TB Case Finding in Hospitals

OBJECTIVES

1. Identify presumptive Tuberculosis2. Assess and examine presumptive TB case3. Decide if a patient have TB4. Refer patient to a hospital TB clinic/desk

2 APPROACHES TO CASE FINDING1. Passive case finding – identifying TB among the symptomatic patients who are screened for disease activity upon consultation at the hospital or health facility.2. intensified case finding - actively seeking out TB among individuals belonging to special or define population. Example: High risk groups like patient with HIV, DM, End stage Renal Disease, cancer, connective tissue diseases, Autoimmune Diseases, Silicosis, patients who underwent gastrectomy or solid organ transplantation and patient on prolong systemic steroids.

STEP1-IDENTIFY PRESUMPTIVE TB PATIENTS

Areas:• OPD• ER• WARDS• RADIOLOGY/X-RAY DEPT.• PHARMACY • SOCIAL SERVICE• LABORATORY• PRIVATE DOCTORS WITHIN THE HOSPITAL

PRESUMPTIVE TB- any person whether adult or child with signs and or symptoms suggestive of TB whether Pulmonary or Extra Pulmonary or those with chest x-ray findings suggestive of active TB.1. Adults (15 y/o and above) who has any of the ff:

a. Cough of atleast 2 weeks duration with or without the following symptoms:

Significant and unintentional weight lossFeverBloody sputum (hemoptysis)Chest/black pains not referable to any musculoskeletal disordersEasy fatigability or malaiseNight sweatsShortness of breath or DOB

b. Unexplained cough of any duration in:Close contact of a known active TB caseHigh risk clinical groupsHigh risk population (elderly, urban poor, inmates and other congregate settings.)

2. Children (below 15 y/o0, who has any of the ff:a. Atleast 3 of the ff clinical criteria:

Coughing/wheezing of 2 weeks or more, especially if unexplainedUnexplained fever of 2 weeks or more after common causes such as malaria or pneumonia have been r/o.Loss of weight /failure to gain weight/weight faltering/loss of appetiteFailure to respond to 2 weeks of appropriate antibiotic txt for lower RTIFailure to regain previous state of health 2 weeks after a viral infection or exanthema. Ex. MeaslesFatigue, reduce playfulness, or lethargy

b. Any of the above signs and symptoms (clinical criteria) in a child who has a close contact of known active TB case

3. A patient with chest x-ray findings suggestive of TB with or without symptoms, regardless of age. 

PRESUMPTIVE EXTRA-PULMONARY TB- may have Any of the following:

Gibbus, especially of recent onset (resulting from vertebral TB)Non-painful enlarged cervical lymphadenopathy with or without fistula formation.Neck stiffness or nuchal rigidity and or drowsiness suggestive of meningitis that is not responding to antibiotic treatmentPleural effusionPericardial effusionDistended abdomen (ex. Big liver and spleen) with ascites Non-painful enlarged jointSigns or tuberculin hypersensitivity

PRESUMPTIVE DRUG RESITANT-TB(DRTB) – any person 9whether adult or child) who belongs to any of the DRTB high risks groups, such as: re treatment cases, new TB cases that are contacts of confirmed DRTB cases or non-converter of Category 1 and people living with HIV with signs and symptoms of TB.

 

STEP II- ASSESMENT OF PRESUMPTIVE TB PATIENT

1. Medical History and Physical Examinationa. Signs and symptoms of the disease-805 of TB cases affect the lungb. History of exposure from active TB cases of presumptive TB (including MDR-TB) within the

family or household and workplace ( present and past exposure)c. Presence of clinical or other high-risk factors.d. History of previous anti-TB treatment and its

details.e. Physical examination- lungs and other organ

affected like larynx, lymph nodes, brain , kidney, bones and joints.

2. Diagnostic test (provided by the NTP)a. Direct Sputum Smear Microscopy- serves as

one of the bases for categorizing TB cases according to standard case definition.

- use to monitor progress of patient with TB while they are on treatment and confirm cure at the end of treatment

- primary diagnostic method adopted by the NTP among such individuals because:1. It provides a definitive diagnosis of active TB.2. Procedure is simple3. Economical4. Microscopy could be put up even in remote

areas 

Contraindication for collecting sputum for DSSM is massive hemoptysis.All presumptive TB patient should undergo DSSM except the following situation:

Mentally incapacitated as decided by specialist or medical institutionDebilitated or bedridden Children unable to expectoratePatients unable to produce sputum despite sputum induction

b. TB Culture and Drug Susceptibility Test (DST) – a routine diagnostic test for Drug resistant

TB cases under the NTP.- Used for TB prevalence surveys, drug resistance surveillance, research and other special cases.

c. Rapid Molecular Diagnostic Test : Xpert MTB /RIF

- Is a fully automated diagnostic molecular test that detects TB and Rifampicin Drug resistant.- Provides accurate result in less than 2 hours so that patient can be given proper treatment on the same day.- Used for TB diagnosis among :

1. Presumptive DRTB 2. Person living with HIV (PLHIV) with signs and symptoms and TB3. Smear negative adults with chest x-ray findings

suggestive of TB 4. Smear negative children

d. Other Tests1.Tuberculin Skin Testing (TST) - Basic Screening Tool

for TB infection among children using PPD solution/Mantoux Test.

2. Chest x-ray – used to compliment bacteriologic testing in making a diagnosis

STEP III – DECIDE IF PATIENT HAVE TB Classification of TB based on anatomical sitea. Pulmonary TB (PTB) – involves the lung parenchyma.b. Extra Pulmonary TB (EPTB) – involves larynx, pleura, lymph nodes, abdomen, GUT, skin, joints and bones, meninges

Classification of TB based on bacteriological statusa. Bacteriology confirmed – a TB patient from whom a biological specimen is positive by smear microscopy, culture or rapid diagnostic test (Xpert MTB/RIF).b. Clinically diagnosed – patient who does not fulfill the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment. It includes cases diagnosed on the basis of x-ray abnormalities or suggestive histology and extra pulmonary cases without laboratory confirmation.

STEP IV – REFER PATIENT TO HOSPITAL TB CLINIC

(INTERNAL REFERRAL)

TB CASE HOLDING AND REFERRAL TO DOTS CENTER

Objectives:

1. Identify patients TB disease registration group

2. Assign Correct Treatment Regimen3. Initiate Treatment and registration in

the Hospital and DOTS Facility4.Refer Patient to a DOTS facility

(External Referral System)5. Monitor patients treatment