1. Integration
Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy

2. Clinical Management
Pulmonology Module

3. 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

4. Differential Diagnoses
Pneumonia
Bronchial Asthma
Upper Airway Cough Syndrome
Chronic Obstructive Pulmonary Disease
GERD
Malignancy

5. 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 5

6. 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

7. 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 T-cell response  activation of macrophages  granuloma formulation  Delayed type hypersensitivity  caseous necrosis

8. 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 cm (called the Ghon lesion or focus)
Ranke complex – Ghon focus + calcified lymph nodes
The primary lesion can then become latent or progressive.

9. 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

10. 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

11. Diagnosing TB
Sputum smear recommended mode of diagnosis for countries without lab capacities for culture sensitivity testing (WHO 2010)

12. 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 high-risk categories
SN: 60%; SP: 78%; PLR: 2.28; NLR: 0.45
Lichuaco et al (2006). Philippine Guidelines for the Screening of Tuberculosis. APLAR Journal of Rheumatology 9: 12

13. Screening for TB: Chest Xray
Leung (1999) Pulmonary Tuberculosis: The Essentials. Radiology Vol. 210 (2)
Lichuaco et al (2006). Philippine Guidelines for the Screening of Tuberculosis. APLAR Journal of Rheumatology 9:
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 13

14. 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

15. 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 Air-fluid 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

16. Treatment of Tuberculosis

17. 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:

18. 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

19. 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

20. 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

21. Preventive Measures
Educating the patient about coughing etiquette and importance of handwashing.
minimize stigma and the exposure of non-infected 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

22. 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.

23. Preventive Measures for the Patient
Wear a surgical mask.
Handwashing
Find ways to get proper ventilation in the house or spend more time outdoors.

24. Gastrointestinal

25. HPI Timeline Signs and Symptoms Implication
2 years, 3.5 mo PTC (Mar 2008)
chronic cough TB
loss of appetite
weight loss
afternoon fever
body malaise
local HC in Cainta: CXR, sputum exam
1 year, 8.5 mo PTC
repeat CXR, claimed cleared, no records available
Resolution of TB? 25

26. HPI Timeline Signs and Symptoms Implication 8 months PTC (Feb 2010)
tolerable colicky abdominal pain
Involvement of a hollow organ
bloatedness
Involvement of more distal segments of intestines
abdominal distention
Hallmark of intestinal obstruction;
relieved by passage of flatus or stool
Not obstipated, partial obstruction

27. HPI Timeline Signs and Symptoms Implication 4 weeks PTC
vomiting of ingested food ~1-2x/week
Obstruction
increased frequency and
severity of abdominal distention
Progressive cause of obstruction
colicky pain localized @ RLQ
Possible locations
Chronicity rules out appendicitis
anorexia
Malabsorption, malnutrition
lost 20-30% weight

28. HPI Timeline Signs and Symptoms Implication 18 days PTC menses
Rules out pregnancy as cause of vomiting, colicky pain
(Ruptured ectopic pregnancy can present as intestinal obstruction)

29. HPI Timeline Signs and Symptoms Implication On admission stable vitals
BP, HR and RR important indicators of compensatory responses to a hypovolemic status.
37.8 degrees Celsius is the cut-off point for normal expected temperature in cases of obstruction
ambulatory
evidence of muscle wasting
Malabsorption, malnutrition
hyposthenia
minimally worked up and diagnosed but cannot be cleared for intervention due to pulmonary complications

30. 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

31. 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

32. 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

33. 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

34. Pathophysiology of the Disease

35. Imaging Studies

36. 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 pseudo-obstruction are ruled out as colicky pain is absent in both conditions
Fauci 2008

37. 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).

38. 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.

39. 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.

