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Integration Chua, de la Cruz, Joaquin, Rayel, Redota, Teo, Uy Clinical Management Pulmonology Module 2 years and 3 months prior to consult Chronic cough – when did the coughing start? Productive or non-productive? Loss of appetite and weight loss (weight at this time: 50 kg) – was the patient able to regain the weight after treatment? Afternoon feverish sensation – sign of infection Body malaise Differential Diagnoses Pneumonia Bronchial Asthma Upper Airway Cough Syndrome Chronic Obstructive Pulmonary Disease GERD Malignancy Personal Social History Patient – laundrywoman while husband is a farmer Family lives in a 1-room shanty house without windows or toilet Nutrition: Drinking water from peddlers Instant noodles and occasionally rice and sardines Consult in local health center Chest xray and sputum smear diagnosed with pulmonary tuberculosis enrolled in DOTS program in Brgy San Roque, Cainta, Rizal Claims to have undergone the program continuously for 6 months 1 year and 9 months prior to admission Repeat chest xray cleared by the doctor to have recovered from TB BUT THERE WAS NO DOCUMENTATION Pathophysiology of Pulmonary TB Interaction of bacilli with alveolar macrophage receptors endocytosis into macrophage inhibition of phagosome-lysosome fusion bacilli free to replicate Cytokines induce Helper Tcell response activation of macrophages granuloma formulation Delayed type hypersensitivity caseous necrosis Primary Pulmonary TB distal airspaces of the lower part of the upper lobe or the upper part of the lower lobe Ghon Focus – initial site of parenchymal involvement at the time of first infection which becomes an area of gray to white inflammation with consolidation measuring 1-1.5 cm (called the Ghon lesion or focus) Ranke complex – Ghon focus + calcified lymph nodes The primary lesion can then become latent or progressive. Progressive Pulmonary TB primary lesion increases in size and evolve in different ways rapidly progressing to clinical illness. resembles acute bacterial pneumonia with lower and middle lobe consolidation and hilar adenopathy pleural effusion - result of penetration of bacilli into the pleural space from a subpleural focus Ghon focus enlarges central necrosis irregular cavity poorly walled off by fibrous tissue Secondary Pulmonary TB apical and posterior segments of the upper lobes and superior segments of the lower lobe due to higher oxygen tension in these areas favoring mycobacterial growth Tuberculous pneumonia - result from massive involvement of pulmonary segments or lobes with coalescence of lesions Diagnosing TB Sputum smear recommended mode of diagnosis for countries without lab capacities for culture sensitivity testing (WHO 2010) Screening for TB: Mantoux Method Tuberculin Skin Test To screen for LATENT tuberculosis Intradermal injection of 0.1 mL of tuberculin purified protein derivative (PPD) into the inner surface of the forearm measure induration (+) when ≥ 10 mm for residents of high-risk congregate settings and infants, children, and adolescents exposed to adults in highrisk categories SN: 60%; SP: 78%; PLR: 2.28; NLR: 0.45 Screening for TB: Chest Xray To identify persons with ACTIVE TB Active disease - detection of any abnormality (parenchymal, nodal or pleural) with or without associated calcification There is no single radiologic finding consistent with active TB. Initial screening method of choice when skin test results are unreliable or high, or when risks of transmission of an undiagnosed case are high Sn: 75.8%; Sp: 80%; PPR: 67% when combined with symptoms Chest Xray for Primary TB Can resemble pneumonia Lymphadenopathy – radiologic hallmark; right paratracheal and hilar stations most common sites (Leung et al 1999) Parenchymal opacities – area of homogenous consolidation Chest Xray for Secondary TB Parenchymal opacities – heterogenous opacities most commonly in apical and posterior segmental upper lobes and the superior segment of the lower lobes Cavitation and Airfluid levels Bronchogenic spread Simon foci – apical nodules that are often calcified resulting from hematogenous seeding from primary infection Chest xray of our patient at the time of admission Treatment of Tuberculosis Anti-TB Treatment for the Patient Category I Anti-TB Regimen for Adult weighing 50 kg: First 2 months daily: Isoniazid – 300 mg Rifampicin – 450 mg Pyrazinamide – 1,200 mg Ethambutol – 800 mg Next 4 months daily: Isoniazid – 300 mg Rifampicin – 450 mg Gauging Response to Treatment Radiographic evaluation is of less importance than sputum smear in assessing response to treatment (Leung 1999) Sputum smears on the 2nd month and 6th month Prognosis Tuberculosis is a very treatable disease