Transcript HPI

Integration
Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy
Clinical Management
Pulmonology Module
2 years and 3 months prior to
consult
Chronic cough – when did the coughing
start? Productive or non-productive?
Loss of appetite and weight loss (weight
at this time: 50 kg) – was the patient able
to regain the weight after treatment?
Afternoon feverish sensation – sign of
infection
Body malaise
Differential Diagnoses
Pneumonia
Bronchial Asthma
Upper Airway Cough Syndrome
Chronic Obstructive Pulmonary Disease
GERD
Malignancy
Personal Social History
 Patient – laundrywoman
while husband is a
farmer
 Family lives in a 1-room
shanty house without
windows or toilet
 Nutrition:
 Drinking water from
peddlers
 Instant noodles and
occasionally rice and
sardines
Consult in local health center
Chest xray and sputum smear 
diagnosed with pulmonary tuberculosis
 enrolled in DOTS program in Brgy
San Roque, Cainta, Rizal
Claims to have undergone the program
continuously for 6 months
1 year and 9 months prior to admission
Repeat chest xray  cleared by the doctor
to have recovered from TB BUT THERE
WAS NO DOCUMENTATION
Pathophysiology
of Pulmonary TB
 Interaction of bacilli with
alveolar macrophage
receptors  endocytosis into
macrophage  inhibition of
phagosome-lysosome fusion
 bacilli free to replicate
 Cytokines induce Helper Tcell response  activation of
macrophages  granuloma
formulation  Delayed type
hypersensitivity  caseous
necrosis
Primary Pulmonary TB
 distal airspaces of the lower part of the upper
lobe or the upper part of the lower lobe
 Ghon Focus – initial site of parenchymal
involvement at the time of first infection which
becomes an area of gray to white inflammation
with consolidation measuring 1-1.5 cm (called
the Ghon lesion or focus)
 Ranke complex – Ghon focus + calcified lymph
nodes
 The primary lesion can then become latent or
progressive.
Progressive Pulmonary TB
 primary lesion increases in size and evolve in
different ways rapidly progressing to clinical
illness.
 resembles acute bacterial pneumonia with lower
and middle lobe consolidation and hilar
adenopathy
 pleural effusion - result of penetration of bacilli
into the pleural space from a subpleural focus
 Ghon focus enlarges  central necrosis 
irregular cavity poorly walled off by fibrous tissue
Secondary Pulmonary TB
 apical and posterior segments of the upper
lobes and superior segments of the lower lobe
due to higher oxygen tension in these areas
favoring mycobacterial growth
 Tuberculous pneumonia - result from massive
involvement of pulmonary segments or lobes
with coalescence of lesions
Diagnosing TB
 Sputum smear recommended mode of diagnosis for countries
without lab capacities for culture sensitivity testing (WHO
2010)
Screening for TB: Mantoux
Method Tuberculin Skin Test
To screen for LATENT tuberculosis
Intradermal injection of 0.1 mL of tuberculin
purified protein derivative (PPD) into the
inner surface of the forearm  measure
induration
(+) when ≥ 10 mm for residents of high-risk
congregate settings and infants, children,
and adolescents exposed to adults in highrisk categories
SN: 60%; SP: 78%; PLR: 2.28; NLR: 0.45
Screening for TB: Chest Xray
To identify persons with ACTIVE TB
Active disease - detection of any abnormality
(parenchymal, nodal or pleural) with or without
associated calcification
There is no single radiologic finding consistent
with active TB.
Initial screening method of choice when skin
test results are unreliable or high, or when
risks of transmission of an undiagnosed case
are high
Sn: 75.8%; Sp: 80%; PPR: 67% when
combined with symptoms
Chest Xray for Primary TB
 Can resemble
pneumonia
 Lymphadenopathy –
radiologic hallmark;
right paratracheal and
hilar stations most
common sites (Leung
et al 1999)
 Parenchymal
opacities – area of
homogenous
consolidation
Chest Xray for Secondary TB
 Parenchymal opacities
– heterogenous
opacities most
commonly in apical and
posterior segmental
upper lobes and the
superior segment of the
lower lobes
 Cavitation and Airfluid levels
 Bronchogenic spread
 Simon foci – apical
nodules that are often
calcified resulting from
hematogenous seeding
from primary infection
Chest xray of our patient at
the time of admission
Treatment of Tuberculosis
Anti-TB Treatment for the
Patient
Category I Anti-TB Regimen for Adult
weighing 50 kg:
First 2 months daily:
 Isoniazid – 300 mg
 Rifampicin – 450 mg
 Pyrazinamide – 1,200 mg
 Ethambutol – 800 mg
Next 4 months daily:
 Isoniazid – 300 mg
 Rifampicin – 450 mg
Gauging Response to
Treatment
Radiographic evaluation is of less
importance than sputum smear in
assessing response to treatment (Leung
1999)
Sputum smears on the 2nd month and
6th month
Prognosis
 Tuberculosis is a very treatable disease  good
prognosis if proper treatment is acquired.
