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2 DISCLAIMER The authors do not warrant the accuracy of the information contained in the TB Technical Guideline and do not take responsibility for any death, loss, damage or injury caused by using the information in this document. While every effort has been made to ensure that this document is correct and in accordance with current evidence based and clinical practices, the dynamic nature requires that users exercises in all cases independent professional judgement and understand the individual clinical scenario. Fiji National Tuberculosis Programme Ministry of Health. Tamavua-Twomey Hospital Princess Road, Suva Republic of Fiji. Tel (679) or (679) Copyright Ministry of Health, All rights reserved. This material may be freely reproduced for education and not-for- profit purposes within the Ministry of Health. No reproduction by or for commercial organisations is allowed without express written permission of the Ministry of Health-Fiji. TB Guideline - Fiji 2

3 This Guideline was prepared by the Fiji National Tuberculosis Programme with the technical and funding support from the Australian Respiratory Council (ARC) and the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for This Guideline was prepared by the Fiji National Tuberculosis Programme with the their valuable contributions to the key technical concepts of this Guide. Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. TB Guideline - Fiji 3 TB Guideline - Fiji 3

4 CONTENTS Preface... 5 Foreword... 6 Acronyms... 7 This Guideline Introduction was... prepared by the Fiji National Tuberculosis 8-10 Programme with the Global TB Fund Programme to fight AIDS, Elements TB and Malaria respectively. Detecting & diagnosing people with TB Particular Treatment gratitude for is people accorded with to TB Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable Preventing contributions TB... to the key technical concepts of this Guide. Monitoring & evaluation The indispensible Programme supervision comments and suggestions by Dr Linh Nguyen of WHO office in Suva must not References go unrecognized Appendices...39 Last but Tub not 1 the least, Referral/transfer the contributions forms and support of the following personnel and institutions Tub 2 is acknowledged: Laboratory Register Dr Josefa Tub Koroivueta 3 Laboratory (AFB microscopy) request form Dr Iobi Tub Batio 4 AFB Microscopy Register Dr Sakiusa Tub 5 Mainawalala TB Register Dr Frank Tub Underwood 6 TB Patient ID Card Dr Apisalome Tub 7 Nakolinivalu TB Contact Register Fiji Red Tub Cross 8 Society TB Treatment Card Fiji Nursing Tub 9 Association HIV testing Consent form Grant Management Tub 10 Unit Pharmacy of Fiji MOH form and Public Tub health 11 officials Domicilliary Treatment Supervision form Tub 12 Treatment Completion form Tub 13 Quarterly Report on Sputum Conversion Tub 14 Quarterly Report on TB case registration Tub 15 Quarterly Report on Treatment Outcome TB Guideline - Fiji 4 TB Guideline - Fiji 43

5 PREFACE This is the third edition of the technical guide for tuberculosis control in Fiji. The first edition was printed in 1996 and the second in This edition updates previous editions to current data, health system and practice, as well as treatment and programme recommendations. The contents of this guide have been developed with reference to the World Health This Guideline was prepared, by the Australian Fiji National Respiratory Tuberculosis Council Programme and the with IUATLD the recommendations. The Global main Fund objectives to fight of AIDS, this TB guideline and Malaria are: respectively. To describe global, regional and local TB burden and the strategy for effective TB Particular control; gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable To describe contributions standardized to the treatment key technical regimens concepts according of this to Guide. TB case definitions; To demonstrate monitoring and evaluation principles for individual patients and the The indispensible Programme; comments and suggestions by Dr Linh Nguyen of WHO office in Suva must not To go provide unrecognized. information on special and emerging situations in TB control This guideline is aimed primarily at TB clinicians, medical physicians, paediatricians, civil society Last but organizations, not the least, but the clinical contributions and public and health support teachers, of the and following students in personnel medical and and nursing institutions will also is acknowledged: find it helpful. TB Guideline - Fiji 5 TB Guideline - Fiji 53

6 FOREWORD There This Guideline will be a warm was welcome prepared to by this the third Fiji edition National of the Tuberculosis TB guidelines. Programme The first and with second the editions technical were and printed funding 1996 support and 2004 from respectively, the Australian and have Respiratory been most Council valuable (ARC) and extensively and the used. Global Fund to fight AIDS, TB and Malaria respectively. The Particular synthesis gratitude of this revised is accorded version to is Professor based on Guy the distressing Marks and epidemiology Ms Kerry Shaw of TB of globally the ARC and for regionally. Further, it was recognized that new diagnostic and therapeutic methods have been their valuable contributions to the key technical concepts of this Guide. discovered, a number of public health challenges have emerged to hinder TB control efforts, and innovative support from civil society institutions have been proved successful in most TB endemic territories. With the global explosion of HIV, and in some countries much ill-informed and chaotic treatment practices, Last but the not world the least, is threatened the contributions with an uncontrollable and support epidemic of the of TB following and MDR-TB. personnel The only and way institutions to prevent is acknowledged: this is to ensure that the concepts and principles outlined in this guideline are universally applied, both in the public and private sector. If Dr and Sakiusa when Mainawalala the guidelines contained in this manual are followed, it will then be possible to reach the Dr Frank overall Underwood aim of the National Tuberculosis Programme, which is to reduce morbidity, mortality and disease transmission due to TB. We must therefore make every necessary effort to ensure that this vital objective is indeed achieved. Time is not on our side and the need is urgent. This Guideline must have the widest possible Grant Management distribution. Unit of Fiji MOH and Dr Neil Sharma Minister of Health, Fiji TB Guideline - Fiji 6 TB Guideline - Fiji 63

7 ABBREVIATIONS ACSM Advocacy Communication Social Mobilization AFB Acid Fast Bacilli AIDS Acquired lmmuno Deficiency Syndrome ART Anti-retroviral therapy BCG Bacillus Calmette Guerin (TB vaccine) CSO Civil Society Organization This Guideline DOT was Directly prepared Observed by Treatment the Fiji National Tuberculosis Programme with the DOTS Directly Observed Treatment Short course DST Drug Susceptibility Testing Global EPTB Fund to fight AIDS, Extra pulmonary TB and Malaria tuberculosis respectively. EQA External Quality Assessment Particular FDC gratitude is Fixed accorded Dose Combination to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable FPBS contributions Fiji Pharmaceutical to the key & Biomedical technical concepts Services of this Guide. HCW Health care worker HIV Human Immunodeficiency Virus The indispensible IPT comments Isoniazid preventative and suggestions therapy by Dr Linh Nguyen of WHO office in Suva must not ISTC go unrecognized. International Standards for Tuberculosis Care IUATLD International Union against Tuberculosis and Lung Disease Last but MDR-TB not the least, Multidrug the Resistant contributions Tuberculosis and support of the following personnel and MO Medical Officer MOH Ministry of Health Dr Josefa NGO Koroivueta Non-Government Organisation Dr Iobi NTP Batio National Tuberculosis Programme (Fiji) Dr Sakiusa OCP Mainawalala Oral contraceptive pill Dr Frank PAL Underwood Practical Approach to Lung Health PICT Pacific Island Countries and Territories PLWHA Person living with HIV & AIDS Fiji Red PTB Cross Society Pulmonary Tuberculosis Fiji Nursing QMRL Association Queenland Mycobacteria Reference Laboratory Grant Management SLT Unit Senior of Laboratory Fiji MOH Technician and Public TB health officials Tuberculosis TBCO TB Control Officer WHO World Health Organization XDR-TB Extensively drug-resistant Tuberculosis Anti-TB Medicines: E Ethambutol H Isoniazid R Rifampicin S Streptomycin Z Pyrazinamide TB Guideline - Fiji 7 TB Guideline - Fiji

8 INTRODUCTION Tuberculosis epidemiology Globally TB incidence rates are falling with the exception in the South-East Asia Region, where the incidence rate is stable. If these trends are sustained, the MDG target 1 will be achieved. Between 1995 and 2009, a total of 41 million TB patients were successfully treated in DOTS programmes, and up to 6 million lives were saved including 2 million among women and children. This Guideline In 2008, was the prepared Pacific had by 8% the fewer Fiji National TB cases Tuberculosis than 2007 notified Programme to National with TB the technical Programmes. and funding Excluding support Papua from New the Australian Guinea (PNG), Respiratory 1,459 TB Council cases were (ARC) notified, and the a Global notification Fund to fight rate AIDS, of 48 TB per and 100,000 Malaria of respectively. the total population. The numbers and rates of TB cases notified in individual countries and territories varied significantly, ranging Particular from gratitude zero in Niue is accorded to 387 in to Solomon Professor Islands Guy Marks to 13,984 and in Ms PNG. Kerry Shaw of the ARC for their valuable The contributions TB case notification to the key rate technical continues concepts to decline of this in Fiji. Guide. The case detection and treatment success rates are now above or close to the internationally recommended The indispensible targets of 70% comments and 85%, and at 95% suggestions and 81% by respectively. Dr Linh Nguyen Reasons of WHO for a low office treatment in Suva must not success go unrecognized. rate are varied but can include: an interrupted TB drug supply, limited access to TB clinic services, poorly functioning or non-effective directly observed Last but therapy not the (DOT), least, and the costs contributions associated with and TB support treatment. of the In addition, following the personnel rate of death and institutions in TB is patients acknowledged: and defaulters influences the treatment success rate. Dr Iobi Figure Batio 1. Trend of TB case notification Case Notification of Tuberculosis in Fiji Number of All TB 220 cases notified Number of Cases Year Notification of New Smear Positive Cases Fiji NTP TB incidence is predicted be decrease in 2015 compared to 1990 levels TB Guideline - Fiji 8 TB Guideline - Fiji 83

9 Structure of the National Tuberculosis Programme Currently there are three (3) DOTS centres in Fiji which are located in Labasa, Lautoka and Tamavua-Twomey hospitals that take charge of TB control activities in the North, West and Central/East respectively. The Fiji National Tuberculosis Programme (NTP) was established in late 1940s and adopted the DOTS strategy in Figure 2. Fiji NTP Structure This Guideline was prepared Ministry by the of Health Fiji National Tuberculosis Programme with the Schematic technical and funding support Public from Health Services the Australian Respiratory Council presentation (ARC) of and the Global Fund to fight AIDS, TB National and Malaria TB Programme respectively. the TB control programme in Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Fiji Shaw of the ARC for their valuable Western Division contributions Northern Division to the key technical Central and concepts Eastern Divisionof this Guide. Lautoka Hospital The indispensible (DOTS center) comments (DOTS Center) and suggestions Hospital (CWMH, Suva) by Dr Hospital Linh (PJTH, Nguyen Suva) of WHO office in Suva TB Laboratory w/culture TB Laboratory Labasa Hospital TB Laboratory Subdivisional Subdivisional Dr Sakiusa Hospitals Hospitals Mainawalala Health Health Centers Centers Fiji Red Cross Society Colonial War Memorial Subdivisional Hospitals Health Centers Zone Nurses Zone Nurses Zone Nurses P J Twomey (Tamavua) 1. Village health workers 2. Red Cross health volunteers Objectives of the National Tuberculosis Programme To reduce the impact of tuberculosis until it is no longer a public health problem To limit the number of re-treatment case to an acceptable minimum (10%) To effectively address emerging issues in TB control such as MDR-TB, TB/HIV co-infection, TB among children and TB in high risk populations To address TB care and control in high risk populations To engage all health care providers TB Guideline - Fiji 9 TB Guideline - Fiji 93

