Integration

Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy

Clinical ManagementPulmonology 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

PneumoniaBronchial AsthmaUpper Airway Cough SyndromeChronic Obstructive Pulmonary DiseaseGERDMalignancy

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 centerChest 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 admissionRepeat 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 T-cell response activation of macrophages granuloma formulation Delayed type hypersensitivity caseous necrosis

Primary Pulmonary TBdistal airspaces of the lower part of the upper lobe or

the upper part of the lower lobeGhon 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 TBprimary 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 tuberculosisIntradermal 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

Screening for TB: Chest XrayTo 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 TBParenchymal 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 spreadSimon 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 mgRifampicin – 450 mgPyrazinamide – 1,200 mgEthambutol – 800 mg

Next 4 months daily: Isoniazid – 300 mgRifampicin – 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 treatmentgaps in the implementation of DOTS in the country.

According to the WHO as well, the

Preventive MeasuresTransmission 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 MeasuresEducating 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 mandatoryCostly to get sputum smears for the whole family Family dynamics when one member is already sickEnvironmental and sanitation conditions

Preventive MeasuresAdequate 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. HandwashingFind ways to get

proper ventilation in the house or spend more time outdoors.

Gastrointestinal

HPITimeline Signs and Symptoms Implication

2 years, 3.5 mo PTC (Mar 2008)

chronic cough TBloss of appetite TB

weight loss TBafternoon fever TB

body malaise TBlocal HC in Cainta: CXR,

sputum examTB

1 year, 8.5 mo PTCrepeat CXR, claimed cleared,

no records availableResolution of TB?

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;

Involvement of more distal segments of intestines

relieved by passage of flatus or stool

Not obstipated, partial obstruction

HPITimeline 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 Malabsorption,

malnutrition

HPITimeline 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)

HPITimeline 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 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 stoolVomiting AnorexiaProgressive

Gastrointestinal TuberculosisGastrointestinal 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 tissueincreased stasis neutral luminal pH absorptive transport mechanisms

route of infection penetration of the bowel wallhematogenous dissemination

Gastrointestinal Tuberculosis and its Correlation with Pulmonary

Tuberculosis25% of gastrointestinal TB cases have

evidence of pulmonary TBthere is a direct correlation between the

severity of pulmonary infection with the presence of GI infectionWith minimally advanced pulmonary disease, 1%

of patients have a concomitant GI infectionmoderately advanced cases of pulmonary TB,

4.5% have evidence of GI TB25% 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 obstructionherniations, 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

Differential DiagnosesCauses 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 painGastroenteritis 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 painGynecologic 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 peritonitisuncommon extrapulmonary manifestationa 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 via nasogastric decompression

2. Correction of nutritional status3. Resection of the involved tissue4. Demonstration of organism via culture of

resected segment followed by sensitivity testing

5. 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 2008Sharma 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 2008Sharma 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

NutritionOBJECTIVE 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 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)

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.

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 18.5-20.5+ 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

Total energy allowance = Weight (kg) x Caloric requirementTotal 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

Rapid Estimation of adult total daily calorie and protein requirement

Severity of Illness

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

Nutrition

Monitoring: Laboratory parameters, Body weight improvement, Functional status

Laboratory parameters (serum albumin, lymphocyte,

cholesterol, transferrin, iron-binding capacity)

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

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)

PUBLIC HEALTH

3 E’s: Evidence, Economics, Ethics

EVIDENCECity 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

EVIDENCEHealth Indicator City A (2007)

Per 1,000Philippines

(FHSIS, 2005)Per 1,000

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

EVIDENCEHealth 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

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 UNDERSTAFFINGDefaulters 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

BHSHIRE more

health care workers

ETHICS

Macroallocation of fundsOther 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 Strategyaim: “a world free of TB”

ObjectivesTo achieve universal access to high-quality

diagnosis and treatment for people with TBTo 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 enhancementPolitical 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

Medical Technologist/Microscopist

Nurse in Charge TB Diagnostic

Committee (TBDC)

Structure

TB DOTS unit associated with a hospital may have more entities above itChairman 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

SystemNational Tuberculosis Program (NTP) is used

as the core policyDepartment of Health (DOH) and Center for

Health Development (CHD)Local Government Units (LGUs)PhilHealthExternal systems

Global Fund through Philippine Business for Social Progress (PBSP)

USAIDWHO

Shared Values

High-quality serviceSustainabilityEfficiencyPatient-centeredness

Staff

TB DOTS unit Unit head, head nurse, medical technician,

BHW, midwife

hospital based NTP coordinatorsmunicipal/city health officersCHD 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 FacilityTB-DOTS is not entirely freeEnrollment in TB-DOTS becomes the

burden of the health care personnelHuman resource issuesRecording 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

Implicationsimportance 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

Balanced Scorecard

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

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 ProcessesGoal 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

100% 100% 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          

Internal Business ProcessesGoal 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

     

FinancingGoal 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

     

CustomerGoal 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

CustomerGoal 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.

Learning & GrowthGoal 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 trained233 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.

  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 & GrowthGoal 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