 As of 2008, the mortality rate of tuberculosis in the
Philippines is 52 out of 100,000  tuberculosis has a
relatively bad prognosis in the Philippines
 The prevalence of TB in the Philippines is 550 out of
100,000
 Incidence is 280 out of 100,000
 As of 2007, case detection rate for new smear positive
cases in the Philippines is 67%
 Reasons:
 poor compliance to the treatment
 gaps in the implementation of DOTS in the country.
According to the WHO as well, the
Preventive Measures
Transmission of TB is through droplet nuclei.
Four factors that determine the likelihood of
transmission of tuberculosis:
(1) number of organisms expelled into the air
(degree of infectiousness of the case)
(2) concentration of organisms in the air
determined by volume of space and ventilation
(shared environment in which contact takes
place)
(3) length of time the case breathes the
contaminated air (proximity and duration of the
contact)
(4) immune status of the exposed individual
Preventive Measures
Educating the patient about coughing
etiquette and importance of handwashing.
minimize stigma and the exposure of noninfected patients to those who are infected
CONTACT Investigation: Get the family
screened!  encouraged but not mandatory
Costly to get sputum smears for the whole
family
Family dynamics when one member is already
sick
Environmental and sanitation conditions
Preventive Measures
 Adequate ventilation of the house, particularly the
room where the patient with infectious TB would
spend considerable time
 Anyone in the family who coughs should be
educated on cough etiquette and respiratory
hygiene, and should follow such practices at all
times
 The smear-positive TB patients should also be
advised to
spend as much time as possible outdoors
sleep alone in a separate, adequately ventilated
room, if possible
spend as little time as possible in congregate settings
or in public transport.
Preventive Measures for the
Patient
Wear a surgical mask.
Handwashing
Find ways to get
proper ventilation in
the house or spend
more time outdoors.
Gastrointestinal
HPI
Timeline
Signs and Symptoms
2 years, 3.5 mo PTC
(Mar 2008)
chronic cough
loss of appetite
weight loss
afternoon fever
body malaise
local HC in Cainta: CXR,
sputum exam
1 year, 8.5 mo PTC
Implication
TB
TB
TB
TB
TB
TB
repeat CXR, claimed cleared,
Resolution of TB?
no records available
HPI
Timeline
8 months PTC (Feb
2010)
Signs and Symptoms
Implication
tolerable colicky abdominal  Involvement of a hollow
pain
organ
 Involvement of more
bloatedness
distal segments of
intestines
 Hallmark of intestinal
obstruction;
abdominal distention
 Involvement of more
distal segments of
intestines
relieved by passage of flatus  Not obstipated, partial
or stool
obstruction
HPI
Timeline
4 weeks PTC
Signs and Symptoms
Implication
vomiting of ingested food
~1-2x/week
 Obstruction
increased frequency and
severity of abdominal
distention
 Progressive cause of
obstruction
 Possible locations
colicky pain localized @ RLQ  Chronicity rules out
appendicitis
 Malabsorption,
anorexia
malnutrition
 Malabsorption,
lost 20-30% weight
malnutrition
HPI
Timeline
18 days PTC
Signs and Symptoms
Implication
menses
 Rules out pregnancy as cause of
vomiting, colicky pain
 (Ruptured ectopic pregnancy
can present as intestinal
obstruction)
HPI
Timeline
Signs and Symptoms
Implication

stable vitals
On admission

BP, HR and RR important
indicators of compensatory
responses to a hypovolemic
status.