10 Targets of the National Tuberculosis Programme To maintain the treatment success rate (of smear positive cases) at >85% To increase case detection rate of smear positive TB up to >70% Strategies of the National Tuberculosis Programme To pursue high quality DOTS in all Divisions; To introduce Fixed Dose Combinations (FDCs) for first-line TB drugs; To formalize Public-Private Mix for TB care and control through an This Guideline was improved prepared referral by system; the Fiji National Tuberculosis Programme with the technical and funding To empower support people from with the TB Australian and communities; Respiratory Council (ARC) and the Global Fund to fight To AIDS, increase TB case and Malaria finding activities respectively. at rural communities through mobilization of community health care workers and volunteers; Particular gratitude To improve is accorded supervised to Professor treatment Guy Marks during and the Ms continuation Kerry Shaw phase of the close ARC to for their valuable contributions the patient to through the key mobilization technical concepts of health of care this workers Guide. and volunteers. The indispensible To implement comments this strategy and suggestions the TB control by Dr programme Linh Nguyen envisages of WHO to: office in Suva Be fully integrated in the general health care structure, including at the periphery; Last but not the Be least, effective the nation-wide, contributions reaching and support rural and of urban the following populations; personnel and institutions is acknowledged: Be permanent; and adapted to the needs of the people. TB services should be as close to the community as possible for both diagnostic and treatment services. Dr Frank The Underwood Ministry of Health in Fiji has followed the principles of the WHO recommended Dr Apisalome DOTS strategy Nakolinivalu successfully since Fiji Nursing The five Association elements of the DOTS strategy are: Grant Management Sustained Unit of Fiji political MOH commitment and For case detection access to quality assured TB sputum microscopy Standardised short course chemotherapy for all cases of diagnosed TB under proper case management conditions, including direct observation of treatment Uninterrupted supply of quality anti-tb drugs for the duration of treatment for each patient Recording and reporting system enabling outcome assessment of every patient as well as of the overall programme performance TB Guideline - Fiji 10 TB Guideline - Fiji 10 3

11 TB PROGRAM ELEMENTS 1.1. Detecting and diagnosing people with tuberculosis The major strategy for detecting tuberculosis in Fiji is to ensure that all people with symptoms of TB are identified as TB suspects and appropriately investigated. For this to be achieved the following public health interventions This Guideline must was be applied: prepared by the Fiji National Tuberculosis Programme with the technical and Community funding support awareness from of the symptoms Australian that Respiratory should lead Council them (ARC) to seek and health the Global Fund care; to fight AIDS, TB and Malaria respectively. Community awareness of appropriate health care workers to attend; Particular gratitude Knowledge is accorded of the symptoms Professor of Guy TB among Marks ALL and Ms health Kerry care Shaw workers of the including ARC for their valuable village contributions health workers, to the key volunteers, technical and concepts traditional of this healers. Guide. Capacity of health care workers to collect and dispatch sputum specimens The indispensible (or slides) comments of TB suspects and suggestions to the nearest by Dr microscopy Linh Nguyen center; of WHO office in Suva must not go unrecognized. Laboratory capacity for high quality sputum microscopy and culture. Last but not The the implementation least, the contributions of this strategy and support for detecting of the and following diagnosing personnel people with and institutions is tuberculosis acknowledged: should be integrated with the implementation of the Practical Approach to Lung Health (PAL). Dr Sakiusa Mainawalala TB suspects Any person who with symptoms or signs suggestive of TB should be Dr Apisalome investigated Nakolinivalu for tuberculosis. The most common symptom of pulmonary TB is Fiji Red Cross a Society productive cough for more than 2 weeks, which may be accompanied by other respiratory symptoms including shortness of breath, chest pains, Grant Management coughing Unit of up Fiji blood MOH (haemoptysis) and and/or constitutional symptoms including loss of appetite, weight loss, fever, night sweats, and fatigue. TB Suspect: Cough >2weeks, breathlessness, chest pain, haemoptysis, fever, night sweats, and fatigue. TB Guideline - Fiji 11 TB Guideline - Fiji 11 3

12 Investigation of TB suspects Patients who are TB suspects should be investigated for TB. Those who live near a DOTS centre should be referred for appropriate care and follow up. However, those who would take more than one day to travel to the DOTS centre, who are too sick to travel, or cannot afford to travel should have the initial investigations performed at the hospital or health centre nearest to where they live. Two sputum specimens should be collected, using the method decribed below. One is collected immediately (spot), when the patient is first seen. The This Guideline second was specimen prepared should by the be Fiji collected National the Tuberculosis following morning. Programme If this with is not the technical and feasible, funding then support the patient from the should Australian be asked Respiratory to wait at Council the health (ARC) facility, and and the Global Fund to produce fight AIDS, a second TB and specimen Malaria one respectively. or two hours after the first specimen. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for Sputum specimens: their valuable contributions to the key technical concepts of this Guide. 1. Spot (collected immediately during first consultation) 2. Early morning sample (collected the following morning) These specimens should be transported to the nearest DOTS or microscopy Last but not centre the least, for slide the contributions preparation and and examination. support of The the responsible following personnel DOTS centre and institutions is should acknowledged: then transfer the original sputum specimen to the DOTS centre in Suva (at Tamavua-Twomey Hospital) for culture. The cost of sputum transport should be borne by the NTP. Fo interior mainland or remote island settings it is advisable to transport fixed slides after performing slide preparation. Fiji Red Cross The Society sputum specimen should reach the DOTS centre within two days of collection. When this is not possible, then sputum should be sent to the Grant Management nearest Unit facility of Fiji where MOH and preparation and fixation of slides could be done and and later sent to the DOTS centre for staining and microscopy. In these circumstances it will not be possible to perform TB culture. TB suspects whose sputum microscopy is negative should be referred to the nearest Health Centre or sub-divisional hospital (if initially seen at a more peripheral level). They should receive a course of simple antibiotics. If the symptoms do not resolve with this treatment they should be referred to the nearest DOTS centre with x-ray facilities where they can be investigated for smear negative TB. TB Guideline - Fiji 12 TB Guideline - Fiji 12 3

13 nearest DOTS centre with x-ray facilities where they can be investigated for smear negative TB. Figure 3. Diagnostic algorithm for a suspected case of Pulmonary TB This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Dr Apisalome Nakolinivalu Standard procedures for sputum collection, processing, transport Fill in the form "Request for sputum examination" (Tub 3 - See Appendix 3). Write the registration number and name of the patient on the form and Grant Management on Unit the of side Fiji of MOH the and sputum cup. Demonstrate to the patient how a good sputum specimen is produced by taking a deep breath and coughing deeply. Find an outdoor location, away from others, for the patient to expectorate sputum into the sputum container. For children, the use of nebulizers may help in stimulating the airways in order to obtain a good sputum sample. Ask the patient to screw the lid onto the container before returning it you. Make sure that the lid on the container is firmly close. Place the container inside a plastic bag. Wash your hands. TB Guideline - Fiji 13 TB Guideline - Fiji 13 3

14 When two specimens have been collected, send both the specimens together with the request form to the laboratory as soon as possible. If it cannot be despatched immediately store in a fridge if one is available or a cool place if there is no fridge. The specimen should be sent to the nearest DOTS centre within two days Laboratory services The details of laboratory procedures are beyond the scope of this guide and should be dealt with in a separate Manual of Laboratory Procedures. a) Microscopy All health care technical staff should be trained to fix sputum smears on This Guideline was prepared by the Fiji National Tuberculosis Programme with the microscopy slides and transport them to the nearest DOTS microscopy centre. All three DOTS microscopy centres should: Global Fund to fight AIDS, TB and Malaria respectively. Perform AFB microscopy Particular gratitude is Provide accorded a written to Professor report Guy on Marks all AFB and microscopy Ms Kerry results Shaw of (positive the ARC and for their valuable contributions negative) to the to the key referring technical HCW. concepts of this Guide. Enter the results of all AFB microscopy performed on TB suspects The indispensible comments onto standard and suggestions Laboratory register by Dr Linh on a Nguyen daily basis. of WHO office in Suva Send replacement sputum containers and request forms to each site that submits sputum specimens for examination on a quarterly Last but not the least, schedule. the contributions and support of the following personnel and institutions is b) acknowledged: Sputum culture Sputum culture remains the gold standard procedure to diagnose TB however it takes 6-8 weeks to obtain results hence clinical dependency on microscopy yield to determine earliest and appropriate intervention. TB culture is only performed at the Central-Eastern DOTS centre (at Tamavua-Twomey Hospital). At least one (1) diagnostic sputum specimen of all the TB suspects should be sent to Daulako Mycobacterium Laboratory (at Tamavua-Twomey Hospital) for culture. Grant Management c) Drug Unit Susceptibility of Fiji MOH and Testing (DST) Drug susceptibility testing is not yet routinely available in Fiji but plans are underway to carry out advance TB diagnostic tests (such as DST & GeneXpert) in the year However, specimens can be referred to the Queensland Mycobacterial Reference Laboratory in Brisbane for DST. This should be done for: Index Case Those who come from areas with high endemicity of MDR-TB Re-treatment cases and Close their contact contacts Cases that remain smear positive after 3 months of TB Signs and chemotherapy No signs or symptoms of TB Cases that have been Symptoms contacts of patients TB with known MDR-TB Cases dually infected with HIV TB Guideline - Fiji Investigate for TB: 14 2 sputum samples Chest x-ray Adult and/or child aged HIV infection five years and over, with Child under 5 years no immune-suppressing Other immunesuppressing Programme conditions with the This Guideline was prepared by the Fiji conditions National Tuberculosis technical and funding TB support No TB from the Australian Respiratory Council (ARC) and the TB Guideline - Fiji Global Fund to fight AIDS, TB and Malaria respectively Register Follow-up and Educate and discharge Tuberculin skin test If chest x-ray is normal commence

15 d) Xpert MTB/RIF The Xpert MTB/RIF test offers a potential solution for improving TB diagnosis. A single Xpert MTB/RIF test is able to confirm active disease among both smear positive and negative TB patients whilst concurrently testing for rifampicin resistance, thus identifying patients who need second-line drug treatment. AFB microscopy remains to be the first line mode of TB diagnosis considering the cost and time factor for Xpert MTB/RIF and culture respectively. Sputum samples eligible for Xpert MTB/RIF test: All diagnostic smear positive sputum samples to ascertain TB disease and to This Guideline was rule prepared out rifampicin by the resistance Fiji National Tuberculosis Programme with the Diagnostic smear negative sputum samples as decided by the clinician For patients with abnormal chest X-ray or as decided by clinician Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude e) Quality is accorded assurance to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions i) Quality to the Assurance key technical for microscopy concepts of this Guide. All three DOTS centers and microscopy units of Divisional hospitals The indispensible participate comments in and External suggestions Quality by Dr Assurance Linh Nguyen (EQA). of This WHO is office achieved in Suva by sending selected AFB slides to the Senior Lab Technician (SLT) who is based at the Daulako Mycobacteria Laboratory in Tamavua-Twomey Last but not the hospital least, the for contributions viewing. The and NTP support office of sends the following selected slides personnel from and the Dauloka Mycobacteriance Laboratory at the Tamavua-Twomey hospital to QMRL on a quarterly rota for EQA purposes. Panel testing: Ten(10) prepared slides are sent by QMRL to all labs that perform microscopy in Fiji annually. Lab technologists from the four microscopy centers 2 who receive prepared slides read and send their findings to the laboratory scientists at QMRL for verification of results reported. Findings at all stages for EQA are exchanged among the respective officers to ascertain quality of microscopy services in Fiji. ii) Quality Assurance for culture Daulako Mycobacterial Laboratory (based at Tamavua-Twomey Hospital) performs culture for diagnostic purposes on all specimens (sputum & body fluids) received from referring clinicians. Plans are underway to implement quality assurance for culture procedures conducted at National level in collaboration with QMRL. 2 All three DOTS centers & CWM hospital laboratory TB Guideline - Fiji 15 TB Guideline - Fiji 15 3

16 Other investigations a) Radiology Tuberculosis should be diagnosed whenever possible by clinical evaluation and sputum examination. Chest X-ray examination is valuable for sputum smear negative cases. Chest X-ray findings suggestive of pulmonary TB in patients with a sputum smear negative result should always be supported by physical examination findings and a clinician should decide on the diagnosis. X-ray may be helpful in assessing the extent of lung damage in complicated cases. It is also important in the diagnosis of tuberculosis in This Guideline was prepared by the Fiji National Tuberculosis Programme with the children and extra-pulmonary TB. Global Fund to fight AIDS, TB and Malaria respectively. b) Tuberculin skin test Tuberculin skin test (TST or Mantoux test) detects tuberculosis infection Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for only. TST is not a test to diagnose active TB disease. their valuable contributions to the key technical concepts of this Guide. This is relevant to support the decision to give isoniazid for treatment of latent tuberculosis infection (Isoniazid Preventative Therapy). It has no role in the initial investigation of patients with suspected pulmonary tuberculosis. institutions Case is acknowledged: definitions and classification A case of tuberculosis. A patient who is AFB smear positive and/or AFB culture positive or in whom the medical officer has diagnosed TB and has decided to treat with a full course of treatment. It should be noted that current techniques do not allow non-tuberculous mycobacteria to be Fiji Red Cross distinguished Society from M. tuberculosis in Fiji. Hence, this case definition may overestimate the burden of TB. However, these cases will be identified as Grant Management non-tuberculous Unit of Fiji MOH if they and do not respond to treatment and specimens are referred to QMRL for DST. Cases of tuberculosis are further classified according to the anatomical site of disease, bacteriological status and the history of previous treatment. This classification is important for: Selecting appropriate treatment regimens Patient registration and notification, which is relevant to analysis of treatment outcomes and evaluation of program performance TB Guideline - Fiji 16 TB Guideline - Fiji 16 3