40. 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

41. Management
Alleviation of symptoms of distention 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

42. Management
Alleviation of symptoms of distention via nasogastric decompression
Correction of nutritional status
serves to prepare the patient for surgical intervention
monitoring of serum albumin

43. Management 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

44. Management 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

45. Management
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

46. Management 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

47. Nutrition

48. 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

49. Nutrition Weight is 35 kg; height is 1.5m; BMI (kg/m2) is 15.6. Based
OBJECTIVE FINDINGS
Weight is 35 kg; height is 1.5m; BMI (kg/m2) is Based
on the Asia-Pacific BMI classification, the patient is
underweight. Normal BMI=
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

50. 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 < impaired general condition or food intake

51. PLAN
Appropriate nutritional assessment.
Institute a nutritional care plan for the patient. (Patient is nutritionally at-
risk, 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)

52. Nutrition: NRS, 2002 ESPEN Guideline
Table 1 Initial Screening Yes No 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)
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.

53. Nutrition: NRS, 2002 ESPEN Guideline
Table 2 Final Screening
Impaired Nutritional Status
Severity of disease (increase in requirements)
Absent Score 0
Normal nutritional Status
Normal nutritional requirements
Mild Score 1
Wt loss >5% in 3 mos or Food intake below 50-75% of normal requirement in preceding week
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 impaired general condition or food intake 25-60% of normal requirement in preceding week
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
Head injury, Bone marrow transplantation, Intensive care patients (APACHE >10)
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.

54. Nutrition
Rapid Estimation of adult total daily calorie and protein requirement
Calculating total energy allowance and protein, carbohydrates, and fats requirement
Severity of Illness
Caloric Requirement (kcal/kg/d)
Protein Requirement
(g/kg/d)
None 25
0.8
Mild to Moderate 35
1.0
Moderate to Severe 45
1.5
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) = / 9 = 45.5 g Fats

55. Nutrition
Monitoring: Laboratory parameters, Body weight improvement, Functional status
Laboratory parameters (serum albumin, lymphocyte, cholesterol, transferrin, iron-binding capacity)

56. Relief from obstructive symptoms
Surgical operation
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)
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

57. 3 E’s: Evidence, Economics, Ethics
PUBLIC HEALTH
3 E’s: Evidence, Economics, Ethics

58. EVIDENCE City A Philippines Literacy Rate 98.32% 93% Unemployment Rate
14.3%
7.3%
of City A’s total population is composed of migrants, most of which end up as informal settlers in the city.
Informal settlers have ,e.g. small living spaces, poor hygiene and sanitation 
55%
poor living conditions
transmission of infectious diseases like TB

59. EVIDENCE Health Indicator City A (2007) Per 1,000
Philippines (FHSIS, 2005)
Crude Death Rate 4
4.2
Crude Birth Rate
15.7
Maternal Mortality Rate
0.7
0.71
Infant Mortality Rate
9.72
Stillbirths
2.5
21.5
4.7

60. EVIDENCE Health Indicator City A (2007) n= 2,861,090 Philippines
(FHSIS, 2005)
BHS
2 per 10,000
Doctors
0.4 per 10,000
Nurses and Midwives
2.6 per 10,000
0.22 per 10,000
0.27 per 10,000
0.83 per 10,000

61. 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%)

62. Tap family members as therapeutic partners
Proposed Solution
Addition of more public health workers (doctors, BHWs, midwives and nurses) and/or BHS
Tap family members as therapeutic partners

63. ECONOMICS More funds needed to: BUILD more BHS
HIRE more health care workers

64. 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

65. Management

66. McKinsey’s 7S Framework
For TB DOTS 66

67. 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 high-quality diagnosis and treatment for people with TB
To reduce suffering and socioeconomic burden associated with TB 67