37.8 degrees Celsius is the cutoff point for normal expected
temperature in cases of
obstruction
ambulatory
evidence of muscle wasting

Malabsorption, malnutrition
hyposthenia

Malabsorption, malnutrition
minimally worked up and diagnosed
but cannot be cleared for
intervention due to pulmonary
complications
Primary Impression: GI
Tuberculosis
History of pulmonary tuberculosis with
undocumented resolution
Abdominal pain localized at the right lower
quadrant
Signs and symptoms of obstruction
Bloatedness
Abdominal disentention relieved by passage
of flatus or stool
Vomiting
Anorexia
Progressive
Gastrointestinal Tuberculosis
 Gastrointestinal Tuberculosis is the 6th most
common extrapulmonary manifestation of
tuberculosis (Chong and Lim 2009)
 Any site of the GI tract may be involved although
studies show a predilection to the ileocecal
segments (Fauci et al, 2008).
increased density of lymphoid tissue
increased stasis
neutral luminal pH
absorptive transport mechanisms
 route of infection
penetration of the bowel wall
hematogenous dissemination
Gastrointestinal Tuberculosis and its
Correlation with Pulmonary
Tuberculosis
25% of gastrointestinal TB cases have
evidence of pulmonary TB
there is a direct correlation between the
severity of pulmonary infection with the
presence of GI infection
With minimally advanced pulmonary disease, 1%
of patients have a concomitant GI infection
moderately advanced cases of pulmonary TB,
4.5% have evidence of GI TB
25% of patients with severely advanced PTB
cases have concomitant GI TB while
55% to 90% of fatal cases have GI involvement.
Hamer et al 1998
Gastrointestinal Tuberculosis
Manifestations
 Ulcerative form
 major form associated with increased pathogenicity and mortality
 appears as superficial ulcerative lesions on the epithelial surface.
 Hypertrophic form
 scarring, fibrosis and mass formation resembling carcinomatous
lesions.
 Ulcerohypertrophic form
 combination of the first two with both ulcerations and scar formation
 The host’s immune system plays a major role in
determining the presentation.
 Those with depressed immune responses are likely to develop the
ulcerative form while those with competent immunologic responses
would present with a hypertrophic form of the disease (Chong and
Lim. 2009).
Hamer et al 1998
Pathophysiology of the Disease
Imaging Studies
Differential Diagnoses
Mechanical causes of obstruction
herniations, volvulus and intussusceptions
are ruled out on physical exam and barium
studies performed on the patient
adhesions secondary to previous surgery
are unlikely as there is no mention of it in
the patient’s history
Adynamic ileus and colonic pseudoobstruction are ruled out as colicky pain is
absent in both conditions
Fauci 2008
Differential Diagnoses
Causes of RLQ pain
Appendicitis, ruled out by the duration of illness.
Right-sided diverticulitis
 less prevalent form of diverticulitis.
 clinical manifestation includes abdominal tenderness,
nausea, emesis, anorexia and GI bleeding (Nirula and
Greaney, 1997)
 Obstruction secondary to scarring from an infectious
process can be a complication of this disease
 Examinations for ruling out this disease include a
complete blood cell count, urinalysis, and flat and
upright abdominal radiography.
 Further examinations include CT imaging studies,
abdominal radiography with contrast and endoscopy
(Roberts et al 1995).
Differential Diagnoses
Causes of RLQ pain
Gastroenteritis and inflammatory bowel
disease
 both do not present with obstructive symptoms
 lack of diarrhea in the patient
 lack of cobblestoning on radiographic studies
rules out inflammatory bowel disease,
particularly Crohn’s disease.
Differential Diagnoses
Causes of RLQ pain
Gynecologic causes of right lower
quadrant pain such as ovarian tumor or
torsion, and pelvic inflammatory
disease as well as
Renal causes such as pyelonephritis,
perinephritic abscess and
nephrolithiasis are ruled out as they do
not present with obstructive symptoms.
Differential Diagnoses
TB peritonitis
uncommon extrapulmonary manifestation
a consideration in patients presenting with
several weeks of abdominal pain, fever,
and weight loss.
Ruled out because of the lack of ascites, a
major feature arising from the exudation of
proteinaceous fluid from the tubercles
Ruptured tubal pregnancy presenting
as intestinal obstruction is unlikely as
the patient reports recent menstruation
Management
1. Alleviation of symptoms of distention
2.
3.
4.