17 a) Anatomical site of disease Pulmonary tuberculosis refers to a case of TB involving the lung parenchyma (including miliary tuberculosis). All other cases where the lung parenchyma is not involved (include intrathoracic lymphadenopathy and pleural effusions) are classified as extrapulmonary tuberculosis (EPTB). Diagnosis should be based on history and examination findings, histological evaluation or strong clinical evidence consistent with active EPTB, followed by a decision by a clinician to treat with a full course of tuberculosis chemotherapy. This Guideline b) was Bacteriological prepared by classification the Fiji National Tuberculosis Programme with the technical and funding A case support of pulmonary from the TB Australian is classified Respiratory as smear positive Council if (ARC) one or and more the Global Fund to fight sputum AIDS, TB specimens and Malaria collected respectively. at the start of treatment are positive for AFBs on microscopy. A case of pulmonary TB is classified as smear Particular gratitude negative is accorded if at to least Professor two sputum Guy Marks specimens and Ms Kerry collected Shaw at of the the start ARC for of their valuable contributions treatment to are the negative key technical for AFBs concepts on microscopy of this Guide. AND either: sputum culture is positive for M. tuberculosis, or decision by a clinician to treat with a full course of anti-tb therapy radiographic abnormalities consistent with active pulmonary TB no improvement in response to a course of broad-spectrum antibiotics (excluding anti-tb drugs and fluoroquinolones and aminoglycosides). c) History of previous treatment At the time of registration each patient meeting the case definition is classified according to whether or not he or she has previously received TB treatment and, if so, the outcome. The following definitions are used: New. These are patients who have never had any treatment for TB or who have taken anti-tb drugs for not more than a month. Relapse. A patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriological positive (smear or culture) TB. Treatment after default. A patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more. Treatment after failure. A patient who is started on a re-treatment regimen after having failed previous treatment. Transfer in. A patient who has been transferred from another TB register to continue treatment. TB Guideline - Fiji 17 TB Guideline - Fiji 17 3

18 1.1.4 TB in children The risk of TB in children is exposure to an active case of (smear positive) tuberculosis in the household. Symptoms of TB in children include Unexplained weight loss or failure to grow normally (failure to thrive) Unexplained fever, especially when it last for more than two weeks Chronic cough Signs of TB include Fast and shallow breathing (as in Pleural effusion) Enlarged non-tender lymph nodes, especially in the neck This Guideline was Signs prepared of meningitis by the (with Fiji spinal National fluid containing Tuberculosis mostly Programme lymphocytes, with low the technical and funding glucose support and elevated from protein) the Australian Respiratory Council (ARC) and the Global Fund to fight Abdominal AIDS, TB swelling and Malaria with respectively. or without palpable lumps Progressive swelling or deformity in a bone or joint (including the spine) Particular gratitude The diagnosis is accorded of intrathoracic to Professor (i.e. Guy pulmonary, Marks and Ms pleural, Kerry and Shaw mediastinal of the ARC for their valuable hilar contributions lymph node) to the tuberculosis key technical concepts in symptomatic of this Guide. children with negative sputum smears should be based on the finding of chest radiographic The indispensible abnormalities comments consistent and suggestions with tuberculosis by Dr Linh and Nguyen either a of history WHO of office exposure in Suva to an infectious case or evidence of tuberculosis infection (positive tuberculin skin test). Sputum specimens should be obtained (by expectoration, gastric Last but not washings, the least, or the induced contributions sputum) for and AFB support microscopy of the and following culture. personnel and Dr Josefa Koroivueta Active case finding (screening) in high risk groups At present there is no formal programme of active case finding by x-ray screening in Fiji. However, operational research projects to establish the role of active case finding in high risk groups are being planned by the NTP. A Dr Apisalome necessary Nakolinivalu pre-condition for active case finding is the availability of an x-ray Fiji Red Cross facility Society that is accessible to the population in whom screening is to be undertaken. Grant Management Unit Contact of Fiji screening MOH and Public health All officials care providers for patients with Tuberculosis should ensure that persons (especially if symptoms suggestive of TB, children <5years of age, persons with HIV infection, and contacts to MDR/XDR-TB) who are in close contact with patients who have infectious TB are screened and attended to accordingly. The key objectives of screening are to assess if the contact: has undiagnosed TB is at high risk of developing TB if infected. is at high risk of having been infected by the index case TB Guideline - Fiji 18 TB Guideline - Fiji 18 3

19 Priorities in contact screening Higher risk of acquiring TB Higher risk of developing TB disease infection Close contacts of smear positive PTB Children <5years of age People with HIV infection People with HIV infection People who are highly exposed to People with other conditions that suppress immunity (Diabetics, those malignant disorders etc) smear +ve PTB a) Adult contacts Assess all household members for signs and symptoms suggestive of This Guideline was TB prepared disease using by the criteria Fiji National in Page 11,(1.1.1) Tuberculosis Programme with the technical and funding If signs support & symptoms from the are Australian present refer Respiratory TB suspects Council for proper (ARC) work and up: the Global Fund to fight AIDS, Sputum TB examination and Malaria respectively. +/- chest x-ray (if resources permit) Tuberculin skin testing (Mantoux test) could be used to determine the Particular gratitude is presence accorded of to latent Professor TB infection Guy Marks (LTBI) and if a Ms contact Kerry is Shaw cleared of the from ARC for their valuable contributions clinical to and the investigation key technical assessments concepts of stated this Guide. above. A positive TST varies among contacts: i) >5mm induration for immune-suppressed The indispensible comments contacts (eg and PLWHA, suggestions malnourished, by Dr Linh diabetics); Nguyen ii) of >10mm WHO office indurated Suva for all other contacts Once active TB is excluded, Isoniazid(INH) preventive therapy may be Last but not the least, given the to contacts contributions with presumed and support diagnosed of the following with LTBI personnel based and clinical and TST results. Recommended regimen: -INH 5mg/kg (max 300mg) daily for six months administered under DOT strategy with Pyridoxine (vitamin B6) 10-20mg/day. Screening methodology: Clinical assessment for TB related symptoms; chest x-ray; and sputum smear microscopy. TST may help in establishing previous exposure (+infection) with M. tuberculosis Grant Management b) Children Unit of Fiji contacts MOH and (<5years old) At this stage targeted treatment of latent tuberculosis infection in Fiji is only recommended for children aged <5 years who are household contacts of patients with smear positive pulmonary tuberculosis. These children should be seen as soon as possible after the index (smear positive) case is diagnosed. They should have a chest x-ray and clinical review to exclude active TB. As TB may progress rapidly in young children it is recommended that ALL such children (in whom active TB is excluded) are commenced. Isoniazid preventative therapy. The dose of isoniazid is 5mg/kg daily for at least 6 (maximum 9) months. TB Guideline - Fiji 19 TB Guideline - Fiji 19 3

20 c) TB screening among Diabetics and vice versa Type 2 diabetes involving chronic high blood sugar, is associated with altered immune response to TB. This leads to patients with diabetes and TB take longer to respond to anti-tb treatment. Patients with active tuberculosis and Type 2 diabetes are more likely to have multi-drug resistant TB. The Fiji NTP promotes screening for diabetes for all registered TB cases and vice versa. This is achieved through a robust collaborative initiative with the NCD unit of MOH, Divisional and subdivisional hospitals.(standard TB screening procedures must be applied to known cases of diabetes depending on resources available at the respective levels of care.) On the other hand, all This Guideline was confirmed prepared TB by patients the Fiji must National be screened Tuberculosis for diabetes Programme on the with day the of technical and funding enlistment support at a from DOTS the centre. Australian The following Respiratory assessment Council protocol (ARC) and should the Global Fund to fight be AIDS, applied: TB and Malaria respectively. If known diabetic ensure proper control of blood glucose with diet Particular gratitude is and accorded prescribed to Professor medications Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions If unknown to the diabetic: key technical concepts of this Guide. Grant Management d) TB Unit Screening of Fiji MOH among and PLWHA People living with HIV infection who are also infected with TB are at greater risk of developing active TB. The clinical features of TB in people with HIV infection may be atypical. Extrapulmonary and disseminated TB disease are common among PLWHA. PLWHA should be thoroughly screened for active TB disease before considering the administration of Isoniazid preventative therapy (IPT). Standard screening techniques above [ (a)] apply. TB Guideline - Fiji 20 TB Guideline - Fiji 20 3

21 e) TB screening in Prisons & Correctional Facilities All Prisons & Correctional facilities should designate a person or a working group with experience in infection control, occupational health and building design to be responsible for the TB infection-control program. These persons should have the capacity and authority to develop, implement, enforce, and evaluate TB infection-control policies in collaboration with NTP. The detail of TB control in Correctional facilities is beyond the scope of this Guideline. Standard screening protocol [as in (a)] is used to identify persons who have active TB disease or latent TB infection: This Guideline was All prepared correctional by the facility Fiji employees National Tuberculosis and inmates who Programme have suspected with the or technical and funding confirmed support TB from disease the Australian should be identified Respiratory promptly, Council and (ARC) the and case(s) the Global Fund to fight AIDS, or suspected TB and Malaria case(s) respectively. should be reported to the nearest Public health facility or DOTS center. Particular gratitude is Employees accorded to and Professor long-term Guy inmates Marks infected and Ms Kerry with M. Shaw tuberculosis of the ARC (i.e., for their valuable contributions those who to the have key positive technical skin-test concepts results) of this Guide. should be identified and evaluated for Isoniazid preventive therapy. The indispensible comments and suggestions by Dr Linh Nguyen of WHO office in Suva Index Case Close contact Signs and No signs or symptoms of TB Symptoms of TB Investigate for TB: Adult and/or child aged HIV infection 2 sputum samples Chest x-ray five years and over, with Child under 5 years no immune-suppressing Other immunesuppressing Programme conditions with the This Guideline was prepared by the Fiji conditions National Tuberculosis technical and funding TB support No TB from the Australian Respiratory Council (ARC) and the Global Fund to fight AIDS, TB and Malaria Educate respectively. and Tuberculin Register Follow-up and discharge skin test If chest x-ray is Particular gratitude and treatis accorded consider to IPT Professor if normal commence Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions indicated Isoniazid preventative to the key technical Negative concepts of this Guide. Positive therapy (monitor)* If chest x-ray is The indispensible comments and suggestions by Dr Linh Nguyen of WHO abnormal office investigate in Suva must not go TB unrecognized. Guideline - Fiji for TB The role of Civil Society & Private health care providers in case finding TB Guideline - Fiji 21 3 The NTP promotes the participation of community/faith based, civil society organizations and private health care facilities 3 to support national efforts to