good prognosis if proper treatment is acquired. As of 2008, the mortality rate of tuberculosis in the Philippines is 52 out of 100,000 tuberculosis has a relatively bad prognosis in the Philippines The prevalence of TB in the Philippines is 550 out of 100,000 Incidence is 280 out of 100,000 As of 2007, case detection rate for new smear positive cases in the Philippines is 67% Reasons: poor compliance to the treatment gaps in the implementation of DOTS in the country. According to the WHO as well, the Preventive Measures Transmission of TB is through droplet nuclei. Four factors that determine the likelihood of transmission of tuberculosis: (1) number of organisms expelled into the air (degree of infectiousness of the case) (2) concentration of organisms in the air determined by volume of space and ventilation (shared environment in which contact takes place) (3) length of time the case breathes the contaminated air (proximity and duration of the contact) (4) immune status of the exposed individual Preventive Measures Educating the patient about coughing etiquette and importance of handwashing. minimize stigma and the exposure of noninfected patients to those who are infected CONTACT Investigation: Get the family screened! encouraged but not mandatory Costly to get sputum smears for the whole family Family dynamics when one member is already sick Environmental and sanitation conditions Preventive Measures Adequate ventilation of the house, particularly the room where the patient with infectious TB would spend considerable time Anyone in the family who coughs should be educated on cough etiquette and respiratory hygiene, and should follow such practices at all times The smear-positive TB patients should also be advised to spend as much time as possible outdoors sleep alone in a separate, adequately ventilated room, if possible spend as little time as possible in congregate settings or in public transport. Preventive Measures for the Patient Wear a surgical mask. Handwashing Find ways to get proper ventilation in the house or spend more time outdoors. Gastrointestinal HPI Timeline Signs and Symptoms 2 years, 3.5 mo PTC (Mar 2008) chronic cough loss of appetite weight loss afternoon fever body malaise local HC in Cainta: CXR, sputum exam 1 year, 8.5 mo PTC Implication TB TB TB TB TB TB repeat CXR, claimed cleared, Resolution of TB? no records available HPI Timeline 8 months PTC (Feb 2010) Signs and Symptoms Implication tolerable colicky abdominal Involvement of a hollow pain organ Involvement of more bloatedness distal segments of intestines Hallmark of intestinal obstruction; abdominal distention Involvement of more distal segments of intestines relieved by passage of flatus Not obstipated, partial or stool obstruction HPI Timeline 4 weeks PTC Signs and Symptoms Implication vomiting of ingested food ~1-2x/week Obstruction increased frequency and severity of abdominal distention Progressive cause of obstruction Possible locations colicky pain localized @ RLQ Chronicity rules out appendicitis Malabsorption, anorexia malnutrition Malabsorption, lost 20-30% weight malnutrition HPI Timeline 18 days PTC Signs and Symptoms Implication menses Rules out pregnancy as cause of vomiting, colicky pain (Ruptured ectopic pregnancy can present as intestinal obstruction) HPI Timeline Signs and Symptoms Implication stable vitals On admission BP, HR and RR important indicators of compensatory responses to a hypovolemic status. 37.8 degrees Celsius is the cutoff point for normal expected temperature in cases of obstruction ambulatory evidence of muscle wasting Malabsorption, malnutrition hyposthenia Malabsorption, malnutrition minimally worked up and diagnosed but cannot be cleared for intervention due to pulmonary complications Primary Impression: GI Tuberculosis History of pulmonary tuberculosis with undocumented resolution Abdominal pain localized at the right lower quadrant Signs and symptoms of obstruction Bloatedness Abdominal disentention relieved by passage of flatus or stool Vomiting Anorexia Progressive Gastrointestinal Tuberculosis Gastrointestinal Tuberculosis is the 6th most common extrapulmonary manifestation of tuberculosis (Chong and Lim 2009) Any site of the GI tract may be involved although studies show a predilection to the ileocecal segments (Fauci et al, 2008). increased density of lymphoid tissue increased stasis neutral luminal pH absorptive transport mechanisms route of infection penetration of the bowel wall hematogenous dissemination Gastrointestinal Tuberculosis and its Correlation with Pulmonary Tuberculosis 25% of gastrointestinal TB cases have evidence of pulmonary TB there is a direct correlation between the severity of pulmonary infection with the