5.
via nasogastric decompression
Correction of nutritional status
Resection of the involved tissue
Demonstration of organism via culture
of resected segment followed by
sensitivity testing
Anti-mycobacterial treatment using
appropriate medications
Management
1. Alleviation of symptoms of distention
via nasogastric decompression
2. Correction of nutritional status
 serves to prepare the patient for
surgical intervention
 monitoring of serum albumin
Management
3. Resection of the involved tissue
 obstruction is a leading indication for
surgery in intestinal tuberculosis
 other indications for surgery include
ulcerative complications such as free
perforation, perforation with abscess,
or massive
 Preoperative drug therapy is still
controversial
Townsend et al 2008
Sharma and Bhatia 2004
Management
3. Resection of the involved tissue
 right hemicolectomy with a 5 cm
margin with anastomosis
 an ileostomy and a mucous fistula with
subsequent anastomosis
Townsend et al 2008
Sharma and Bhatia 2004
Management
4. Demonstration of organism via culture
of resected segment followed by
sensitivity testing
 definitive diagnosis of mycobacterial
infection by acid-fast stain or culture
 PCR methods
 culture and sensitivity to determine
which drugs are still effective
Management
5. Anti-mycobacterial treatment using
appropriate
 HRZES
 RCT: standard 6 month course vs
prolonged courses of conventional TB
medication shows no significant
difference in cure rates
Sharma and Bhatia 2004
Nutrition
Nutrition
SUBJECTIVE FINDINGS
 1 month prior to consult, patient claimed to have lost 20-




30% of her weight (can be classified as severe weight loss),
anorexic
Markedly decreased oral intake (short starvation) due to
vomiting after each oral intake
Patient lived on water, coffee, and diluted Bear Brand
(intolerance of both solid and soft diet becoming almost
daily)
Weak, able to stand up with support and poor hand grip
Evidence of muscle wasting
Nutrition
OBJECTIVE FINDINGS





Weight is 35 kg; height is 1.5m; BMI (kg/m2) is 15.6. Based
on the Asia-Pacific BMI classification, the patient is
underweight. Normal BMI= 18.5-22.9
Severe weight loss (>5-10%)
Ideal body weight computation = 45kg
Patient is less than 10 kg of his Ideal Body weight
%IBW= 35kg/45kg = 78%, meaning that current weight is
78% of ideal body weight, patient is classified under
moderate malnutrition
ASSESSMENT
 ABC’s of Nutritional Assessment
1. Anthropometric Measurements (Height, Weight, BMI, Triceps Skin Fold,
Mid-Arm Circumference, Mid Arm Mass Circumference)
BMI=15.6 (Underweight); IBW (Tanhausser’s)= 45kg; %IBW= 78%moderate malnutrition
%wt loss= severe (>5% in 1 month)
2. Biochemical Parameters (Common: Serum albumin <3.0g%;
Total Lymphocyte <1500)
3. Clinical Parameters or Manifestations
(Nutritional Risk Screening, 2002, First and Second Screening)
Impaired Nutritional Status= Wt loss >5% in 1 mos or >15% in 3 mos, or
BMI <18.5 + impaired general condition or food intake
PLAN


Appropriate nutritional assessment.
Institute a nutritional care plan for the patient. (Patient is nutritionally atrisk, NRS score of >=3)
 Calculate for total energy allowance and protein, carbohydrates, and fats
requirement
 Method of delivery: IV route then oral upon improvement (Pt has been
vomiting, pt has poor hand grip)
Nutrition: NRS, 2002
ESPEN Guideline
Table 1 Initial Screening
Yes
1
Is BMI<20.5
2
Has the patient lost weight
within the last 3
months?
3
Has the patient had a
reduced dietary intake
in the last week
4
Is the patient severely ill?
(e.g intensive therapy)
No
Yes: If the answer is “Yes” to any of the question, the screening in Table 2 is performed.
No: If the answer is “No” to all questions, the patient is re-screened at weekly intervals. If the patient e.g is
schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk
status.