22 If chest x-ray is The indispensible comments and suggestions by Dr Linh Nguyen of WHO abnormal office investigate in Suva for TB Last but not the least, the contributions and support of the following personnel and Index Case The role Take of Civil overall Society responsibility & Private health to work care up providers suspects in referred case finding from The NTP promotes community/faith the participation based, civil of society community/faith organizations based, and private civil society health Close contact organizations care and facilities, private to health confirm care or facilities rule out 3 TB to and support to design national and efforts apply the to scale up TB appropriate Signs case and detection. treatment regimen a) Community/faith No signs or symptoms Supply of TB anti-tb based, medicines civil society supplies groups free and of private charge health to civil care society Symptoms of TB Fiji facilities organizations should: and private health care facilities with adequate shelf life Nursing Association Investigate Follow and for establish TB: national a guidelines reliable system to detect for TB re-supply (in events where the Grant Management Unit of Fiji MOH and Adult and/or child aged HIV infection 2 sputum samples Refer patient all opts TB suspects for care by to the private nearest health DOTS care center provider or public or CSO health rep Chest x-ray five years and over, with Child under 5 years facility Supply for reporting diagnosis and no and immune-suppressing recording treatment formats to community/faith Other immunesuppressing Programme facilities conditions with the based, This Guideline was Report civil prepared society on programme by organizations the Fiji conditions activities National and private using Tuberculosis MOH health systems care technical and funding TB Neither support No possess TB from nor the sell Australian anti-tb medicines This Guideline was In prepared collaboration by the Fiji with National community/faith Respiratory Tuberculosis Council based, Programme (ARC) civil with and society the Global technical Fund and to fight funding AIDS, Communicate organizations support TB and from Malaria promptly and the Educate private respectively. Australian with and health the NTP Respiratory care regarding Tuberculin facilities Council defaulters carry (ARC) and out and ACSM the 4 Register Follow-up and discharge skin test If chest x-ray is Global Fund to fight AIDS, absentees activities TB and that Malaria aim to respectively. improve attitude, behaviour and practice to Particular gratitude and treat normal commence is accorded consider to IPT Professor if Guy Marks and Ms Kerry Shaw of the ARC for control TB in Fiji Isoniazid preventative their valuable contributions indicated Particular gratitude b) The NTP should: to the key technical Negative concepts of this Guide. is Monitor accorded and to report Professor on community Guy Marks based and Positive Ms DOT Kerry activities Shaw therapy on of a the (monitor)* quarterly ARC for their valuable contributions If chest x-ray is 3 The Privately indispensible administered Take comments health and overall annual to the centers and & basis. key technical concepts of this Guide. responsibility pharmacy suggestions outlets by to Dr work Linh up Nguyen suspects of WHO referred abnormal office investigate in from Suva community/faith Lead and provide based, capacity civil development society organizations opportunities and for private for TB health The indispensible comments TB Guideline - Fiji care communities and facilities, to on suggestions confirm TB DOT or care. by Dr Linh Nguyen of WHO office in Suva rule out TB and to design and apply the 22 Last but not the least, appropriate the contributions treatment regimen and support of the following personnel and Supply anti-tb medicines supplies free of charge to civil society organizations and private health care facilities with adequate shelf life institutions is acknowledged: The role of Civil Society & Private health care providers in case finding Iobi Batio and establish a reliable system for re-supply (in events where the TB Guideline The NTP - Fiji promotes the participation of community/faith based, civil society 3 Sakiusa Mainawalala patient opts for care by private health care provider or CSO rep 22 organizations and private health care facilities Frank Underwood 3 to support national efforts to Dr Sakiusa Supply reporting and recording formats to community/faith based, scale Mainawalala up TB case detection. Dr Apisalome Frank Underwood Nakolinivalu civil society organizations and private health care facilities a) Community/faith based, civil society groups and private health care This Dr Apisalome Guideline Nakolinivalu was facilities In prepared collaboration should: by the Fiji with National community/faith Tuberculosis based, Programme civil with society the Nursing Association technical Fiji Red and Cross funding Society organizations Follow support national from and the guidelines private Australian health to detect Respiratory care TB facilities Council carry (ARC) out and ACSM the 4 Global Fiji Nursing Fund to Association fight AIDS, activities Refer TB all and that TB Malaria suspects aim to respectively. improve to the nearest attitude, DOTS behaviour center or public and practice health to Grant Management control Unit of facility TB Fiji for in MOH diagnosis Fiji and and treatment Particular Public health gratitude officials is Monitor accorded Report and on to programme report Professor on community Guy activities Marks based using and Ms MOH DOT Kerry activities systems Shaw on of a the quarterly ARC for their valuable contributions and Neither annual to the possess basis. key technical nor sell anti-tb concepts medicines of this Guide. Lead Communicate and provide promptly capacity with development the NTP regarding opportunities defaulters for and The indispensible comments communities and suggestions by Dr Linh Nguyen of WHO office in Suva absentees on TB DOT care. b) The NTP should: institutions 3 Privately administered is acknowledged: health centers & pharmacy outlets Dr Josefa Koroivueta 4 Advocacy Communication Social Mobilization TB Guideline - Fiji 22 TB Guideline - Fiji 23 Fiji Nursing TB Guideline Association - Fiji 22 3 Grant Management TB Guideline - Unit Fiji of Fiji MOH and 23 3

23 1.2 TREATMENT OF PEOPLE WITH TUBERCULOSIS Registering the case and initiating treatment All patients diagnosed with tuberculosis must be registered by the Divisional TB control officer right after diagnosis and at the start of treatment. A unique registration number is assigned for each new patient. Details of the registration procedure are enclosed in the TB register (Appendix 5). A treatment card is completed and a TB identity card is given to the patient upon registration. In the event the diagnosis of TB is made at a regional or peripheral location, the patient is transfered to the nearest DOTS center for This Guideline commencement was prepared of by intensive the Fiji phase National of treatment. Tuberculosis Programme with the Global Fund to Recommended fight AIDS, TB and regimens Malaria respectively. NTP now uses Fixed Dose Combination (GDF Kits-antiTB medicines) for Particular gratitude intensive is accorded and continuation to Professor phase Guy of Marks treatment. and Ms Regimens Kerry Shaw are of available the ARC for their valuable contributions adults and children to the key and technical for new concepts patient of this and Guide. re-treatment cases. The regimens below are based on FDC preparations. For adults these are available The indispensible patient comments kits which and suggestions should be by supplied Dr Linh for Nguyen individual of WHO patients. office Paediatric in Suva preparations are available upon request from FPBS. Last but not the least, New the contributions cases and support of the following personnel and a) Adults and children > 30kg Table 1. Standard regimen: 2RHZE/4RH Treatment Essential anti-tb medicine Dosage (mg/kg) phase Intensive Rifampicin (R) Isoniazid (H) Pyrazinamide (Z) Ethambutol (E) Continuation Rifampicin (R) Isoniazid (H) b) Children < 30 kg Regimen: 2RHZ/4RH or 2RHZE/4RH Table 2. Children between 5kg and 20kg (without ethambutol) Weight R 30 H 30 Z 150 Intensive Phase (2 months) R 60 H Continuation phase (4 months) R 60 R 60 H 30 H 60 5 to 7 kg to 14 kg to 20 kg TB Guideline - Fiji 24 TB Guideline - Fiji

24 Table 3. Children between 5kg and 20kg (with ethambutol) Weight R 30 H 30 Z 150 Intensive Phase (2 months) R 60 H 60 Continuation phase (4 months) R 60 H 60 E 100 R 60 H 30 5 to 7 kg to 14 kg Table 15 to kg Children between 3 5kg 2 and 20kg 3 (with ethambutol) 3 2 Intensive Phase (2 months) Continuation phase (4 months) Weight R 30 R 60 E 100 R 60 R 60 H 30 H 60 H 30 H 60 Table 4. Children between Z 15021kg and 30kg without ethambutol 5 to 7 kg Intensive 1 Phase 1 (2 months) 1 Continuation 1 phase (4 months) 1 8 to 14 kg Weight 15 to 20 kg R H 75 R 60 2 H 60 Z 3 R H 75 R 60 2 H 60 5 to 7 kg Table 4. Children between 21kg and 30kg without ethambutol Intensive Phase (2 months) Continuation phase (4 months) Table 5. Children between 21kg and 30kg with ethambutol Weight Intensive R 150 Phase R 60 (2 Z Continuation R 150 phase (4 months) R 60 H 75 months) H 60 H 75 H 60 5 Weight to 7 kg R R 60 2 R R 2 60 H 75 H 60 H 75 H 60 Z 400 E 275 Table 215. to Children 30 kg between 2 21kg and 230kg with ethambutol 2 2 Intensive Phase (2 Continuation phase (4 months) months) Weight R 150 R 60 R 150 R Re-treatment cases H 75 H 60 H 75 H 60 All re-treatment patients Z 400 should have cultures sent to the QMRL in Brisbane for DST. While awaiting E the 275 results of DST, re-treatment patients who have 21 to 30 kg defaulted or relapsed after their first treatment regimen should be started on the standard re-treatment regimen. The treatment regimen should be adjusted on Re-treatment the basis of DST cases when results are available. All re-treatment patients should have cultures sent to the QMRL in Brisbane Table for DST. 6. Standard While awaiting re-treatment the results regimen: of DST, 2RHZES/1RHZE/5RHE re-treatment patients who have Treatment defaulted or relapsed Intensive after phase their first Intensive treatment phase regimen should Continuation be started phase on the phase standard re-treatment (2months) regimen. (1month) The treatment regimen (5months) should be adjusted Regimen* on the basis Rifampicin of DST when results Rifampicin are available. Rifamipicin (5) Isoniazid Isoniazid Isoniazid (5) Table 6. Standard Pyrazinamide re-treatment regimen: Pyrazinamide 2RHZES/1RHZE/5RHE Ethambutol (5) Ethambutol Ethambutol Treatment Intensive Streptomycin phase Intensive phase Continuation phase * phase (2months) (1month) (5months) Regimen* For doses Rifampicin refer to above. Rifampicin Rifamipicin (5) Isoniazid Isoniazid Isoniazid (5) Pyrazinamide Pyrazinamide Ethambutol (5) Ethambutol Ethambutol TB Guideline - Fiji Streptomycin * 25 For doses refer to above. TB Guideline - Fiji 24 25

25 If the organism is confirmed as fully-susceptible to the standard first-line drugs then the re-treatment regimen should be continued. Streptomycin is ceased after two months, the other intensive phase therapy (rifampicin, isoniazid, pyrazinamide and ethambutol) is continued for a third month. The standard continuation phase (rifampicin,isoniazid & ethambutol) then begins and continues for five months. This regimen totals at least 8 months. Streptomycin should not be used in children, in pregnant women or people with renal failure MDR-TB This Guideline was prepared by the Fiji National Tuberculosis Programme with the technical and Fiji funding has never support encountered from the a Australian case of MDR-TB. Respiratory However, Council the (ARC) NTP and has the Global Fund to capacity fight AIDS, to recognise TB and Malaria and diagnose respectively. MDR-TB, should it occur. If MDR-TB is suspected, on the basis of treatment failure, or confirmed on DST then Particular gratitude consultation is accorded with an to expert Professor (through Guy Marks WHO) and in the Ms management Kerry Shaw of of the MDR-TB ARC for is their valuable advised. contributions The patient to the key should technical be placed concepts in a of single this Guide. room with respiratory isolation precautions in one of the three(3) DOTS centers. Usually, it is The indispensible safest comments to withhold and second-line suggestions drugs by Dr until Linh susceptibility Nguyen of WHO is confirmed office in Suva on DST. Emperical regimens of second line drugs will be used for the MDR- TB patients based on the DST results. institutions is acknowledged: Regimens for extra-pulmonary tuberculosis The regimens described above are given for all forms of tuberculosis except that the continuation phase should be extended to months (or directed by the TBCO) in patients with miliary, meningeal, and bone or osteo-articular tuberculosis. Patients with tuberculous pericarditis or tuberculous meningitis should receive prednisone for the first weeks of therapy. The Dr Apisalome dose Nakolinivalu should start at 50 mg daily (1 mg/kg/day in children) and taper of Fiji Red Cross this Society period. Grant Management Unit Regimens of Fiji MOH for and patients with liver disease or renal failure Standard TB treatment can be administered to patients with mild abnormalities of liver function. However, expert consultation is recommended before embarking on treatment of TB in patients with severe underlying liver disease. For patients with renal failure or severely impaired renal function it is recommended that ethambutol and pyrazinamide are given only three times per week (in the standard doses). This means that, during the intensive phase, the regimen described above is given three days per week and on the remaining four days per week, the four drug FDC is replaced by rifampicin 150 / isoniazid 75 FDC. TB Guideline - Fiji 26 TB Guideline - Fiji 25 3