presence of GI infection With minimally advanced pulmonary disease, 1% of patients have a concomitant GI infection moderately advanced cases of pulmonary TB, 4.5% have evidence of GI TB 25% of patients with severely advanced PTB cases have concomitant GI TB while 55% to 90% of fatal cases have GI involvement. Hamer et al 1998 Gastrointestinal Tuberculosis Manifestations Ulcerative form major form associated with increased pathogenicity and mortality appears as superficial ulcerative lesions on the epithelial surface. Hypertrophic form scarring, fibrosis and mass formation resembling carcinomatous lesions. Ulcerohypertrophic form combination of the first two with both ulcerations and scar formation The host’s immune system plays a major role in determining the presentation. Those with depressed immune responses are likely to develop the ulcerative form while those with competent immunologic responses would present with a hypertrophic form of the disease (Chong and Lim. 2009). Hamer et al 1998 Pathophysiology of the Disease Imaging Studies Differential Diagnoses Mechanical causes of obstruction herniations, volvulus and intussusceptions are ruled out on physical exam and barium studies performed on the patient adhesions secondary to previous surgery are unlikely as there is no mention of it in the patient’s history Adynamic ileus and colonic pseudoobstruction are ruled out as colicky pain is absent in both conditions Fauci 2008 Differential Diagnoses Causes of RLQ pain Appendicitis, ruled out by the duration of illness. Right-sided diverticulitis less prevalent form of diverticulitis. clinical manifestation includes abdominal tenderness, nausea, emesis, anorexia and GI bleeding (Nirula and Greaney, 1997) Obstruction secondary to scarring from an infectious process can be a complication of this disease Examinations for ruling out this disease include a complete blood cell count, urinalysis, and flat and upright abdominal radiography. Further examinations include CT imaging studies, abdominal radiography with contrast and endoscopy (Roberts et al 1995). Differential Diagnoses Causes of RLQ pain Gastroenteritis and inflammatory bowel disease both do not present with obstructive symptoms lack of diarrhea in the patient lack of cobblestoning on radiographic studies rules out inflammatory bowel disease, particularly Crohn’s disease. Differential Diagnoses Causes of RLQ pain Gynecologic causes of right lower quadrant pain such as ovarian tumor or torsion, and pelvic inflammatory disease as well as Renal causes such as pyelonephritis, perinephritic abscess and nephrolithiasis are ruled out as they do not present with obstructive symptoms. Differential Diagnoses TB peritonitis uncommon extrapulmonary manifestation a consideration in patients presenting with several weeks of abdominal pain, fever, and weight loss. Ruled out because of the lack of ascites, a major feature arising from the exudation of proteinaceous fluid from the tubercles Ruptured tubal pregnancy presenting as intestinal obstruction is unlikely as the patient reports recent menstruation Management 1. Alleviation of symptoms of distention 2. 3. 4. 5. via nasogastric decompression Correction of nutritional status Resection of the involved tissue Demonstration of organism via culture of resected segment followed by sensitivity testing Anti-mycobacterial treatment using appropriate medications Management 1. Alleviation of symptoms of distention via nasogastric decompression 2. Correction of nutritional status serves to prepare the patient for surgical intervention monitoring of serum albumin Management 3. Resection of the involved tissue obstruction is a leading indication for surgery in intestinal tuberculosis other indications for surgery include ulcerative complications such as free perforation, perforation with abscess, or massive Preoperative drug therapy is still controversial Townsend et al 2008 Sharma and Bhatia 2004 Management 3. Resection of the involved tissue right hemicolectomy with a 5 cm margin with anastomosis an ileostomy and a mucous fistula with subsequent anastomosis Townsend et al 2008 Sharma and Bhatia 2004 Management 4. Demonstration of organism via culture of resected segment followed by sensitivity testing definitive diagnosis of mycobacterial infection by acid-fast stain or culture PCR methods culture and sensitivity to determine which drugs are still effective Management 5. Anti-mycobacterial treatment using appropriate HRZES RCT: standard 6 month course vs prolonged courses of conventional TB medication shows no significant difference in cure rates Sharma and Bhatia 2004 Nutrition Nutrition SUBJECTIVE FINDINGS 1 month prior to consult, patient claimed to have lost 20- 30% of her