Nutrition: NRS, 2002
ESPEN Guideline
Table 2 Final Screening
Impaired Nutritional
Status
Severity of disease (increase in requirements)
Absent Score 0
Normal nutritional Status
Absent Score 0
Normal nutritional requirements
Mild Score 1
Wt loss >5% in 3 mos or Food intake
below 50-75% of normal
requirement in preceding week
Mild Score 1
Hip fracture, Chronic patients in
particular with acute complications:
cirrhosis, COPD, chronic
hemodialysis, diabetes, oncology
Moderate Score 2
Wt loss >5% in 2 mos or BMI 18.520.5+ impaired general condition or
food intake 25-60% of normal
requirement in preceding week
Moderate Score 2
Major abdominal surgery, Stroke,
Severe Pneumonia, hematologic
malignancy
Severe Score 3
Wt loss >5% in 1 mo or BMI <18.5
+impaired general condition or food
intake 0-25% of normal
requirement in preceding week
Severe Score 3
Head injury, Bone marrow
transplantation, Intensive care
patients (APACHE >10)
Score
+
Score
Total Score
Age
If >=70 years old, add 1 to total score = age adjusted total score
Score >=3: the patient is nutritionally at risk and a nutritional care plan is initiated
Score <3: weekly re-screening of the patient. If the patient e.g is schedules for a major operation, a preventive
nutritional care plan is considered to avoid the associated risk status.
Nutrition
 Calculating total energy allowance and
protein, carbohydrates, and fats
requirement
Rapid Estimation of adult total
daily calorie and protein
requirement
Caloric
Require
ment
(kcal/kg/
d)
Protein
Requireme
nt
(g/kg/d)
None
25
0.8
Mild to
Moderate
35
1.0
Moderate
to Severe
45
1.5
Severity
of Illness
Total energy allowance = Weight (kg) x Caloric requirement
Total energy allowance = 35 x 45(kcal/kg/d) = 1575 kcal
Protein ( 1.0 – 1.5 g/kg/d) = (35 x 1.5) x 4; Protein = 210 kcal
Carbs= [(Total energy allowance – Calories from protein) x 0.7] / 4
Carbs = (1575 – 210) x (0.7) = 955 / 4 = 239 g CHO
Fats (30-40% of non-CHON calories) =
[(Total energy allowance – Calories from protein) x 0.3] / 9
Fats = (1575 – 210) x (0.3) = 409.5 / 9 = 45.5 g Fats
Nutrition
 Monitoring: Laboratory parameters, Body weight improvement,
Functional status
 Laboratory parameters (serum albumin, lymphocyte,
cholesterol, transferrin, iron-binding capacity)
 Surgical operation

General goal:
Restore the patient’s nutritional, metabolic and
functional status.

Specific goals:
1. Provide the needed total caloric need to the
patient following the macronutrient
requirements of protein 15-20%, fats-30-35%,
carbohydrates 50-60% of total calories.
2. Prevent complications of electrolyte and
metabolic derangement that could lead to
potentially life-threatening situations.
3. Prevent further complications of
malnutrition such as muscle wasting
 Relief from obstructive symptoms
 Prevention of malabsorption
caused by ileocecal TB
 Nutritional delivery must prepare
the patient for the surgical
operation (monitoring of serum
albumin)
 VitB12 supplementation given
post-surgery (since Vit B12
absorption is impaired in the
terminal ileum)
PUBLIC HEALTH
3 E’s: Evidence, Economics,
Ethics
EVIDENCE
City A
Philippines
Literacy Rate
98.32%
93%
Unemployment
Rate
14.3%
7.3%
55%
of City A’s total population is composed of migrants,
most of which end up as informal settlers in the city.
Informal settlers have poor living conditions
small living spaces, poor hygiene and sanitation 
transmission of infectious diseases like TB
,e.g.
EVIDENCE
Health Indicator
City A (2007)
Per 1,000
Crude Death Rate
4
Crude Birth Rate
15.7
Maternal Mortality
Rate
Infant Mortality
Rate
Stillbirths
0.7
21.5
Philippines
(FHSIS, 2005)
Per 1,000
4.2
0.71
9.72
2.5
4.7
EVIDENCE
Health Indicator
BHS
City A (2007)
n= 2,861,090
0.22 per 10,000
Doctors
Philippines
(FHSIS, 2005)
2 per 10,000
0.4 per 10,000
0.27 per 10,000
Nurses and
Midwives
2.6 per 10,000
0.83 per 10,000
Lack of Manpower
 One of the factors associated with low cure
rates (WHO):
“Directly observed therapy is not
functioning or does not work well” due to
UNDERSTAFFING
Defaulters are NOT TRACED (Defaulter
rate= 11%)
Proposed Solution
Addition of more public
health workers (doctors,
BHWs, midwives and
nurses) and/or BHS
Tap family members as
therapeutic partners
ECONOMICS
More funds
needed to:
BUILD more
BHS
HIRE more
health care
workers
ETHICS
Macroallocation of funds
Other leading causes of mortality and
morbidity may be prioritized
Improvement of IMR, stillbirth rate or
unemployment rate may be prioritized
instead
Ethical dilemma may be resolved by
adding more health care providers to
address all health problems
Management
McKinsey’s 7S Framework
For TB DOTS
Strategy
TB DOTS program is part of WHO’s
overall Stop TB Strategy
aim: “a world free of TB”
Objectives
To achieve universal access to highquality diagnosis and treatment for people
with TB
To reduce suffering and socioeconomic
burden associated with TB
Strategy
To protect poor and vulnerable populations
from TB, TB/HIV and MDR-TB
To support the development of new tools
and enable their timely and effective use.