26 1.2.3 Ensuring adherence Every dose of chemotherapy taken by a patient with tuberculosis should be directly observed by an appointed DOT supervisor. At present this is being achieved during the intensive phase by keeping all patients in hospital throughout this phase. It is not generally being achieved during the continuation phase. The implementation of strategies to ensure direct observation of therapy during the intensive phase is a high priority. This should be accompanied by implementation of strategies to enable direct observation of treatment in the community during the intensive phase Strategies for direct observation of therapy (DOT) in the This Guideline was prepared community by the Fiji National Tuberculosis Programme with the technical and All funding patients support who do from not otherwise Australian need to Respiratory be hospitalised Council for medical (ARC) reasons and the Global Fund to can fight be AIDS, treated TB in and the Malaria community, respectively. in either or both the intensive phase and the continuation phase. Patients who do NOT adhere to DOT will need to be Particular gratitude hospitalised is accorded for supervised to Professor treatment. Guy Marks A range and Ms of Kerry alternative Shaw strategies of the ARC will for their valuable be contributions required to to enable the key DOT technical in the community. concepts of These this Guide. may include: Requiring patients to attend a nearest health or DOTS centre for treatment Arranging for zone nurses to visit patients at home on a fortnightly basis to supervise implementation of DOT. Last but not the Arranging least, the for contributions DOT to be administered and support by of peripheral the following health personnel centres and or nursing stations. Arranging for DOT to be administered by trained community based volunteers from civil society (such as Red Cross), village health workers or faith based organisations. Arranging for DOT to be administered by traditional healers in the village dispensary. Fiji Red Cross Society Identifying other appropriate, independent and trustworthy individuals who can deliver DOT in the village setting. The Divisional TBCO should identify the appropriate DOT supervisor, in consultation with local health staff and other civic leaders, at the time of commencing therapy or prior to discharge from hospital. The Divisional TBCO will need to ensure that the designated TB supervisor receives: Motivation and instruction about DOT Advice about how to report non-adherence Advice on adverse effects and how to report them Treatment cards The appropriate medication supply (kits) for the patient A contact number for assistance TB Guideline - Fiji 27 TB Guideline - Fiji 26 3

27 During the continuation phase, daily regimens should be used, to implement DOT. Where DOT supervision is undertaken by non-health system staff, the Zone nurse responsible should make a fortnightly visit to supervise the DOT process and more importantly to obtain regular upd progress Defaulter tracing The peripheral health staff (particularly zone nurses) should organise the tracing of patients who are reported by their DOT supervisors to have missed more than one dose during the intensive phase or more than one week of treatment during the continuation phase. The Divisional TBCO and the Divisional Medical Officer should be This Guideline was made prepared aware by of the all such Fiji cases. National Priority Tuberculosis must always Programme be given to with smear the technical and funding positive support TB patients. from the Australian Respiratory Council (ARC) and the Global Fund to fight AIDS, If the TB patient and Malaria is absent respectively. for more than two months, he or she is declared a defaulter and his/her sputum must be investigated again. Such patients should be re-admitted to hospital to undergo re-treatment Particular gratitude is regimen. accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide Clinical monitoring of treatment The indispensible comments Patients and should suggestions have regular by Dr medical Linh Nguyen monitoring of WHO planned office in by Suva the responsible TB medical officer. This should include medical examination, particularly on biochemical assays for liver, kidney and hematological functions, at the DOTS centre at least at the end of the intensive phase and at the end of treatment. The patients should bring his/her treatment card to all these appointments Bacteriological monitoring of patients Dr Apisalome Sputum Nakolinivalu smear examinations should be performed: at the end of the intensive phase, that is, two months for new patients and three months for the standard, non-mdr, re-treatment regimen; at the end of three months if they were smear positive at the two Grant Management Unit month of Fiji examination; MOH and one month before the end of treatment, that is, five months for new patients and seven months for the standard, non-mdr, re-treatment regimen. (This only applies patients who were smear positive at the start of treatment). Patients with positive sputum smears at the end of three months or one month before the end of treatment should have specimens sent for culture and DST. TB Guideline - Fiji 28 TB Guideline - Fiji 27 3

28 1.2.4 Adverse events (side-effects) & drug interactions Patients with HIV infection, alcohol dependency, malnutrition, diabetes, chronic liver disease or renal failure as well as pregnant or breastfeeding women should receive pyridoxine (vitamin B6) throughout their course of treatment to prevent peripheral neuropathy. Patients taking the oral contraceptive pill (OCP) should be advised to use alternative means of contraception during TB treatment as rifampicin makes the OCP unreliable. Patients should be warned that their urine will turn orange and advised that they should not be alarmed. Patients should be informed of the more common or serious side This Guideline was effects prepared of treatment by the Fiji at the National time they Tuberculosis commence on Programme treatment. with the Global Fund Table to fight 7. Symptom AIDS, TB based and Malaria approach respectively. to side effects of anti-tb drugs. SIDE EFFECT ANTI-TB DRUG MANAGEMENT Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for RESPONSIBLE their valuable Minor contributions to the key technical concepts Continue of this anti-tb Guide. drugs, check doses Anorexia, nausea, R, Z Give drugs with small meals or last thing at abdominal pain night. Joint pains Z Aspirin Last but not Burning the least, sensation the in contributions H, and R support Pyridoxine of the 100mg following daily personnel and institutions is feet, acknowledged: Orange/red urine Major Itching, skin rash Deafness, no wax on auroscopy Fiji Red Cross Dizziness Society (vertigo & nystagmus) H, R, Z, S S S Reassurance Stop responsible drug(s) Stop anti-tb Stop S, use E Stop S, use E Grant Management Jaundice Unit (other of causes Fiji MOH and Public health excluded) officials H, Z, R Stop anti-tb drugs Confusion (acute liver failure if jaundice is present) Most anti-tb drugs Stop anti-tb drugs, urgent LFTs & PTTK Visual impairment (other causes excluded) Shock, purpura, acute renal failure E R Stop E Stop R TB Guideline - Fiji 29 TB Guideline - Fiji 28 3

29 facilities should: Follow national guidelines to detect TB Refer all TB suspects to the nearest DOTS center or public health facility for diagnosis and treatment Report on programme activities using MOH systems Co-management Neither possess of nor HIV sell and anti-tb active medicines TB disease Communicate promptly with the NTP regarding defaulters and HIV pre-test counselling should be offered to all newly diagnosed cases of absentees TB by a health care worker trained in provider intitiated counselling & testing (approved by PSH) who is responsible for their care. HIV testing b) The NTP should: must be aligned with the new HIV Decree in Fiji Standard TB treatment regimens should be implemented without delay 3 Privately administered health centers & pharmacy outlets for all patients with HIV infection who are diagnosed with tuberculosis. Daily therapy should be administered throughout both intensive and TB Guideline - Fiji 22 continuation phases. TB treatment should be observed daily for HIV infected TB patients either at DOTS centres or if this is not feasible by This Guideline was zone prepared nurses in by both the the Fiji intensive National and Tuberculosis continuation phase Programme of treatment. with the technical and funding Co-trimoxazole support from preventive the Australian therapy should Respiratory be provided Council to (ARC) all HIV-infected and the Global TB Guideline Fund to - Fiji fight TB AIDS, patients TB and at the Malaria time respectively. of diagnosis and should be available at both TB 22 3 and HIV care facilities. Particular gratitude All is TB accorded patients to with Professor a positive Guy HIV Marks test and should Ms Kerry be discussed Shaw of with the HIV ARC care for their valuable contributions facilities for to the appropriate key technical anti-retroviral concepts of therapy this Guide. (ART). ART should be commenced as soon as possible and within eight weeks of commencing The indispensible TB comments treatment. and The suggestions administration by Dr Linh of ART Nguyen must of WHO follow office standardised in Suva national HIV guidelines. Adverse drug effects are common in HIV-positive TB patients, and some toxicities are common to both ART, co-trimoxazole and TB drugs. Careful monitoring for adverse events is important. All adverse drug reactions must be reported by the responsible health worker and shared with FPBS TB Guideline - Fiji 30 TB Guideline - Fiji 29 3

30 4 Advocacy Communication Social Mobilization 1.3 PREVENTING TUBERCULOSIS TB The Guideline prevention - Fiji of TB involves the protection of the population vulnerable from 23 infection and suppressing the development of active disease among those already infected with M. tuberculosis. TB Guideline - Fiji Vulnerable Infection with population 23 3 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Active TB disease Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide Infection control The indispensible The comments goal of infection and suggestions control activities by Dr Linh is Nguyen to minimise of WHO the office risk in of Suva TB transmission. -Infection Control Manual o TB, as a Last but not matter the least, of priority, the contributions all patients and diagnosed support with of the or following suspected personnel of having and TB must be separated from other patients, placed in adequately ventilated areas, educated on cough etiquette and respiratory hygiene, and assessed for risk for TB transmission. All patients with TB or suspected TB should be categorised as having a high, medium, low or negligible risk for transmission of TB. This will guide isolation requirements for the TB patient or suspect. All care should be taken to minimise the exposure of non-infected patients (in particular, those who are immunocompromised) to TB. Grant Management Patients Unit of living Fiji MOH with and HIV or with strong clinical evidence of HIV infection, or with other forms of immunosuppression, should be physically separated from those with suspected or confirmed infectious TB. To minimise the spread of droplet nuclei, patients with or suspected of having TB, should be educated in cough etiquette and respiratory hygiene that is, in the need to cover their nose and mouth using a piece of cloth, tissue or surgical mask when sneezing and or coughing. The cloth, tissue or a surgical mask should be disposed of as infectious waste. TB Guideline - Fiji 31 TB Guideline - Fiji 30

31 Isolation Each DOTS centre or hospital caring for patients with tuberculosis should have well ventilated rooms suitable for housing patients with TB. Airborne precautions should be implemented when these rooms are occupied. DOTS centers should also have a few isolation rooms with acceptable standards for housing the following patients: People suspected of having infectious drug resistant TB. These are all re-treatment or treatment failure cases. They should be accommodated in a single room until MDR-TB is excluded by DST. People with confirmed MDR-TB or XDR-TB. They should remain in a single room until sputum is culture negative. While patients are in isolation (they are considered infectious). Contact with visitors should be minimised (or appropriate infection control measures adhered to), Visitors who are less than 5 years of age or those who are immunosuppressed (eg HIV) should be discouraged from visiting patients in the isolation room Patients should wear surgical masks (not N95 masks) to reduce the risk of transmission when they are not in isolation rooms eg during transportation. Mothers with infectious TB should wear surgical masks if/when caring for their infants eg breastfeeding Use of N95 masks Personal protective equipment should be used by health workers and visitors in situations where there is an increased risk of transmission to reduce the risk of infection or re-infection with TB. These situations include: Those entering the isolation rooms described above; HCWs performing or attending aerosol-generating procedures associated with high risk of TB transmission (e.g. bronchoscopy, intubation, sputum induction procedures, aspiration of respiratory secretions, and autopsy or lung surgery) N95 masks are recommended for this purpose. HCWs should be trained in the use of N95 masks and educated on managing stigma which may arise as a result of using N95 masks Natural ventilation Simple natural ventilation may be effective in reducing the risk of transmission. This should be optimized in DOTS center by maximizing the size of the opening of windows and locating them on opposing walls. TB Guideline - Fiji 32 31

32 1.3.2 BCG vaccination BCG vaccination is included in the Expanded programme of Immunisation. In Fiji BCG vaccination is given at birth. The dosage is 0.05ml of BCG vaccination injected intradermally on the upper aspect of the right arm (at the point of insertion of the deltoid muscle into the humerus). BCG vaccination after infancy is not recommended Preventative chemotherapy The following group of persons should be properly examined for the presence of active TB disease. Once active TB is ruled out, Isoniazid preventative treatment (IPT) should be instituted for at least 9 months: This Guideline was prepared by the Fiji National Tuberculosis Programme with the a) People living with HIV/AIDS Global Fund to fight AIDS, TB and Malaria respectively. Patients with HIV infection who are also infected with TB are at great risk of developing active TB. The clinical features of TB in people with HIV infection Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for may be atypical. Extrapulmonary and disseminated TB disease is common their valuable contributions to the key technical concepts of this Guide. among PLWHA. PLWHA should be evaluated for the presence of TB and, if this is not present, should receive isoniazid preventive therapy institutions is If acknowledged: active TB is excluded, they should be screened for latent tuberculosis infection by Mantoux test. The Mantoux test should be performed by a HCW experienced in performing this test. Patients with HIV infection who have a should be considered to have latent tuberculosis infection and should be prescribed a six month course of Isonazid Dr Apisalome 300 Nakolinivalu mg daily (5mg/kg up to a maximum of 300mg daily in children) together Fiji Red Cross with Society vitamin B6 (pyridoxine) 25 mg daily. They should be reviewed on a monthly schedule to ensure proper adherence to prescribed treatment. Public health b) officials All children contacts (<5yrs old):refer to Page 19. Management of latent TB infection in children. TB Guideline - Fiji 33 TB Guideline - Fiji 323

