TB Screening And Diagnosis Procedures PDF

SECTION 2.1. SYSTEMATIC SCREENING DEFINITION OF TERMS 1. Systematic screening for active TB – refers to the systematic identification of presumptive TB in a predetermined target group, using examinations or other procedures that can be applied rapidly. a. Active case finding (ACF)...

SECTION 2.1. SYSTEMATIC SCREENING DEFINITION OF TERMS 1. Systematic screening for active TB – refers to the systematic identification of presumptive TB in a predetermined target group, using examinations or other procedures that can be applied rapidly. a. Active case finding (ACF) – systematic screening implemented outside health facilities (i.e. high-risk populations or settings) by bringing the screening examination/procedures such as chest X-ray to the community. 1,2 b. Intensified case finding (ICF) – systematic screening in health facilities among all consults. In the program context, ICF will also utilize chest X-ray screening. c. Enhanced case finding (ECF) – systematic screening in the community using symptoms screening, such as house-to-house visits by community workers. 2. Presumptive pulmonary tuberculosis – refers to any person having: i) two weeks or longer of any of the following – cough, unexplained fever, unexplained weight loss, night sweats; or ii) chest X-ray finding suggestive of TB. 1,2,3 3. Presumptive extrapulmonary tuberculosis – refers to anyone having signs and symptoms specific to the suspected extrapulmonary site with or without general constitutional signs and symptoms such as unexplained fever or weight loss, night sweats, fatigue and loss of appetite.3 4. Symptom-based screening – refers to screening using any of the four cardinal TB signs and symptoms.1,2 The four cardinal signs and symptoms of TB are at least two weeks duration of cough, unexplained fever, unexplained weight loss and night sweats. 5. Screening by chest X-ray – refers to using chest X-ray to identify presumptive pulmonary TB (PTB) which will manifest with common abnormalities that are suggestive of PTB. 1,2 6. Primary screening tool – refers to the test or tool that is used initially to detect presumptive TB in the systematic screening of TB. It may be symptom-based or chest X-ray. 1,2 7. Health facility with TB services – a health-care facility, whether public or private, that provides the entire spectrum of TB services in accordance with the policies and guidelines of the National Tuberculosis Control Program (NTP), Department of Health (DOH). This was formerly referred to as directly observed treatment, short course (DOTS) facility. 8. Close contact – a person who shared an enclosed space, such as the household, a social gathering place, workplace or facility, for extended periods within the day with the index case during the three months before diagnosis of TB.3 9. Index case – the initially identified TB case of any age in a specific household or other comparable setting in which others may have been exposed.3 10. Children – any person who is less than 15 years old. SCREENING AND DIAGNOSIS OF TUBERCULOSIS 9 POLICIES 1. Systematic screening for TB shall be implemented in all health facilities. 2. Symptom screening using any of the four cardinal signs and symptoms (at least two weeks of cough, unexplained fever, unexplained weight loss and night sweats) shall be the primary screening tool for systematic screening in health facilities among all consults including for immunization, maternal health and child health. Accompanying persons will also be screened by asking for TB signs and symptoms. 3. Screening by chest X-ray shall be recommended annually among all health facility consults. 4. Active case finding shall be implemented in congregate settings, targeted communities and workplaces using chest X-ray as the primary screening tool and Xpert as the diagnostic test. 5. All people living with HIV (PLHIV) shall be screened for the TB co-infection. 6. All health facilities shall screen its workers for TB annually using both symptom and chest X-ray screening. 7. Household and close contacts of all ages of a diagnosed TB case shall be screened for TB using symptoms and chest X-ray. PROCEDURES The screening strategies shall consider the adequacy and efficiency of specimen transport systems, the capacity of laboratory and clinical services to offer diagnosis and treatment, the availability of drugs, and the characteristics (risk groups) of the populations being served. Screening may be done in health facilities, in communities or congregate settings, and among health workers and TB contacts. A. Systemic screening in health facilities (intensified case finding) Systematic screening in facilities shall be done for all clients visiting the facility regardless of reason for consult. If the patient consults due to any of the four cardinal signs/symptoms (i.e. at least two weeks of cough, unexplained fever, unexplained weight loss and night sweats), simply follow the guidelines below and in Fig. 1. If patient consults for other reasons, also ask for the four cardinal signs/symptoms as stated below. 