68. 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 68

69. 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 69

70. Structure DOTS UNIT Head Medical Technologist/ Microscopist
Nurse in Charge
 TB Diagnostic Committee (TBDC) 70

71. 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 71

72. 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 72

73. Shared Values High-quality service Sustainability Efficiency
Patient-centeredness 73

74. Staff TB DOTS unit hospital based NTP coordinators
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 74

75. 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 75

76. Gap Identification & Analysis76

77. 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 77

78. Gaps between goals, targets and actual performance
(Balanced Score Card)
Gaps in financing 78

79. Financial Analysis 79

80. 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 to Php
complete treatment of a GI TB has an additional cost of ~ Php86250 to Php 80

81. 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 81

82. Implications
importance of control of new cases of PTB and prevention of development of extrapulmonary complications
need for accurate identification of Extra-PTB and complicated TB cases
provision for resource allocation for these cases 82

83. Balanced Scorecard 83

84. Vision – “a world free of TB” Goal
(G1)To achieve universal access to high-quality 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 84

85. 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. 85

86. Internal Business Processes
Goal area/Perspective
Objectives
Baseline Measure
Measures
Targets
Actual
Initiatives
G1 unversal access
to provide universal coverage
100%
number or percentage of areas covered by TB-DOTS
nationwide coverage of TB-DOTS, all Local health units have access to the TB-DOTS program
to provide quality assured bacteriology
number of new cases detected by sputum testing
255084/86,960,000 (0.29%)
2009
78,352/107,734
(73%) 2004
DOTS case detection rate
85%
75%
to effectively monitor and evaluate patients
number of cases enrolled and receiving treatment
*recording
*reporting 86

87. Internal Business Processes
Goal area/Perspective
Objectives
Baseline Measure
Measures
Targets
Actual
Initiatives
G2 reduce suffering
to effectively coordinate and manage drug supply
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 87

88. Financing Goal area/Perspective Objectives Baseline Measure Measures
Targets
Actual
Initiatives
G2 reduce suffering
To coordinate resources
total cost of drugs purchased
To account for expenses
total cost of non-drugs purchased
total current assets
total current liabilities 88

89. Customer Goal area/Perspective Objectives Baseline Measure Measures
Targets
Actual
Initiatives
G1 universal access
To identify and treat cases successfully
78,352/107,734
(73%) 2004
DOTS case detection rate
85% (GTC WHO 2009)
75% (2007)
52,319/59,453 (88%) 2003
DOTS treatment success rate
80% (GTC WHO 2009)
88% (2006) `
patient education and public awareness campaigns by LGUs
G2 reduce suffering
To provide cheap services
new enrollees are given discounted sputum and xray services after being diagnosed
To provide free drugs
drugs provided for free after enrolling in TB DOTS 89

90. Customer Goal area/Perspective Objectives Baseline Measure Measures
Targets
Actual
Initiatives
G3 protect groups
To prevent MDR and complications of TB/HIV
0.30%
New Adult TB Cases
95% GF: # of MDR-TB patients whose sputum culture converts to negative at the end of 6-months 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
key actions for preventing and controlling drug-resistant TB include use of recommended treatment regimens, a reliable supply of quality-assured first- and second-line anti-TB drugs, and adherence to treatment by patients and to its proper provision by health-care providers. 90

91. Learning & Growth Goal area/Perspective Objectives Baseline Measure
Measures
Targets
Actual
Initiatives
G1 universal access
to provide standardized service by competent health care personnel
training of personnel
Cum. 12,067 (120%) GF: # of service deliverers trained
233 for yr 2005
availability of a manual for personnel
YES
G2 reduce suffering
to provide inspiration, motivation and support to TB patients
NTPs should provide support to frontline health workers to help them create an empowering environment,
G3 protect groups
recognition and acknowledgement of existence of risk groups and their special requirements.
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. 91

92. Learning & Growth Goal area/Perspective Objectives Baseline Measure
Measures
Targets
Actual
Initiatives
G4 support development
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
Number of service deliverers (community based support group
2,622 (92) GF: # of service deliverers (community based support group) trained
cordinating body that includes TB and HIV patient support groups;
67 (2006)
Number of Public-private Mix
100 99 92