33 1.4 Monitoring & evaluation Cohort analysis Evaluation of treatment outcome in new pulmonary smear-positive patients is used as a major indicator of programme quality and performance. Outcomes in other patients (re-treatment, pulmonary smear-negative, extrapulmonary) are analysed in separate cohorts. Each registered patient should have his/her outcome recorded in the register as soon as treatment course is completed. The following treatment outcome definitions should be used for sputum smear-positive patients. This Guideline was prepared by the Fiji National Tuberculosis Programme with the Table 8. Treatment outcome definitions Global Fund to Outcome fight AIDS, TB and Definition Malaria respectively. Particular gratitude Cured is accorded to A patient Professor whose Guy sputum Marks smear and Ms was Kerry positive Shaw at the of beginning the ARC for their valuable contributions to the of key the technical treatment concepts but who of was this smear-negative Guide. in the last month of treatment and on at least one previous occasion. The indispensible Treatment comments and A patient suggestions who completed by Dr Linh treatment Nguyen but of who WHO does office not have in Suva a completed negative sputum smear result in the last month of treatment and on at least one previous occasion. Last but not Treatment the least, the contributions A patient whose and support sputum of smear the is following positive personnel (and culture and failure positive) at 5 months or later during treatment. Also included in this definition are patients found to harbour a multidrug-resistant (MDR) strain at any point of time during the treatment, whether they are smear-negative or positive. Died A patient who dies for any reason during the course of TB treatment. Dr Apisalome Default Nakolinivalu A patient whose treatment was interrupted for 2 consecutive months or more. Transfer out A patient who has been transferred to another recording and Grant Management Unit of Fiji MOH reporting and (DOTS) unit and whose treatment outcome is unknown. Treatment A sum of cured and completed treatment. success These treatment outcomes should be determined by the Divisional TBCO in charge. This will allow the National TB Office to perform cohort analysis on a quarterly and annual basis. TB Guideline - Fiji 34 TB Guideline - Fiji 333

34 1.4.2 Recording and reporting system TB patient register The TB patient register is kept at the: Divisional DOTS centers should contain register of all patients covered under the respective Divisional DOTS center. Sub-divisional hospitals should contain register of all patients covered under the respective sub-divisional hospital. Primary health care centers (Health centers) should contain register of all patients covered under the respective primary health care center. This Guideline was prepared Laboratory by by the registers Fiji National Tuberculosis Programme with the technical and Laboratory funding support aspects from of tuberculosis the Australian management Respiratory are beyond Council the (ARC) scope and of this the Global Fund to to Guide. fight AIDS, However, TB and each Malaria laboratory respectively. performing TB microscopy (in the three DOTS centres) should keep a laboratory register. The technologist in charge Particular gratitude of the is laboratory is accorded is to to responsible Professor Guy for Marks maintaining and Ms this Kerry register Shaw up-to-date of of the ARC on for a their valuable daily contributions basis. to to the key technical concepts of of this Guide. The indispensible comments Treatment and suggestions cards by by Dr Dr Linh Nguyen of of WHO office in in Suva must not go go unrecognized. The treatment card contains all the information about the patient. Two copies of a treatment card will be completed for each patient, as well as a patient's Last but not identification the least, the card. contributions One copy of and the support treatment of of the card following is retained personnel at the DOTS and institutions is is centre acknowledged: responsible for the patient. Dr Dr The second copy of the treatment card is sent to the health facility/person Dr (TB liaison officer) responsible for delivering supervised treatment to the Dr patient. The person administering treatment (either in hospital or in the Dr Dr Apisalome community) Nakolinivalu must record the patient's daily intake of prescribed drugs Fiji Red Cross according Society to that patient's treatment schedule on this treatment card. Each administered dose should be signed for (with initials). The Treatment card, Grant Management domiciallery Unit of of Fiji form MOH and and Patient identification card can be found in the enclosed Appendices Reporting mechanisms a) DOTS centres should report the following on a quarterly (within the first month of new quarter) and annuall schedule to the National TB Programme Office in Suva on: TB Case Notification: number (age/gender distribution, classification) TB-HIV coinfection & MDR-TB Treatment outcome (highlighting those cured, treatment completed, died, failures, defaulters, & transfers) TB Guideline - Fiji 35 TB TB Guideline - - Fiji 334 3

35 b) The National TB Programme reports to Health Information Unit at the MOH quarterly & annually on: TB Case Notification - number & rate (age & gender distribution, classification & type of TB case) TB-HIV coinfection & MDF-TB + TB -Diabetes co-infection Number and proportion of children (0-13 years) screened for TB and starting TB prophylaxis. Treatment outcome (highlighting those cured, treatment completed, died, failures, defaulters, & transfers) This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Last but not the least, Managing the contributions anti-tb drug and supply support of the following personnel and The FPBS work in partnership with the NTP in determining the required supply of anti-tb drugs on an annual basis. Procurement and distribution of anti-tb drugs to DOTS centres and Divisional hospital pharmacies are solely the responsibility of the FPBS. Divisional hospitals also possess anti- TB drugs, and advise their respective DOTS centres of a newly diagnosed case of TB before or when commencing treatment. DOTS centres are responsible for the dispensing and recording of appropriate supply of anti- TB drugs on a case by case basis to Sub-divisional or peripheral level. TB Guideline - Fiji 36 TB Guideline - Fiji

36 1.5 PROGRAMME SUPERVISION National supervision The NTP office at Tamavua-Twomey hospital in Suva provides technical and programmatic oversight of all TB control activities in Fiji. This is done through: conduct of quarterly supervisory visits to the three(3) DOTS centres standardising operating procedures provision of technical support to other TB stakeholders.ie. FRCS, FNA, FNU, NRL, HIU and FPBS. liaison to donor and technical partners.ie. WHO, GFATM, GMU-MOH, This Guideline was SPC prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight Divisional AIDS, TB supervision and Malaria respectively. The three(3) DOTS centres are located in Lautoka (Tagimoucia unit), Labasa Particular gratitude and Tamavua-Twomey is accorded to Professor hospitals. Guy They Marks provide and and Ms conduct: Kerry Shaw of the ARC for their valuable contributions Divisional to TB the control key technical services concepts of this Guide. Supervision of sub-divisional health centres (TB patient health care The indispensible comments provider-health and suggestions service) and by to Dr community Linh Nguyen settings of WHO where office TB patient in Suva is under DOT care by community health worker. Report to NTP head office on quarterly & annual basis institutions is acknowledged: Sub-divisional supervision The sixteen (16) sub-divisional hospitals in Fiji are in charge of the following TB control activities: Supervision of identified health centres and communities Provide complementary TB services particularly on suspect referral, contact screening and continuum of care for patients undergoing continuation phase of treatment Report on quarterly & annual basis to their respective DOTS centers Grant Management Unit (indicator of Fiji elements MOH and pertaining to TB case notification, and treatment outcome) Laboratory supervision and EQA Daulako Mycobacterium laboratory (at Tamavua-Twomey hosp.) offers the following services: Supervises and provides EQA for all three(3) divisional hospital laboratories Offer technical support to staff of the three(3) divisional laboratories TB Guideline - Fiji 37 TB Guideline - Fiji

37 Appendix 2 Organises capacity building programmes planned for divisional technicians related to TB microscopy and culture Collaborates with QMRL (Queensland) on the conduct of DST for MDR- TB suspects Tuberculosis Referral/Transfer Form Divisional laboratories play a pivotal role in: TUB 1 Supervising and conducting Ministry EQA of for Health sub-divisional laboratories Fiji National Tuberculosis Programme Offering technical support to all sub-divisional labs Providing TUBERCULOSIS quarterly and REFERRAL/TRANSFER annual reports to Daulako FORM Mycobacterium laboratory on TB (cases, TB cases tested for HIV, TB-HIV coinfected, Name: smear negative-culture positive, smear positive-culture Phone: positive, This Guideline was Address: smear prepared positive-culture by the Fiji negative) National Tuberculosis Programme with the technical and funding Koro dina: Providing support capacity from the building Australian Tikina: opportunities Respiratory Yasana: sub-divisional Council (ARC) laboratory and the Global Fund to fight DOB: AIDS, staff. TB and Malaria respectively. Sex: Age: Ethnicity: Contact person: Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for TUBERCULOSIS PATIENT TRANSFER their valuable contributions to the key technical concepts of this Guide. TB REG No.: OPF No.: Date Treatment started: Transferred From: The indispensible To: comments and suggestions by Dr Linh Nguyen of WHO office in Suva Diagnosis: PTB Smear Pos. PTB Smear Neg. EPTB Treatment: SCC (new case) Re-treatment (relapse, failure, default) RIF/ INH ETH PZA STREP 150/100mg 100mg 500mg 300/150mg 400mg 400mg inj. g Remarks: Date of Transfer: Signed: TUBERCULOSIS SUSPECT REFERRAL Referred From: To: Cough for more than 2 weeks Other symptoms: Grant Management Sputum Unit specimen of Fiji No.: MOH and Date produced: Remarks: Date: Cut/Tear Here Signed: Phone: TUBERCULOSIS TRANSFER/ REFERRAL The patient/suspect: Address: 1. Who was transferred to reported/ did not report for treatment 2. Who was referred to Has been diagnosed with PTB smear pos. PTB smear neg. EPTB Tuberculosis treatment will be started at: on date Has NOT been diagnosed with tuberculosis TB Guideline - Fiji 38 Date: Signed: 42 TB Guideline - Fiji TB Guideline Fiji

38 REFERENCES 1. Ministry of Health-Fiji. Technical Guide for Tuberculosis Control in Fiji; 2 nd edition, Ministry of Health-Fiji. Tamavua-Twomey Hospital Annual Report, Ministry of HealthFiji. NTP Review Report, Ministry of Health-Fiji. Annual Report, Ministry of Health-Fiji. Fiji Global Fund Proposal (R 8/9), WHO. Stop TB Global Plan, WHO. Guidelines for intensified TB case finding & Isoniazid preventative therapy for This Guideline PLWHA, 2010 was prepared by the Fiji National Tuberculosis Programme with the technical 8. WHO. and TB funding Treatment support Guidelines, from the 2010 Australian Respiratory Council (ARC) and the Global 9. Fund WHO. to Guidelines fight AIDS, for TB intensified and Malaria tuberculosis respectively. case finding and isoniazid preventive therapy for people living with HIV in resource constrained settings, 2010 Particular 10. WHO/IFRC. gratitude Tuberculosis accorded to control Professor in prisons, Guy Marks 2001 and Ms Kerry Shaw of the ARC for their 11. valuable WHO. Guidelines contributions fro surveillance to the key technical of drug concepts resistance of in this tuberculosis-4 Guide. th edition, SPC. Guidelines for TB contact tracing in Pacific Island Countries & Territories, 2010 The 13. indispensible SPC. TB Surveillance comments in and the PICTs, suggestions 2010 by Dr Linh Nguyen of WHO office in Suva must 14. not TBCTA. go unrecognized. International standards for tuberculosis care, IUATLD. Interventions for tuberculosis control & elimination, 2002 Last 16. but IUATLD. not the Management least, the of contributions tuberculosis and (A guide support for the of essentials the following of good personnel practice); and institutions 6 th edition, is acknowledged: 2010 TB Guideline - Fiji 39 TB Guideline - Fiji 383

39 APPENDICES Tub 1 Referral/transfer forms Tub 2 Laboratory Register Tub 3 Laboratory (AFB microscopy) request form Tub 4 AFB Microscopy Register This Guideline was prepared by the Fiji National Tuberculosis Programme with the technical Tub 5 and TB funding Register support from the Australian Respiratory Council (ARC) and the Global Fund to fight AIDS, TB and Malaria respectively. Tub 6 TB Patient ID Card Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for Tub 7 TB Contact Register their valuable contributions to the key technical concepts of this Guide. Tub 8 TB Treatment Card must Tub 9 not go unrecognized. HIV testing Consent form Last Tub 10 but not Pharmacy the least, the form contributions and support of the following personnel and Tub 11 Domicilliary Treatment Supervision form Dr Tub Iobi 12 Batio Treatment Completion form Dr Tub Frank 13 Underwood Quarterly Report on Sputum Conversion Fiji Tub Red 14 Cross Quarterly Society Report on TB case registration Grant Tub 15 Management Quarterly Unit of Report Fiji MOH on and Treatment Outcome TB Guideline - Fiji 40 TB Guideline - Fiji 393