1. The following steps are involved in screening for pulmonary TB (PTB) in adults ≥ 15 years old (Fig. 1): 1.1 Record the patient’s demographic and contact information in a register of consults. 1.2 Ask all patients consulting the health facility, if they have the following cardinal signs and symptoms that are lasting for ≥2 weeks: (Annex 2A. Sample Screening Form) a. cough b. unexplained fever c. unexplained weight loss d. night sweats. 1.3 If any of the above signs/symptoms are present for at least two weeks, identify as a presumptive TB. 1.4 For those who do not have any of the cardinal signs/symptoms above or experienced it for less than two weeks, offer chest X-ray screening if one has not been conducted in the past year.9 10 NATIONAL TUBERCULOSIS CONTROL PROGRAM: MANUAL OF PROCEDURES 6TH EDITION  A chest X-ray posteroanterior (PA) upright view should be requested and previous chest X-rays should be brought for comparison. For pregnant women, a written consent shall be taken and abdominal protective shield shall be used by the X-ray facility. The National TB Prevalence Survey in 2016 showed that “screening for TB cases using symptoms alone would have missed one-third to two-thirds of bacteriologically confirmed pulmonary TB cases.” If resources are limited, you have the option to prioritize those with TB risk factors as primary clients for chest X-ray screening. Risk factors1–8 include: a. contacts of TB patients; b. those ever treated for TB (i.e. with history of previous TB treatment); c. people living with HIV (PLHIV); d. elderly (> 60 years old); e. diabetics; f. smokers; g. health-care workers; h. urban and rural poor (indigents); and i. those with other immune-suppressive medical conditions (silicosis, solid organ transplant, connective tissue or autoimmune disorder, end-stage renal disease, chronic corticosteroid use, alcohol or substance abuse, chemotherapy or other forms of medical treatment for cancer). If a chest X-ray is not available and these high-risk patients have signs and symptoms lasting less than two weeks, the physician may decide whether to consider the patient a presumptive TB case. 1.5 All patients with chest X-ray findings suggestive of TB should be identified as presumptive TB. Screening by chest X-ray may be done once a year. 1.6 For PLHIV, screening by both chest X-ray and symptoms should be done at the time of diagnosis of HIV/AIDS and annually, thereafter. Symptom-based screening should be done at every visit (Fig. 2). Note that signs and symptom for PLHIV (cough, unexplained fever, unexplained weight loss and night sweats) can be of any duration, not necessarily two weeks.11,12 In the presence of one or more TB signs and symptoms and/or a chest X-ray suggestive of TB, identify as presumptive TB in PLHIV. 1.7 For all presumptive TB identified, ask about previous history of treatment and exposure to TB cases to determine the risk for DR-TB. Presumptive DR-TB cases are those with previous history of TB treatment, close contacts of a known DR-TB case or a non-converter of DS-TB regimen. 1.8 Record the patient in Form 1. Presumptive TB Master List and follow the diagnostic algorithm as outlined in the diagnosis section (pages 27, Fig. 7). Record also on a monthly basis the total number of clients who underwent chest X-ray screening from ICF in the assigned portion of Form 1. SCREENING AND DIAGNOSIS OF TUBERCULOSIS 11 Fig. 1. Systematic screening for pulmonary PTB in adults ≥ 15 years old with unknown HIV infection status in health facilities Ask for the following signs and symptoms (lasting for ≥ 2 weeks): 1. cough 2. unexplained fever 3. unexplained weight loss 4. night sweats No ≥ 1 Yes Chest X-ray Chest X-ray finding suggestive of TB No Yes Presumptive TB Consultation for Request Xpert MTB Rif Test other diseases (SM/TB LAMP if Xpert not available) Fig. 2. Systematic screening for the diagnosis of active PTB disease in PLHIV At the time of diagnosis of HIV and annually Every visit Screen for TB Signs and Screen for TB S/S: symptoms: cough; cough; Chest X-ray unexplained fever; unexplained fever; unexplained weight loss; unexplained weight loss; night sweats night sweats and “Yes” to any of the criteria Suggestive of TB “Yes” to any of the criteria /or If No symptoms Collect one sputum sample Collect one sputum sample and Chest X-ray not suggestive of TB, end of Request Xpert MTB/Rif Request for Xpert MTB/Rif test screening. (SM/TB LAMP when Xpert test (SM/TB LAMP when Xpert test is not available) is not available) 12 NATIONAL TUBERCULOSIS CONTROL PROGRAM: MANUAL OF PROCEDURES 6TH EDITION  2. The following steps are involved in the screening for pulmonary TB (PTB) in children < 15 years old: 2.1 Ask if the child has TB signs and symptoms. Identify as presumptive TB if the child has at least one of the three main signs and symptoms suggestive of TB:13,14 a. coughing/wheezing of two weeks or more, especially if unexplained (e.g. not responding to antibiotic or bronchodilator treatment); b. unexplained fever of two weeks or more after common causes such as malaria or pneumonia have been excluded; and c. unexplained weight loss or failure to thrive not responding to nutrition therapy. 