weight (can be classified as severe weight loss), anorexic Markedly decreased oral intake (short starvation) due to vomiting after each oral intake Patient lived on water, coffee, and diluted Bear Brand (intolerance of both solid and soft diet becoming almost daily) Weak, able to stand up with support and poor hand grip Evidence of muscle wasting Nutrition OBJECTIVE FINDINGS Weight is 35 kg; height is 1.5m; BMI (kg/m2) is 15.6. Based on the Asia-Pacific BMI classification, the patient is underweight. Normal BMI= 18.5-22.9 Severe weight loss (>5-10%) Ideal body weight computation = 45kg Patient is less than 10 kg of his Ideal Body weight %IBW= 35kg/45kg = 78%, meaning that current weight is 78% of ideal body weight, patient is classified under moderate malnutrition ASSESSMENT ABC’s of Nutritional Assessment 1. Anthropometric Measurements (Height, Weight, BMI, Triceps Skin Fold, Mid-Arm Circumference, Mid Arm Mass Circumference) BMI=15.6 (Underweight); IBW (Tanhausser’s)= 45kg; %IBW= 78%moderate malnutrition %wt loss= severe (>5% in 1 month) 2. Biochemical Parameters (Common: Serum albumin <3.0g%; Total Lymphocyte <1500) 3. Clinical Parameters or Manifestations (Nutritional Risk Screening, 2002, First and Second Screening) Impaired Nutritional Status= Wt loss >5% in 1 mos or >15% in 3 mos, or BMI <18.5 + impaired general condition or food intake PLAN Appropriate nutritional assessment. Institute a nutritional care plan for the patient. (Patient is nutritionally atrisk, NRS score of >=3) Calculate for total energy allowance and protein, carbohydrates, and fats requirement Method of delivery: IV route then oral upon improvement (Pt has been vomiting, pt has poor hand grip) Nutrition: NRS, 2002 ESPEN Guideline Table 1 Initial Screening Yes 1 Is BMI<20.5 2 Has the patient lost weight within the last 3 months? 3 Has the patient had a reduced dietary intake in the last week 4 Is the patient severely ill? (e.g intensive therapy) No Yes: If the answer is “Yes” to any of the question, the screening in Table 2 is performed. No: If the answer is “No” to all questions, the patient is re-screened at weekly intervals. If the patient e.g is schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Nutrition: NRS, 2002 ESPEN Guideline Table 2 Final Screening Impaired Nutritional Status Severity of disease (increase in requirements) Absent Score 0 Normal nutritional Status Absent Score 0 Normal nutritional requirements Mild Score 1 Wt loss >5% in 3 mos or Food intake below 50-75% of normal requirement in preceding week Mild Score 1 Hip fracture, Chronic patients in particular with acute complications: cirrhosis, COPD, chronic hemodialysis, diabetes, oncology Moderate Score 2 Wt loss >5% in 2 mos or BMI 18.520.5+ impaired general condition or food intake 25-60% of normal requirement in preceding week Moderate Score 2 Major abdominal surgery, Stroke, Severe Pneumonia, hematologic malignancy Severe Score 3 Wt loss >5% in 1 mo or BMI <18.5 +impaired general condition or food intake 0-25% of normal requirement in preceding week Severe Score 3 Head injury, Bone marrow transplantation, Intensive care patients (APACHE >10) Score + Score Total Score Age If >=70 years old, add 1 to total score = age adjusted total score Score >=3: the patient is nutritionally at risk and a nutritional care plan is initiated Score <3: weekly re-screening of the patient. If the patient e.g is schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Nutrition Calculating total energy allowance and protein, carbohydrates, and fats requirement Rapid Estimation of adult total daily calorie and protein requirement Caloric Require ment (kcal/kg/ d) Protein Requireme nt (g/kg/d) None 25 0.8 Mild to Moderate 35 1.0 Moderate to Severe 45 1.5 Severity of Illness Total energy allowance = Weight (kg) x Caloric requirement Total energy allowance = 35 x 45(kcal/kg/d) = 1575 kcal Protein ( 1.0 – 1.5 g/kg/d) = (35 x 1.5) x 4; Protein = 210 kcal Carbs= [(Total energy allowance – Calories from protein) x 0.7] / 4 Carbs = (1575 – 210) x (0.7) = 955 / 4 = 239 g CHO Fats (30-40% of non-CHON calories) = [(Total energy allowance – Calories from protein) x 0.3] / 9 Fats = (1575 – 210) x (0.3) = 409.5 / 9 = 45.5 g Fats Nutrition Monitoring: Laboratory parameters, Body weight improvement, Functional status Laboratory parameters (serum albumin, lymphocyte, cholesterol, transferrin, iron-binding capacity) Surgical operation General goal: Restore the patient’s nutritional, metabolic and functional status. Specific goals: 1. Provide the needed total caloric need to the patient following the macronutrient requirements of protein 15-20%, fats-30-35%, carbohydrates 50-60% of total calories. 