40 Appendix 2 Tuberculosis Referral/Transfer Form Ministry of Health Fiji National Tuberculosis Programme TUBERCULOSIS REFERRAL/TRANSFER FORM TUB 1 Name: This Guideline was Address: prepared by the Fiji National Tuberculosis Programme with the technical and funding Koro dina: support from the Australian Tikina: Respiratory Yasana: Council (ARC) and the Global Fund to fight DOB: AIDS, TB and Malaria respectively. Sex: Age: Ethnicity: Contact person: Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for TUBERCULOSIS PATIENT TRANSFER their valuable contributions to the key technical concepts of this Guide. TB REG No.: OPF No.: Date Treatment started: Transferred From: The indispensible To: comments and suggestions by Dr Linh Nguyen of WHO office in Suva Diagnosis: PTB Smear Pos. PTB Smear Neg. EPTB Treatment: SCC (new case) Re-treatment (relapse, failure, default) RIF/ INH ETH PZA STREP 150/100mg 100mg 500mg 300/150mg 400mg 400mg inj. g Remarks: Date of Transfer: Signed: TUBERCULOSIS SUSPECT REFERRAL Referred From: To: Cough for more than 2 weeks Other symptoms: Grant Management Sputum Unit specimen of Fiji No.: MOH and Date produced: Remarks: Date: Cut/Tear Here Signed: Phone: Phone: TUBERCULOSIS TRANSFER/ REFERRAL The patient/suspect: Address: 1. Who was transferred to reported/ did not report for treatment 2. Who was referred to Has been diagnosed with PTB smear pos. PTB smear neg. EPTB Tuberculosis treatment will be started at: on date Has NOT been diagnosed with tuberculosis Date: Signed: 42 TB Guideline - Fiji 40 3 TB Guideline Fiji

41 Laboratory Request for Sputum Examination TUB 2a This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Ministry of Health Fiji National Tuberculosis Programme LABORATORY REQUEST FOR SPUTUM EXAMINATION Gender Ethnicity Ward Hosp. No. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Name: Other Name: DOB MO I/Charge Facility: Clinical Note: Specimen Collection Date: Received: 1st Specimen 2nd Specimen 3rd Specimen Follow-up: Signature: AFB Microscopy TB Culture Drug Susceptibility Test REMARKS: Note: This form is to be used for Tuberculosis diagnosis only. TB Guideline - Fiji 41 3 TB Guideline Fiji 43

42 Laboratory Report of TB Examination TUB 2b This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Ministry of Health Fiji National Tuberculosis Programme LABORATORY REPORT OF TB EXAMINATION Name Other Name DOB Gender Ethnicity Ward Hosp. No. Lab Reg. No. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. MO I/Charge Facility: Specimen Collection Date: Brief Clinical Note (Diagnosis): Received: R E P O R T DRUG SUSCEPTIBILITY TEST CULTURE AFB MICROSCOPY DRUGS SENSITIVITY Actual No. Streptomycin Isoniazid Rifampicin Ethambutol Pyrazinamide Negative/ No AFB Seen Examined by: Date Reported : Officer In-charge TB Guideline - Fiji TB Guideline Fiji 42 3

43 Laboratory Register for AFB Microscopy (a) TUB 3 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme LABORATORY REGISTER FOR AFB MICROSCOPY OFFICER³ REFERRAL CENTRE² DATE NAME SEX DOB PATIENT'S ADDRESS TB REG. No./ Hosp. No.¹ LAB REG. No. ¹ Note TB REG. No. if patient is registered TB case, otherwise note hospital no. ² Where patient/specimen is referred from. ³ Person sending specimen. TB Guideline Fiji 45 TB Guideline - Fiji 43 3

44 Laboratory Register for AFB Microscopy (b) TUB 3 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme LABORATORY REGISTER FOR AFB MICROSCOPY YEAR: SMEAR RESULT 6 REMARKS HIV TEST DONE (Y/N) DST SENT (Y/N) CULTURE DONE (Y/N) 5 REASON FOR DIAGNOSIS (D or F) CLINICAL NOTE NATURE OF SPECIMEN 4 Macroscopic appearance of specimen. 5 Write D for Diagnosis or F for Follow-up 6 Indicate result with (N) No AFB, Positive as or actual number (mark positives with red pen) with dates of respective results in the space below. 46 TB Guideline - Fiji 44 3 TB Guideline Fiji

45 Laboratory Register TB Culture (a) TUB 4 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme LABORATORY REGISTER FOR TB CULTURE Date Specimen Inoculated Clinician Date Specimen Collected Lab Serial No. TB Reg. No./Hosp. No. Age Referral Health Facility Specimen Patient's Name Sex (M/F) TB Guideline - Fiji 45 3 TB Guideline Fiji 47

46 Laboratory Register TB Culture (b) TUB 4 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme Signature Comments Sensitivity Test 3 Date DST Result Reported Culture Sent for DST (Y/N) Date Reported Result of Confirmatory Test for MTB (pos /neg) 2 Result of Culture (Weeks) ¹ R H E S Z Reason for Examination (D or F) ¹ Write D for Diagnosis or F for Follow-up; 2 Outcome of culture reported as follows; Indicate sensitivity with (I) intermediate (S) sensitive (R) resistant No growth reported 0 Fewer than 10 colonies Write the number of colonies colonies + More than 100 colonies ++ Innumerable or confluent growth TB Guideline - Fiji 46 3 TB Guideline Fiji

47 Tuberculosis Register (a) TUB 5 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme TUBERCULOSIS REGISTER Remarks HIV Test Done (Y/N) Treatment Result LABORATORY RESULTS End of Treatment End of 5th Month End of 2nd or 3rd Month Start of Treatment Culture Drug Sensitivity Test Date Smear R H E Z S Date Smear Date Smear Date Smear Date Result Enter S (Sensitive) or R (Resistant), A smear at the end of 3 rd and 5 th months are only done for those who failed to convert, Cured (C), Treatment Completed (TC), Treatment Failure (F), Died from whatever cause (M), Defaulted or lost to follow-up (D), Transferred Out (O) HIV test conducted. Enter Y (Yes) N (No) TB Guideline - Fiji 3 TB Guideline Fiji 49 47

48 Tuberculosis Register (b) TUB 5 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme TUBERCULOSIS REGISTER Type of Disease Treatment Name Sex ² DOB Address Treatment Date of TB Patient Class Regimen³ Centre Reg.¹ Reg. No. ¹ Date when the patient was entered into the sub divisional register, ² Male (M), Female (F), ³ HRZE or HRZES, Smear positive pulmonary TB (PTB+), smear negative pulmonary TB (PTB-), Extra - pulmonary TB (EPTB), Enter the correct code: New (N), Relapse (R), Treatment After Failure (F), Treatment After Default (D), Transfer in (I), Others (O). 50 TB Guideline - Fiji 48 3 TB Guideline Fiji

49 Patient ID Card PATIENT ID CARD This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. FIJI NATIONAL TUBERCULOSIS PROGRAMME (NTP) PATIENT IDENTITY CARD DISEASE CLASSIFICATION Dr Frank Name: Underwood Sex : M F PULMONARY EXTRA-PULMONARY SMEAR POS. SITE: OPF No. /NHN TB Reg. No. SMEAR NEG. Address: TYPE OF PATIENT DOB Phone: NEW TREATMENT AFTER FAILURE Treatment Centre: TRANSFER IN TREATMENT AFTER DEFAULT Date Treatment Started: Completed RELAPSE OTHER Public REMINDER: health officials Remember that: 1. If you miss taking your medicine (even 3 doses in a month) DRUG RESISTANCE can develop. 2. This is bad for you and your community. 3. If you stop you will become ill within months or a year. 4. Medicines MUST NOT be shared with family and friends. 5. If you find it difficult taking your medicine regularly, DISCUSS with health workers. 6. Seek support from your treatment supervisor, family or friends. 7. If you change your address please notify your nurse or doctor, AS SOON AS POSSIBLE 8. If you feel unwell when you take your medicine, see your nurse or doctor. 9. Visit your doctor at least once a month for review. Possible Side Effects of Anti-TB Medicines: No appetite Abdominal pain Nausea Tingling/numbness around the mouth Orange/red urine Skin rash Dizziness Ringing in the ears PLEASE SEE YOUR DOCTOR AS SOON AS POSSIBLE IF YOU HAVE ANY OF THE ABOVE TREATMENT REGIMEN INTENSIVE PHASE CONTINUATION PHASE RIF 150/300 mg INH 100/150 mg ETH PZA STREP 100/400 mg 400/500 mg mg Doctor s Visit Dates: Drug Collection Dates: Final Review Dates: APPOINTMENT DATES TB Guideline - Fiji 49 3 TB Guideline Fiji 51

50 Register of TB Contacts TUB 7 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme REGISTER OF TB CONTACTS Facility Year Prophylaxis 3 Remarks/Relationship to Index Case Sex SCREENING Age Address of Contact Name of Contact ¹ TB Register No. Name of Index Cases Date Method Result ¹ List all contacts consecutively under the name of the index case. 2 Enter method of screening: Symptom Screening (Sym), Tuberculin Skin test (TST), Chest x-ray(cxr) or sputum smear examination (SSE). 3 Prophylaxis Regimen: 9H or 6HR 52 TB Guideline - Fiji TB Guideline Fiji 50 3

51 Tuberculosis Treatment Card (a) TUB 8 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme TUBERCULOSIS TREATMENT CARD 1 Name : Phone: ²² Address: Occupation: Koro dina Tikina Yasana DISEASE CLASSIFICATION/ SITE OF TB DISEASE ¹¹ PULMONARY EXTRA PULM SITE Contact Person: Phone: Sex: Date of Birth : Ethnicity: Paediatric Cases (<15 years) Yes No Country of Birth 8 : History of TB contact: Yes No Previous diagnosis of TB: Yes No If yes, year of diagnosis: Sputum date collected ¹² Smear: Positive Negative TYPE OF PATIENT ² Status: Dead Alive Weight: (DOTS) START: kg. New Transfer in Relapse Defaulter Treatment Failure Others RHZE 150/75/400/275mg TABS OD RIFAMPICIN SUSP N ml OD RIF/INH 150/100 mg TABS OD ISONIAZIDE SUSP N ml OD RIF/INH 300/150 mg TABS OD (INTENSIVE PHASE) DRUG REGIMEN 29 Status at TB Diagnosis 10 : Dead Alive DOTS Therapy Stopped/Not Started 38 : Died Others Date Stopped DOTS Therapy Extended 39 NO YES Duration months. INTENSIVE PHASE (DOTS) START DATE Laboratory Results Date Lab Smear Culture No. Day Month ENTER X on day of supervised drug administration or DC when drugs are collected. DRAW A LINE to include number of days supply given.tick appropriate box after the drugs have been taken by the patient. 13 Sputum Culture Not Done Neg. Pos. Date: Reference Lab 14 Smear/Pathology/Cytology of Tissue/Other body Fluids. Done? Yes No 16 CXR: Normal Abnormal Cavity: Yes No 17 Skin Test (TST) Date Pos. Neg. Not done 15 Culture of Tissue/Other Body Fluids, Done? Yes No 18 Primary reason evaluated for TB: TB Symptom Onset Date 19 TB Symptoms: Cough Coughing of blood Chest pain Loss of appetite Loss of weight Fatigue NOTE: SUPERSCRIPT NUMBERS CORRESPOND TO EPIANYWHERE DATA INFO TB Guideline - Fiji TB Guideline Fiji