2.2 Ask if the child is a close contact of a known TB case. If the child is a contact, the presence of fatigue, reduced playfulness, decreased activity, not eating well or anorexia that lasted for two weeks or more should also be considered and identify them as a presumptive TB. 2.3 If the child already has a chest X-ray, review the results. If chest X-ray findings are suggestive of PTB, identify as presumptive TB. Screening by chest X-ray is not routinely recommended for children, except for TB household contacts who are 5 years old and above.1, 35 2.4 For all PTB identified, ask about previous history of treatment and exposure to TB case to determine risk for DR-TB. 2.5 Record the patient in Form 1. Presumptive TB Master List and follow the diagnostic algorithm as outlined in the diagnostic section (Fig. 5). 3. The following steps are involved in the screening for extrapulmonary TB (EPTB), all ages13: 3.1 Note any of the following to identify presumptive EPTB: a. gibbus deformity, especially of recent onset (resulting from vertebral TB); b. non-painful enlarged cervical lymphadenopathy with or without fistula formation; c. neck stiffness (or nuchal rigidity) and/or drowsiness suggestive of meningitis, with a sub-acute onset or raised intracranial pressure; d. pleural effusion; e. pericardial effusion; f. distended abdomen (i.e. big liver and spleen) with ascites; g. non-painful enlarged joint; and h. signs of tuberculin hypersensitivity (e.g. phlyctenular conjunctivitis, erythema nodosum). 3.2 For all presumptive TB identified, ask about previous history of treatment and exposure to TB case to determine risk for DRTB. 3.3 Record the patient in Form 1. Presumptive TB Master List and follow the diagnostic algorithm as outlined in the diagnostic section (page 27). B. Active case finding in targeted community, workplace and congregate settings The priority target population groups in the community are urban and rural poor. In the workplace setting, the priority includes miners, construction workers, public transport drivers and garment factory workers. They are considered priority due to their exposure SCREENING AND DIAGNOSIS OF TUBERCULOSIS 13  to industrial dust (e.g. silicon), pollutant particles and fumes, or enclosed and crowded working condition.1,2,5,7,9 Congregate settings include jails, detention centers, and residential homes or residential care facilities for the elderly, disabled and orphans, as well as crowded living places (e.g. evacuation centers for internally displaced population).1,2,5 1. Screening, using “chest X-ray for ALL” regardless of TB signs and symptoms, shall be conducted annually (Fig. 3). This is specifically for adults (i.e. ages 15 years old and above). For children, only symptom screening as described in section A.2 (page 13) is recommended. The target populations are already high-risk settings and all individuals are eligible for chest X-rays. However, depending on available resources and manpower (i.e. presence of health staff who can do risk screening), you may consider implementing an initial risk factor and symptom screening to prioritize chest X-rays among those with risk factors or symptoms. 2. Estimate the required logistics for the screening activity and plan with all stakeholders. Ensure the availability of sufficient supply, especially of Xpert cartridges and drugs. (Annex 2B. Planning logistics and Estimation of presumptive TB yield). 3. Orient and sensitize the people in the community, workplace or congregate settings. 4. During the actual screening day, inform patients of the purpose of screening and the next steps in the event their chest X-ray is positive. For pregnant women, obtain written consent and use protective shield when taking a chest X-ray. 5. All patients with chest X-ray findings suggestive of TB should be identified as presumptive TB. Sputum should be collected for an Xpert MTB/RIF test. Using smear microscopy (SM) in ACF will not be as cost-effective as Xpert MTB/RIF because of the expected lower yield of bacteriologically confirmed TB cases since SM is less sensitive than Xpert. Further, there is higher chance of clinical diagnosis and, hence, the risk of false positive diagnosis.16-27 6. For all presumptive TB identified, ask about a patient’s previous history of treatment and exposure to a TB case to determine risk for DR-TB. 7. Record the patient in Form 1. Presumptive TB Master List and follow the diagnostic algorithm as outlined in the diagnosis section (Fig. 7). Record also the total number of clients who underwent chest X-ray screening during the ACF activity in the assigned portion of Form 1. Between ACF activities, enhanced case finding (i.e. surveillance for presence of TB signs and symptoms) should be installed and maintained. This is especially applicable to high- risk populations and congregate settings. All those who have any of the cardinal signs and symptoms of TB (i.e. at least two weeks of cough, unexplained fever, unexplained weight loss and night sweats) should be identified as presumptive TB and referred to the health facility. 