2. Prevent complications of electrolyte and metabolic derangement that could lead to potentially life-threatening situations. 3. Prevent further complications of malnutrition such as muscle wasting Relief from obstructive symptoms Prevention of malabsorption caused by ileocecal TB Nutritional delivery must prepare the patient for the surgical operation (monitoring of serum albumin) VitB12 supplementation given post-surgery (since Vit B12 absorption is impaired in the terminal ileum) PUBLIC HEALTH 3 E’s: Evidence, Economics, Ethics EVIDENCE City A Philippines Literacy Rate 98.32% 93% Unemployment Rate 14.3% 7.3% 55% of City A’s total population is composed of migrants, most of which end up as informal settlers in the city. Informal settlers have poor living conditions small living spaces, poor hygiene and sanitation transmission of infectious diseases like TB ,e.g. EVIDENCE Health Indicator City A (2007) Per 1,000 Crude Death Rate 4 Crude Birth Rate 15.7 Maternal Mortality Rate Infant Mortality Rate Stillbirths 0.7 21.5 Philippines (FHSIS, 2005) Per 1,000 4.2 0.71 9.72 2.5 4.7 EVIDENCE Health Indicator BHS City A (2007) n= 2,861,090 0.22 per 10,000 Doctors Philippines (FHSIS, 2005) 2 per 10,000 0.4 per 10,000 0.27 per 10,000 Nurses and Midwives 2.6 per 10,000 0.83 per 10,000 Lack of Manpower One of the factors associated with low cure rates (WHO): “Directly observed therapy is not functioning or does not work well” due to UNDERSTAFFING Defaulters are NOT TRACED (Defaulter rate= 11%) Proposed Solution Addition of more public health workers (doctors, BHWs, midwives and nurses) and/or BHS Tap family members as therapeutic partners ECONOMICS More funds needed to: BUILD more BHS HIRE more health care workers ETHICS Macroallocation of funds Other leading causes of mortality and morbidity may be prioritized Improvement of IMR, stillbirth rate or unemployment rate may be prioritized instead Ethical dilemma may be resolved by adding more health care providers to address all health problems Management McKinsey’s 7S Framework For TB DOTS Strategy TB DOTS program is part of WHO’s overall Stop TB Strategy aim: “a world free of TB” Objectives To achieve universal access to highquality diagnosis and treatment for people with TB To reduce suffering and socioeconomic burden associated with TB Strategy To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB To support the development of new tools and enable their timely and effective use. Component of the strategy that pertains to TB DOTS: pursue high-quality DOTS expansion and enhancement Political commitment with increased and sustained financing Strategy Case detection through quality-assured bacteriology Standardized treatment, with supervision and patient support An effective drug supply and management system Monitoring and evaluating system, and impact measurement Structure DOTS UNIT Head Nurse in Charge Medical Technologist/ Microscopist TB Diagnostic Committee (TBDC) Structure TB DOTS unit associated with a hospital may have more entities above it Chairman of the Infection Control Committee Chairman of the Pulmonary Diagnostics and Therapeutic Center Senior Vice President of the Patient Services Group Assistant Vice President of the Special Services Division System National Tuberculosis Program (NTP) is used as the core policy Department of Health (DOH) and Center for Health Development (CHD) Local Government Units (LGUs) PhilHealth External systems Global Fund through Philippine Business for Social Progress (PBSP) USAID WHO Shared Values High-quality service Sustainability Efficiency Patient-centeredness Staff TB DOTS unit Unit head, head nurse, medical technician, BHW, midwife hospital based NTP coordinators municipal/city health officers CHD NTP Coordinators at the regional and provincial levels Skills All TB DOTS health care workers are trained and certified by DOH before being allowed to work in a DOTS unit trained according to the Manual of Procedures for the National TB Control Program, 2001 Gap Identification & Analysis Interview with TB-DOTS personnel in The Medical City TB-DOTS Facility TB-DOTS is not entirely free Enrollment in TB-DOTS becomes the burden of the health care personnel Human resource issues Recording and Reporting are not updated Gaps between goals, targets and actual performance (Balanced Score Card) Gaps in financing Financial Analysis cost of treatment for PTB greatly differs from treatment for extra-pulmonary TB requiring surgery complete treatment of a New Case of Pulmonary TB: Php 2660.73 to Php 7584.90 complete treatment of a GI TB has an additional cost of ~ Php86250 to Php 228750 additional costs are mainly from cost of surgery (GI surgeon Professional fee, 45% of which is the Anesthesiologist Professional Fee and hospital costs Differences