Strengthening hospital services to

TB patients

Dr. Regina BerbaJuly 2010

Flow of discussion

Why TB • Philippines is 9th among the 22 high TB burden

countries• TB is the sixth leading cause of deaths and illnesses• Problem of multi-drug resistant and extremely

resistant TB (MDR-TB / XDR-TB)• Millennium development goal (MDG) in 2015 to

reduce TB mortality and prevalence

Why hospital• Hospitals are no. 1 providers of TB care; 4 out of 10

persons with signs and symptoms of TB are consulting a hospital

• Study of 14 hospitals in Metro Manila – estimated 11,000 TB cases have not been reported to NTP in 2008

• Most hospitals are not implementing DOTS, the country’s strategy to stop TB

• Strategic objective of the National TB Control Program: involve all hospitals in TB control

Health Care Worker/Facility

2007 National TB Prev Survey

(%)

1997 NTPS(%)

Public Health Center (DOTS)

26.7 24.5

Hospitals (Public and

Private)

43.0 19.9

Private physician 21.7 36.2

Others 2.6 19.4

How many TB symptomatics consulted hospitals

• DOH Administrative Order 24A s. 1997 “Guidelines in the Implementation of Hospital-Based TB Control Program under the Hospitals as Center of Wellness”- for all DOH hospitals

• A.O. no. 140 s. 2004: “Revised Guidelines for Hospital-Based TB Control Program under the Hospitals as Center of Wellness” - expands to LGU-owned hospitals- Options for hospital participation

DOTS Service Providing Facility DOTS Service Providing Facility DOTS Referring FacilityDOTS Referring Facility

What is the policy on hospital participation in TB control

What should be our mission

All TB cases seen in our hospital are promptly diagnosed, registered, treated and reported

in accordance with the policies of the National TB Control Program (NTP) and the

International Standards of TB Care (ISTC)

What is the International Standards of TB Care (ISTC)• List of standards on diagnosis, treatment and

public health functions on TB care

• Endorsed by the WHO, IUATLD, CDC, ATS and local organizations such as the Philippine Medical Society and six specialty societies (PCCP, PCP, PPS, PSMID, PCOM and PAFP)

What shall we do to improve TB services

1. DOTS strategy

National protocol on TB

1.1 On diagnosis:• Direct sputum smear microscopy (DSSM) is the

primary diagnostic tool• TB laboratory will be quality assured under the QA

system of the National TB reference Laboratory of RITM

• Hospital will have a TB Diagnostic Committee to review smear negative, x-ray positive cases

1.2 On treatment of TB cases

Category Type of patient Regimen

I and III New smear positive casesNew smear negative case but with findings suggestive of TB

2HRZE / 4HR

II Retreatment cases 2HRZES /1HRZE / 4HRE

IV Chronic To be managed as MDR suspect and

referred to treatment centers

• TB kits provided by the Department of Health• Treatment partner to supervise treatment• Monitoring through sputum follow-up• Cohort analysis to determine outcome

1.3 On recording and reporting

Adopt standardized recording and reporting system:• Registries / logbooks: symptomatic, laboratory, case and

referral• Other forms: laboratory request, treatment card, patient ID

card, intrahospital and external referral form• Reports: quarterly laboratory, case finding, case holding and

referral

S Situational assessment

T Talk with management

A Assign hospital TB team

R Role clarification through MOU / MOA

P Plan and policy development

L Logistics preparation

A Internal advocacy

C Capacity-building

E Provision of enablers

R Establishment of Referral system

S Supervision, monitoring and evaluation

What are processes to be done to implement DOTS

2. Establish intra-hospital TB referral system• All TB cases (admitted or seen at OPD) will be

referred to the TB DOTS clinic / office using an intra-hospital referral form

• All referrals will be listed in the hospital referral logbook

• Options for TB patients: For treatment at the TB clinic/ward orFor referral to health center

3. Establish external referral system

• Those who are not to be treated in the hospital will be referred to health centernearest the patient’s residence using the NTP referral form

• National directory of DOTS facilities • TB team has to know the result of referral:

(return referral slip, text, telephone call, etc)

Review the following forms

• TB symptomatic registry

• Intra-hospital referral form(upper and lower portion)

• NTP referral form

Hospital TB team• Dr. Camilo Roa Jr. – Head of the TB Committee• Dr. Regina Berba – Coordinator for Internal Networking• Dr. Norman Maghuyop – Coordinator for External

Networking• Ms. Grace Rondilla – Nurse, TB- DOTS Clinic• Dr. Jubert Benedicto – Pulmonary Section• Dr. Teresa Benedicto – Radiology Department• Dr. Myrna Mendoza – Infectious Disease Section

Location of TB clinic / ward

4. Working with our partners

DOH (Infectious Disease Office) – drugs, laboratory supplies, funds for upgrading, microscope

WHO/Canadian International Development Agency (CIDA) – through the CATCH TB cases project

Local Government Units – the health centersOther DOTS facilities e.g. private clinics and

hospitals

What is the CATCH TB Cases project

• A three-year project being managed by DOH and supported by WHO/CIDA

• The Philippines is one of the 5 countries testing innovative strategies to detect more TB cases

• 3 components: hospital engagement, contact investigation and high risk group

• Will assist hospitals enhance its participation in TB control

• DOH-owned: LCP, Jose Reyes, San Lazaro, East Avenue, Rizal Medical Center*, Amang Rodriguez, Tondo General Hospital and National Mental Hospital

• LGU-owned: Ospital ng Maynila* and Q.C General Hospital*

• Philippine General Hospital*

Participating hospitals (11)

What are the expected outputs

• Functional referral system• All TB cases detected by the hospitals are

properly treated and successfully referred

A challenge to all

Let us work together towards a TB-free Philippines !!

THANK YOU