14 NATIONAL TUBERCULOSIS CONTROL PROGRAM: MANUAL OF PROCEDURES 6TH EDITION Fig. 3. Screening for PTB in targeted community, workplace and congregate settings Screen all by chest X-ray (annually) Suggestive of TB Not suggestive of TB Identify as presumptive TB End of evaluation Request Xpert MTB Rif test C. Screening among health-care workers Health-care workers (HCWs) are considered high-risk groups for TB because of occupational exposure. In this context, HCWs include all those present in the health facility, whether medical, paramedical or ancillary staff. These include those who provide janitorial, logistics, maintenance and ambulance services.15 1. Symptom surveillance shall be implemented in all health facilities (Fig. 4). All health workers with any of the four cardinal signs and symptoms (Two weeks of any of cough, unexplained fever, unexplained weight loss or night sweats) should be identified as presumptive TB. 2. Baseline chest X-ray screening followed by annual chest X-ray shall be done for all HCWs. Those with findings suggestive of tuberculosis or with progression of lesions compared to a previous chest X-ray shall be identified as presumptive TB. 3. Orient and sensitize the activity to the HCWs. Reassure HCWs on the entitlement of medical benefits, sick leave and job safety if they are found to have TB. 4. For all presumptive TB identified, ask about previous history of treatment and exposure to TB case to determine risk for DR-TB. 5. Record the patient in Form 1. Presumptive TB Master List and follow the diagnostic algorithm as outlined in the diagnosis section (Fig. 7). SCREENING AND DIAGNOSIS OF TUBERCULOSIS 15 Fig. 4. Screening among health-care workers Baseline screening TB symptoms screening when the staff is recruited + chest X-ray TB symptom screening: Signs and symptoms lasting 2 weeks of any of the following: Follow-up screening cough TB symptoms screening biannually unexplained fever unexplained weight loss Follow-up screening night sweats TB symptoms screening annually + chest X-ray If any symptoms Collect sputum and/or specimen for Xpert any abnormality TB/Rif test (or SM/TB compatible with TB on LAMP if not available) Chest X-ray D. Contact tracing 1. Screening household contacts of DS-TB cases13,35 (Table 1) a. Instruct index case to bring all household members to the health facility or use trained barangay health workers or community health workers to do community- based contact screening. Household contacts should be evaluated within seven days from treatment initiation of the index case to ensure prompt diagnosis. b. If chest X-ray is available and accessible, perform chest X-ray on all household contacts who are 5 years old and above. If not, perform symptom screening including those under 5 years of age. c. All household contacts identified to be a presumptive TB based on a chest X-ray or symptom screening should undergo diagnostic testing. d. Consider latent tuberculosis infection (LTBI) if not a presumptive TB or after exclusion of active TB disease (refer to Chapter 4. TB Preventive Treatment, page page 65).35 e. Advise contacts to follow-up every six months for the next two years. Do symptom screening every six months and chest X-ray screening annually. f. Educate about TB signs and symptoms and advise to consult immediately if signs and symptoms of TB develop. 16 NATIONAL TUBERCULOSIS CONTROL PROGRAM: MANUAL OF PROCEDURES 6TH EDITION Table 1. Comparison of procedures for screening DS-TB and DR-TB household contacts DS-TB contacts DR-TB contacts Chest X-ray screening All 5 years old and above (symptom All contacts screening only for < 5 years old) If chest X-ray not available, do If chest X-ray not available, do symptom Xpert test directly for all contacts. screening Diagnostic test Xpert, if not available SM/loop mediated Xpert isothermal amplification (TB LAMP) If active TB ruled-out Consider TB preventive treatment (TPT) TPT currently not recommended Follow-up contacts Every six months for two years Every six months for two years (Symptom screen every six months, chest (Symptom screen every six months, X-ray every year) chest X-ray every year. If chest X-ray not available, do Xpert test directly.) 2. Screening household contacts of DR-TB cases13,35 (Table 1) a. Evaluate all household contacts of diagnosed DR-TB cases by screening with signs and symptoms and chest X-ray. Those with signs and symptoms or a positive chest X-ray result should be identified as presumptive TB. If it is not feasible to do chest X-ray screening, proceed directly to do Xpert test for DR-TB contact (irrespective of symptoms). b. Refer all household contacts identified as presumptive TB to Xpert MTB/RIF testing. c. All household contacts who have no signs and symptoms or with chest X-ray findings not suggestive of TB should be educated about TB signs and symptoms and advised to immediately return to the health facility if signs and symptoms of TB develop. d. Follow-up contacts every six months for the next two years. Do symptom screening every six months and chest X-ray annually. If it is not feasible to do a chest X-ray, directly do Xpert MTB/RIF test annually. SCREENING AND DIAGNOSIS OF TUBERCULOSIS 17