Component of the strategy that pertains
to TB DOTS: pursue high-quality DOTS
expansion and enhancement
Political commitment with increased and
sustained financing
Strategy
Case detection through quality-assured
bacteriology
Standardized treatment, with supervision
and patient support
An effective drug supply and management
system
Monitoring and evaluating system, and
impact measurement
Structure
DOTS UNIT
Head
Nurse in Charge
Medical
Technologist/
Microscopist
TB Diagnostic
Committee
(TBDC)
Structure
TB DOTS unit associated with a hospital
may have more entities above it
Chairman of the Infection Control Committee
Chairman of the Pulmonary Diagnostics and
Therapeutic Center
Senior Vice President of the Patient Services
Group
Assistant Vice President of the Special
Services Division
System
National Tuberculosis Program (NTP) is used
as the core policy
Department of Health (DOH) and Center for
Health Development (CHD)
Local Government Units (LGUs)
PhilHealth
External systems
Global Fund through Philippine Business for
Social Progress (PBSP)
USAID
WHO
Shared Values
High-quality service
Sustainability
Efficiency
Patient-centeredness
Staff
TB DOTS unit
Unit head, head nurse, medical technician,
BHW, midwife
hospital based NTP coordinators
municipal/city health officers
CHD NTP Coordinators at the regional
and provincial levels
Skills
All TB DOTS health care workers are
trained and certified by DOH before
being allowed to work in a DOTS unit
trained according to the Manual of
Procedures for the National TB Control
Program, 2001
Gap Identification & Analysis
Interview with TB-DOTS personnel in
The Medical City TB-DOTS Facility
TB-DOTS is not entirely free
Enrollment in TB-DOTS becomes the
burden of the health care personnel
Human resource issues
Recording and Reporting are not updated
Gaps between goals, targets and actual
performance
(Balanced Score Card)
Gaps in financing
Financial Analysis
cost of treatment for PTB greatly differs
from treatment for extra-pulmonary TB
requiring surgery
complete treatment of a New Case of
Pulmonary TB: Php 2660.73 to Php
7584.90
complete treatment of a GI TB has an
additional cost of ~ Php86250 to Php
228750
additional costs are mainly from cost of
surgery (GI surgeon Professional fee,
45% of which is the Anesthesiologist
Professional Fee and hospital costs
Differences in pharmacotherapy
regimen, the choice of drugs and
manufacturer affects the total cost of
medication
cost of diagnostic modalities may also
differ depending on the hospital or
facility
Implications
importance of control of new cases of PTB
and prevention of development of
extrapulmonary complications
need for accurate identification of ExtraPTB and complicated TB cases
provision for resource allocation for these
cases
Balanced Scorecard
Vision – “a world free of TB”
Goal
(G1)To achieve universal access to highquality diagnosis and patient-centred
treatment
(G2)To reduce the suffering and
socioeconomic burden associated with TB
(G3) To protect poor and vulnerable
populations from TB, TB/HIV and MDR-TB
(G4) To support development of new tools
and enable their timely and effective use
Strategy
(S1) Sustained political commitment
(S2) Access to quality-assured sputum
microscopy
(S3) Standardized short-course
chemotherapy for all cases of TB under
proper case management conditions,
including direct observation of treatment
(S4) Uninterrupted supply of quality-assured
drugs.
(S5) Recording and reporting system enabling
outcome assessment of all patients and
assessment of overall program performance.