52 Tuberculosis Treatment Card (b) TUB 8 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme CONTINUATION PHASE (DOT) START DATE : WEIGHT: START kg ; END kg Laboratory Results Day Smear Cult Date Lab No. Month Drug regimen: HR HRE (DOT) Others ENTER X on day of supervised drug administration or DC when drugs are collected. DRAW A LINE to include number of days supply given. TICK appropriate box after the drugs have been taken by the patient NOTE: SUPERSCRIPT NUMBERS CORRESPOND TO EPIANYWHERE DATA INFO 20 HIV Testing at TB Diagnosis: NO YES 21 Homeless within past year NO YES 23 Illegal drug use within past year: NO YES INJ NON-INJ Weekly Alcohol Use within past year: NO YES Not Known 26 TB Risk Factors: Diabetes Pos Neg Others: Missed contact 2 years or less Contact with TB Disease Others 30 Genotype Testing Done: NO YES Isolate submitted for genotype testing: NO YES Date isolate received at genotyping laboratory: 31 Drug Susceptibility Testing done: NO YES Date: If yes, genotyping accession number for episode: Enter specimen type: Sputum or Anatomic Code: Pulmonary Extrapulmonary 32 Drug Susceptibility Results: Sensitive to: Resistant to: 39 Reason standard therapy regimen extended: 33 If MDR, is the case Green Light Committee Approved: NO YES 40 Local Health Provider Available NO YES 34 Sputum Smear Conversion: Date 1st sputum smear negative: Date 2nd sputum smear negative: 35 Sputum Culture Conversion: Date 1st sputum culture negative 41 Directly Observed Therapy (DOT): NO YES No. of weeks 36 Transfer/ Moved: Did the patient move/ transfer during TB Therapy? NO YES 42 Treatment Outcome: Out of Division: Specify: WD CE ND Out of Country; CURED TREATMENT COMPLETED DIED 38 Reason DOT therapy stopped/ Never started: 37 Date stopped: DEFAULTED TRANSFERRED OUT FAILED Was TB death registered in the registration system of: NO YES Date: 54 TB Guideline - Fiji TB Guideline Fiji 52 3

53 Consent Form (HIV/AIDS and TB) Ministry of Health Fiji National Tuberculosis Programme TUB 9 CONSENT FORM HIV/AIDS and TB This Guideline was prepared by the Fiji National Tuberculosis Programme with the technical and funding support from the (Name Australian of Facility) Respiratory Council (ARC) and the Global Fund to fight AIDS, TB and Malaria respectively. Name: DOB: Sex: F/ M Particular gratitude Contact Home: is accorded Work: to Professor Guy NHN Marks and Ms Kerry Shaw of the ARC for their valuable Address: contributions to the key technical concepts of this Guide. Occupation: Marital Status: History of presenting complaint: Last but not the least, the contributions and support of the following personnel and institutions is acknowledged: COUNSELLING AND TESTING PICT VCCT Explanation of the signs/ symptoms of TB and HIV/AIDS Officer provides knowledge on HIV/AIDS and TB Assess client's knowledge on HIV/AIDS and TB o What is the difference between HIV/AIDS and TB o What are some of the signs and symptoms of HIV/AIDS and TB o What are some of the ways to protect oneself from getting HIV/AIDS and TB Client understands the risks associated with HIV/AIDS and TB Client knows what to do if result is positive or negative I, agree/disagree to be tested for HIV/AIDS. Signature: Date: Counsellor: (Name) (Signature) TB Guideline - Fiji TB Guideline Fiji

54 Pharmacy Form Ministry of Health Fiji National Tuberculosis Programme TUB 10 PHARMACY FORM ANTI TUBERCULOSIS MEDICATION This Guideline TO: was prepared by the Fiji FOR:(RECIPIENT National Tuberculosis OF TB MEDICATION) Programme with the technical and NAME: funding support from the Australian PATIENTS FULL Respiratory NAME : Council (ARC) and the DESIGNATION: ADDRESS: Global Fund to fight AIDS, TB and Malaria respectively. ADDRESS: SEX: FACILITY: DOB: Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for TB MEDICATION: INTENSIVE PHASE CONTINUATION PHASE their valuable contributions to the key technical concepts of this Guide. Name & Strength Dosage Quantity Comments Supplied RHZE 150/75/400/275 mg Rif/Inh 150/100 mg tabs OD tabs OD Last but not Rif/Inh the least, 300/150 the mg contributions tabs and OD support of the following personnel and Rifampicin Suspension ml OD Isoniazide Suspension ml OD STATUS OF SUPPLY: Balance Final/ Last Supply(Y/N) SIGNATURE (PHARMACIST IN CHARGE) DATE SENT DATE TAKEN BY PATIENT (FILLED BY ZONE NURSE):...Cut and send back to the pharmacist... LETTER Pharmacist Date received Facility Patient's Name/ Recipient: Drugs Supplied Quantity 1) 2) 3) Receiver's Name Signature Facility 56 TB Guideline - Fiji 54 3 TB Guideline Fiji

55 Domicillary Supervision Form TUB 11 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme DOMICILLARY SUPERVISION FORM INTENSIVE / CONTINUATION PHASE MEDICATIONS (DOT) Rifampicin/ Isoniazid Combination 300/150mg Ethambutol 400mg Streptomycin 150/100mg Pyrazinamide 400/500mg YEAR: Phone: Name: Address: Koro dina: Tikina: Yasana: DOB: Sex: Age: Ethnicity: Contact person: Phone: DAYS MONTH Remarks: Zone nurse home visit dates (once every 2 weeks): TB Guideline - Fiji TB Guideline Fiji

56 Treatment Completion Form Ministry of Health Fiji National Tuberculosis Programme TUB 12 TREATMENT COMPLETION FORM (To be completed by a Medical Officer) This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. NAME: Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions ADDRESS: to the key technical concepts of this Guide. HOSPITAL NO/NHN: TB REGISTER NO.: Last but not the DIAGNOSIS: least, the contributions and support of the following personnel and INTENSIVE PHASE STARTED IN: INCLUSIVE DATES: FACILITY CONTINUATION PHASE STARTED IN: DATE STARTED: FACILITY DURATION OF CONTINUATION PHASE: DATE COMPLETED: *Pharmacist to fill-up Patient s name and details. SUBMITTED BY: FACILITY: DOB: SEX: SIGNATURE: DATE SUBMITTED: CC TO: 1. DIVISIONAL TB CONTROL OFFICER - White 2. SDMO - Yellow 3. MO HEALTH CENTRE - Pink 4. BOOK COPY - Green THANK YOU FOR YOUR COOPERATION TOWARDS OUR GOAL OF A TB FREE FIJI. 58 TB Guideline - Fiji TB Guideline Fiji 56 3

57 Quarterly Report on Sputum Microscopy Conversion TUB 13 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Ministry of Health Fiji National Tuberculosis Programme QUARTERLY REPORT ON SPUTUM SMEAR MICROSCOPY CONVERSION quarter of year Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Name of Division: Date of completion of this form: Facility: Name: Signature: Sputum smear microscopy conversion at: Sputum smear microscopy not done at either 2 or 3 months 2 months 3 months Number of new sputum smear microscopy positive cases registered in quarter recorded above 2 Total converted at 2 or 3 months: Sputum smear microscopy conversion at: 2 months 3 months Sputum smear microscopy not done at either 2 or 3 months Number of sputum smear microscopy positive retreatment cases registered in quarter recorded above 2 Total converted at 2 or 3 months: 1 Quarter: This form applies to patients registered (recorded in the TB Register) in the quarter that ended 3 months ago. For example, if completing this form at the beginning of the 3rd quarter, record data on patients registered in the 1st quarter. 2 This number should match the number of new sputum smear microscopy positive cases in Block 1, Column 1, first row of the Quarterly Report on TB Case Registration previously completed for patients registered in this quarter. White Copy - NTP OFFICE Yellow Copy - DOTS CENTRE TB Guideline - Fiji TB Guideline Fiji

58 Quarterly Report on TB Case Registration TUB 14 This Guideline was prepared by the Fiji National Tuberculosis Programme with the Global Fund to fight AIDS, TB and Malaria respectively. Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for their valuable contributions to the key technical concepts of this Guide. Ministry of Health Fiji National Tuberculosis Programme QUARTERLY REPORT ON TB CASE REGISTRATION Patients registered during 1 quarter of year Name of Division: Unit: Date of completion of this form: Name of TB Coordinator: Signature: Block 1: All TB cases registered during the quarter 2 Other previously Extrapulmonary Pulmonary sputum smear negative Pulmonary sputum smear positive Previously treated treated 3 Total Pulmonary smear not done / not available After default After failure New cases Relapses Block 2. Breakdown of TB cases by sex and age group New Total M New Smear positive F M F Pulmonary smear negative/not done/ not available M F Extrapulmonary Total Block 3: Laboratory activity - direct smear 4 Block 4: Quarterly report on TB/HIV activities No. HIV positive No. tested for HIV before or during TB treatment 5 No. of TB suspects with sputum smear microscopy positive result No. of TB suspects examined for diagnosis by sputum smear microscopy New sputum smear microscopy positive TB All TB cases except new smear positive, 'transferred in' and chronic cases 6 1 Registration period is based on date of registration of cases in the TB register, following the start of treatment. Q1: 1 January-31 March; Q2:1 April -30 June; Q3: 1 July-30 September ; Q4:1 October-31 December. 2 In areas routinely using culture, a quarterly report on TB case registration for unit using culture should be used. Transferred in and chronic cases are excluded. 3 Other previously treated cases include pulmonary cases with unknown result of previous treatment, sputum smear negative pulmonary cases and extra-pulmonary cases previously treated. Transferred in and chronic cases are excluded. 4 Data collected from the TB laboratory register related to activity performed in the unit during the quarter. 5 Documented evidence of HIV tests (and results) performed in any recognized facility before or during TB treatment should be reported here. 6 Includes smear negative, smear not done, extra-pulmonary cases and all previously treated cases. White Copy - NTP OFFICE Yellow Copy - DOTS CENTRE 60 TB Guideline - Fiji 58 3 TB Guideline Fiji

59 Quarterly Report on TB Treatment Outcomes and TB/HIV Activities Ministry of Health Fiji National Tuberculosis Programme Name of Division: QUARTERLY REPORT ON TB TREATMENT OUTCOMES AND TB/HIV ACTIVITIES Patients registered during 1 quarter of year This Guideline was prepared by the Fiji National Tuberculosis Date of completion Programme of this form: with the Name of TB Coordinator: Signature: Block 1: Quarterly report on TB treatment outcomes Global Fund to fight AIDS, TB and Malaria respectively. Type of case Total number of patients registered Cured Treatment completed Treatment outcomes Died Treatment Default failure 2 Total number evaluated for outcomes (sum of during quarter* ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 ) ( 6 ) Columns 1 to 6) Particular gratitude is accorded to Professor Guy Marks and Ms Kerry Shaw of the ARC for Sputum smear positive their valuable Sputum contributions smear neg and not to the key technical concepts of this Guide. done Extrapulmonary Relapses Treatment after failure Treatment after default Other previously treated 3 Last but not Block the 2: least, Quarterly the report contributions on TB/HIV activities and (same support quarter analysed of as the Block following 1) personnel and 4 No. tested for HIV 6 No. HIV positive (a) No. on CPT 6 No. on ART 6 New sputum smear microscopy pos. TB All TB cases except new smear positive, 'transferred in' and chronic cases 5 Block 3: Quarterly report on TB treatment outcomes of HIV-positive patients Type of case Total number of Treatment outcomes Total number HIV positive TB Cured Completed Died Failure 7 Default Transfer evaluated for patients out outcomes: Block 2, Column ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 ) ( 6 ) (sum of Columns (a)* 1 to 6) New sputum smear microscopy pos. TB Grant Management All TB cases Unit except of Fiji MOH and new smear positive, 'transferred in' and chronic cases 5 * Of these patients, (number) were excluded from evaluation for the following reasons: Transfer out TUB 15 * These numbers are transferred from the Quarterly Report on TB Case Registration for the above quarter. Of these patients, (number) were excluded from evaluation for the following reasons: "Not TB": Other reasons: 1. Quarter: This form applies to patients registered (recorded in the Divisional Tuberculosis Register) in the quarter that ended 12 months ago. For example, if completing this form at the beginning of the 3rd quarter, record data on patients registered in the 2nd quarter of the previous year. 2. Include patients switched to Cat. 4 because sputum sample taken at start of treatment turned out to be MDRTB. 3. Include pulmonary cases with unknown result of previous treatment, sputum smear-negative pulmonary cases and extrapulmonary cases previously treated. 4. Documented evidence of HIV tests (and results) performed in any recognized facility during or before TB treatment should be reported here. 5. Includes smear negative, smear not done, extrapulmonary cases and all previously treated cases. 6. Includes TB patients tested for HIV before and during TB treatment, continuing on CPT or ART started before TB diagnosis and those started on CPT or ART during TB treatment (till last day of TB treatment). 7. Include patients switched to Cat. 4 because sputum sample taken at start of treatment turned out to be MDRTB. White Copy - NTP OFFICE Yellow Copy - DOTS CENTRE TB Guideline - Fiji 3 TB Guideline Fiji 61 59

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