
< 1 month No No N/A doses

▪ Continue Rx and prolong to compensate for missed

Negative or EPTB N/A
doses
▪ Continue Rx and prolong to compensate for missed
Yes < 5 months doses
1-2 months
(2 samples)
If 1 or more positive
▪ Collect and send sample for GeneXpert MTB/RIF
>5 months ▪ Treat patient according to GeneXpert MTB/RIF result.

▪ Clinical decision on individual basis whether to restart

Negative or EPTB N/A or continue treatment, or no further treatment

Yes
2 or more months ▪ Collect and send sample for GeneXpert MTB/RIF
(2 samples)
If 1 or more positive N/A ▪ Treat patient according to GeneXpert MTB/RIF result.

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 TREATMENT OUTCOME
Died

Failure

Total regimen
Not evaluated
1
Total
registered in
the quarter
Loss to follow up
Total regimen
2

Cured
Treatment completed

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Key messages

Case holding and management of treatment

1 interruption affects treatment outcome

Use of SOP for management of patients who defaults is

2 very important

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OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

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Learning Objectives

At the end of this session, Participants will be able to;

1 Recognize the signs and symptoms of TB complication

Recognize the common side effects of anti TB drugs

2
and when to stop treatment

Take appropriate action for TB complication and

3
common side effect of drugs

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 COMPLICATIONS OF TUBERCULOSIS AND ACTIONS TO TAKE

▪ Reassure the patient

▪ Record the volume of blood
Coughing Blood (Haemoptysis)
▪ Refer to the nearest hospital urgently, if frequent or the amount is plenty
▪ If facilities are available, determine the blood group

Spontaneous Pneumothorax
▪ Refer urgently
(sudden shortness of breath)

Pleural Effusion ▪ Refer urgently

Corpumonale ▪ Refer urgently

Destructive lung disease

(Breathlessness on effort despite ▪ Refer urgently
anti-tuberculosis treatment)

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 Symptom-based approach to managing major side effects
of R, H, Z and E
Drug(s) probably
Side effects Management
responsible
Skin rash with or without
H,R,Z Stop anti-TB drugs and refer to the Medical Officer
itching

Jaundice (other causes

H,Z,R Stop anti-TB drugs and refer to the Medical Officer
excluded), hepatitis

Visual impairment (other

E Stop ethambutol and refer to the Medical Officer
causes excluded)

Shock, purpura, acute renal

R Stop rifampicin and refer to the Medical Officer
failure

Major side effects: Stop responsible drug(s) and refer to clinician urgently

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 Symptom-based approach to managing minor side effects
of R, H, Z and E
Drug(s) probably
Side effects Management
responsible
Anorexia, nausea, abdominal
Z,R,H Give drugs with small meals or just before bedtime;
pain

Advise patient to swallow pills slowly with small sips of water;

Joint pains Z
If symptoms persist or worsen, refer to hospital
Burning/numbness in the hands/
H Non-steroidal anti- inflammatory (e.g. Ibrufen) or paracetamol
feet

Orange/red urine R Pyridoxine 50 -100mg daily

Reassure, counsel patients before starting treatment, encourage

Drowsiness H
increase fluid intake.
Flu syndrome (fever, chills, Intermittent dosing of Change intermittent to daily rifampicin administration (Intermittent
malaise, headaches, bone pains) Rifampicin doing is not use in Nigeria)

Minor side effects: Continue anti-TB drugs, check doses

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Key messages

1 Refer all patients with complication to Medical officer

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OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 91

Learning Objectives

At the end of this session, Participants will be able to;

Develop a good and systematic recording and reporting

1
format

2 Be acquainted with using the TB recording forms

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INTRODUCTION

It is essential for the successful control of tuberculosis

that there must be good and systematic recording
and reporting

The following recording forms must be completely

filled by facility health care workers

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 CORE PACKAGE FOR R & R AT FACILITY LEVEL (1/2)
Register and Forms Content and Purpose
1 Tuberculosis clinic sputum register ▪ This register is placed at the clinic and filled when suspects or
their sputa are sent to the laboratory for diagnosis or follow
up examination
2 Sputum Examination Request/Report Form (TB 05) ▪ Request for AFB microscopy to laboratory with report of
results to requesting unit

3 Laboratory sputum results despatch register ▪ N/A

4 Culture & Susceptibility Test Request/Report ▪ Request for TB culture/susceptibility to laboratory with
Form (TB 06) report of results to requesting unit

5 TB Laboratory Register (TB 04) ▪ Record of each AFB microscopy examination at laboratory

6 Treatment Card (TB 01) ▪ Individual record of diagnosis, treatment and follow-up of
each TB patient for proper case management at treatment
unit

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 CORE PACKAGE FOR R & R AT FACILITY LEVEL (1/2)
Register and Forms Content and Purpose
1 Appointment Card (TB 02) ▪ Personal record of diagnosis, treatment and follow-up for
information to the TB patient especially when undergoing
DOT under a treatment supporter in the community
2 TB facility register ▪ Record of diagnosis, treatment and follow-up of each TB
patient in the district or equivalent catchment area

3 Child INH prophylaxis card ▪ Personal record of child and appointment information for
follow up

4 Child INH prophylaxis register ▪ N/A

5 Defaulter tracing form ▪ Completed by health worker charged with tracing patients
who interrupted or defaulted from treatment

6 Referral/Transfer Form (TB 09) ▪ Form to refer/transfer TB patient to other unit

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 HIV/AIDS INFORMATION ON TB REPORTING FORMS/REGISTERS

Additional information that will have to be captured in TB recording and reporting forms:

Offered HIV test

Counselled and tested

Test result positive/negative

Given cotrimoxazole

Referred for HIV care and support

Given ART during or at end of ART treatment

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 HIV/AIDS INFORMATION ON TB REPORTING FORMS/REGISTER

Response

The TB register already contains confidential patient

1 information which should be treated with the same
level of confidentiality as HIV results
Main Issue:
Confidentiality of
HIV test results in
the TB register
The solution is not to hide HIV results but rather to
2 improve the confidentiality of the TB/ register

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 TREATMENT OUTCOME
Within the NTBLCP the outcome of all smear-positive cases (both on cat. 1 and Cat. 2.) are evaluated in the quarterly
“Tuberculosis Cohort Report”
The LGTBLS has to ensure that S/he obtains the outcome of every patient, including those that were referred to another health
facility if possible
Cured
A patient who was smear-positive at diagnosis, who completed
8 months of treatment and who is smear-negative at the end of
7th month of treatment and at least one previous occasion

Treatment completed 01 Died

▪ Patients who were smear-positive at diagnosis and \Any patient who dies for any reason during the
who completed treatment but in whom smear
examination results are not available at the end of
06 02 course of his/her chemotherapy

treatment.

▪ All smear-negative and extra-pulmonary patients who Treatment

completed treatment
outcome
Treatment failure Transferred out
Any patient who remains or becomes smear positive 05 03 A patient who has been transferred to another treatment center in
again at the end of fifth month or later during another State and whose treatment result is not known. Note:
chemotherapy ‘transferred out’ is not allowed within the same state; rather the patient
04 can be referred to another LGA and his treatment outcome obtained
during the quarterly supervisors meeting
Defaulter
Any patient who has interrupted for 8 consecutive
weeks or more after the date of the last attendance
during the course of treatment.

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Key messages

Record keeping is very important in Tuberculosis

1 management

Treatment outcomes are Died, Defaulter and

2 Transferred out

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OVERVIEW OF TUBERCULOSIS
Sessions Components
4.1 Overview of NTBLCP

4.2 Identification of Presumptive TB case (Probable/Suspected)

4.3 Discussions on completing Clinic Register for Presumptive TB Cases

4.4 Classifying the TB Patient

4.5 Administering TB Treatment (Determining Appropriate Treatment for TB)

4.6 Monitoring of TB treatment

4.7 Case Holding and Management of Treatment Interruption

4.8 Management of TB Complications

4.9 Recording and Reporting in TB Control

4.10 Recording and Reporting in TB Control

NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY | 100

Learning Objectives

At the end of this session, Participants will be able to;

Explain the interaction between TB and HIV in simple

1
terms

Describe the intervention/services accessible to TB and

2
HIV patients

3 Use the flow chat for TB/HIV collaborative services

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INTRODUCTION

We cannot win the battle against

AIDS if we do not also fight TB.

TB is too often a death sentence for

people with AIDS. “

Nelson Mandela

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 BASIC INFORMATION ON HIV:

HIV is caused by a virus HIV can be transmitted through:

04 01 ▪
▪
Unprotected sexual intercourse
Transfusion with infected blood
and blood products
▪ Use of unsterilized sharps

HIV can be managed with anti retroviral HIV transmission can be prevented
drugs through:
▪ A- Abstinence

03 02 ▪
▪
B- Being faithful
C- Condom

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 INTERACTION BETWEEN HIV AND TB

01 Infection with HIV leads to progressive destruction of the body’s immune system. Therefore persons who are infected with HIV are
more prone to TB disease either through activation of latent TB infection or progression of new TB infection to disease

02 Most HIV patients with TB often present with atypical TB symptoms and are particularly associated with an increased number of
smear-negative PTB and EPTB cases.

03 When HIV-positive patients develop PTB, the number of bacilli present in the sputum is fewer than in HIV-negative patients. This makes
diagnosis by conventional sputum microscopy difficult among this group of patients

04 Most HIV patients with TB often present with atypical TB symptoms and are particularly associated with an increased number of
smear-negative PTB and EPTB cases

05 When HIV-positive patients develop PTB, the number of bacilli present in the sputum is fewer than in HIV-negative patients. This makes
diagnosis by conventional sputum microscopy difficult among this group of patients

06 Furthermore, studies have shown that up to 17% of new TB cases are acquired from smear-negative cases; therefore it is important to
identify and treat smear-negative cases early in order to break the cycle of TB transmission in the community and health facilities

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 SERVICES FOR CONFIRMED TB CASE:

TB Patients

HIV status Unknown HIV status Positive

Commence anti-TB treatment

Provide HTS for Presumptive TB case
Refer to MO for evaluation and decision
to Offer Co-trimoxazole Preventive
Therapy(CPT)
Green marketing is a practice
Refer/Evaluation and decision to
Green marketing is a practice
commence Anti-retroviral drugs (ARVs)

Refer for care and support

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 SERVICES FOR CONFIRMED TB CASE:
Use the chart below as a guide:

All TB suspects

Provide health Education on

infection control: Cough etiquette

HCT AFB
microscopy

HIV positive HIV positive HIV negative HIV negative

No active TB Active TB Active TB No active TB

Refer to ART for: 1. Commence DOTS 1. Commence 1. Provide HIV

1. Evaluation for and CPT DOTS preventive
eligibility for 2. Link patient to ART 2. Provide HIV measures
ART and support preventive 2. Manage patient
2. Provision of services site for measures appropriately
IPT evaluation

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SERVICES FOR CONFIRMED TB CASE:

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INTRODUCTION

“The world has made defeating AIDS

a top priority. This is a blessing. But TB
remains ignored. Today we are calling
on the world to recognize that we
can't fight AIDS unless we do much
more to fight TB as well“

Nelson Mandela

Bangkok, 2004

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