Internal Business Processes
Goal
area/Perspecti
ve
G1 unversal
access
Objectives
to provide
universal coverage
to provide quality
assured
bacteriology
to effectively
monitor and
evaluate patients
*recording
*reporting
Baseline
Measure
100%
Measures
number or
percentage of
areas covered by
TB-DOTS
number of new
cases detected
by sputum
testing
78,352/107,734 DOTS case
(73%) 2004
detection rate
number of cases
enrolled and
receiving
treatment
Target
s
100%
85%
Actual
100%
255084/86,96
0,000
(0.29%)
2009
75%
Initiatives
nationwide coverage of TBDOTS, all Local health units
have access to the TB-DOTS
program
Internal Business Processes
Goal
area/Perspective
Objectives
G2 reduce
suffering
to effectively
coordinate and
manage drug
supply
Baseline
Measure
Measures
inventory of
drugs received
inventory of
drugs consumed
by patients
G3 protect
groups
to prevent and
control MDR-TB
number of MDR
cases among
new TB cases
Target
s
Actual
Initiatives
Financing
Goal
area/Perspective
Objectives
Baseline
Measure
Measures
G2 reduce
suffering
To coordinate
resources
total cost of
drugs purchased
To account for
expenses
total cost of nondrugs purchased
total current
assets
total current
liabilities
Target
s
Actual
Initiatives
Customer
Goal
area/Perspecti
ve
G1 universal
access
Objectives
To identify and
treat cases
successfully
Baseline
Measure
Measures
78,352/107,734 DOTS case
(73%) 2004
detection rate
52,319/59,453
(88%) 2003
DOTS treatment
success rate
`
G2 reduce
suffering
To provide cheap
services
To provide free
drugs
Target
s
Actual
85%
(GTC
WHO
2009)
80%
(GTC
WHO
2009)
75% (2007)
Initiatives
88% (2006)
patient education and public
awareness campaigns by
LGUs
new enrollees are given
discounted sputum and xray
services after being diagnosed
drugs provided for free after
enrolling in TB DOTS
Customer
Goal
area/Perspecti
ve
G3 protect
groups
Objectives
Baseline
Measure
To prevent
MDR and
complication
s of TB/HIV
0.30%
Measures
Target
s
Actual
Initiatives
95% GF: # of MDR-TB
patients whose sputum
culture converts to
negative at the end of 6months of treatment
(among the patients
enrolled 9 months from
the start date of last
member of cohort)
development and
implementation of a joint
national plan; HIV surveillance
among TB patients, irre
spective of HIV prevalence
rates
New Adult TB
Cases
key actions for preventing and
controlling drug-resistant TB
include use of recommended
treatment regimens, a reliable
supply of quality-assured firstand second-line anti-TB drugs,
and adherence to treatment by
patients and to its proper
provision by health-care
Learning & Growth
Goal
area/Perspecti
ve
G1 universal
access
Objectives
to provide
standardized
service by
competent
health care
personnel
Baseline Measures
Measure
training of
personnel
availability
of a manual
for
personnel
G2 reduce
suffering
G3 protect
groups
to provide
inspiration,
motivation and
support to TB
patients
recognition and
acknowledgem
ent of existence
of risk groups
and their
special
requirements.
Target
s
Actual
Initiatives
Cum. 12,067
(120%) GF: # of
service deliverers
trained
233 for yr 2005
YES
NTPs should provide support to frontline
health workers to help them create an
empowering environment,
training of
personnel
268 (117%) GF:
Number of service
deliverers trained
in TB/HIV
collaborative
activities
advocacy to influence policy changes and
sustain political and financial
commitment; two-way communication
between the care providers and people
with TB as well as communities to
improve knowledge of TB control policies,
programmes and services; and social
mobilization to engage society, especially
the poor, and all allies and partners in the
campaign to Stop TB.
Learning & Growth
Goal
area/Perspectiv
e
G4 support
development
Objectives
Baseline
Measure
to participate actively in
both country-led and global
efforts to improve action
across all major areas of
health systems, including
policy, human resources,
financing, management,
service delivery (including
infrastructure and supply
systems) and information
systems
Measures
Targets
Number of
service
deliverers
(community
based support
group
67 (2006)
Number of
Public-private
Mix
100
Actual
Initiatives
2,622 (92) GF:
# of service
deliverers
(community
based support
group) trained
cordinating body that
includes TB and HIV
patient support groups;
99