in pharmacotherapy regimen, the choice of drugs and manufacturer affects the total cost of medication cost of diagnostic modalities may also differ depending on the hospital or facility Implications importance of control of new cases of PTB and prevention of development of extrapulmonary complications need for accurate identification of ExtraPTB and complicated TB cases provision for resource allocation for these cases Balanced Scorecard Vision – “a world free of TB” Goal (G1)To achieve universal access to highquality diagnosis and patient-centred treatment (G2)To reduce the suffering and socioeconomic burden associated with TB (G3) To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB (G4) To support development of new tools and enable their timely and effective use Strategy (S1) Sustained political commitment (S2) Access to quality-assured sputum microscopy (S3) Standardized short-course chemotherapy for all cases of TB under proper case management conditions, including direct observation of treatment (S4) Uninterrupted supply of quality-assured drugs. (S5) Recording and reporting system enabling outcome assessment of all patients and assessment of overall program performance. Internal Business Processes Goal area/Perspecti ve G1 unversal access Objectives to provide universal coverage to provide quality assured bacteriology to effectively monitor and evaluate patients *recording *reporting Baseline Measure 100% Measures number or percentage of areas covered by TB-DOTS number of new cases detected by sputum testing 78,352/107,734 DOTS case (73%) 2004 detection rate number of cases enrolled and receiving treatment Target s 100% 85% Actual 100% 255084/86,96 0,000 (0.29%) 2009 75% Initiatives nationwide coverage of TBDOTS, all Local health units have access to the TB-DOTS program Internal Business Processes Goal area/Perspective Objectives G2 reduce suffering to effectively coordinate and manage drug supply Baseline Measure Measures inventory of drugs received inventory of drugs consumed by patients G3 protect groups to prevent and control MDR-TB number of MDR cases among new TB cases Target s Actual Initiatives Financing Goal area/Perspective Objectives Baseline Measure Measures G2 reduce suffering To coordinate resources total cost of drugs purchased To account for expenses total cost of nondrugs purchased total current assets total current liabilities Target s Actual Initiatives Customer Goal area/Perspecti ve G1 universal access Objectives To identify and treat cases successfully Baseline Measure Measures 78,352/107,734 DOTS case (73%) 2004 detection rate 52,319/59,453 (88%) 2003 DOTS treatment success rate ` G2 reduce suffering To provide cheap services To provide free drugs Target s Actual 85% (GTC WHO 2009) 80% (GTC WHO 2009) 75% (2007) Initiatives 88% (2006) patient education and public awareness campaigns by LGUs new enrollees are given discounted sputum and xray services after being diagnosed drugs provided for free after enrolling in TB DOTS Customer Goal area/Perspecti ve G3 protect groups Objectives Baseline Measure To prevent MDR and complication s of TB/HIV 0.30% Measures Target s Actual Initiatives 95% GF: # of MDR-TB patients whose sputum culture converts to negative at the end of 6months of treatment (among the patients enrolled 9 months from the start date of last member of cohort) development and implementation of a joint national plan; HIV surveillance among TB patients, irre spective of HIV prevalence rates New Adult TB Cases key actions for preventing and controlling drug-resistant TB include use of recommended treatment regimens, a reliable supply of quality-assured firstand second-line anti-TB drugs, and adherence to treatment by patients and to its proper provision by health-care Learning & Growth Goal area/Perspecti ve G1 universal access Objectives to provide standardized service by competent health care personnel Baseline Measures Measure training of personnel availability of a manual for personnel G2 reduce suffering G3 protect groups to provide inspiration, motivation and support to TB patients recognition and acknowledgem ent of existence of risk groups and their special requirements. Target s Actual Initiatives Cum. 12,067 (120%) GF: # of service deliverers trained 233 for yr 2005 YES NTPs should provide support to frontline health workers to help them create an empowering environment, training of personnel 268 (117%) GF: Number of service deliverers trained in TB/HIV collaborative activities advocacy to influence policy changes and sustain political and financial commitment; two-way communication between the care providers and people with TB as well as communities to improve knowledge of TB control policies, programmes and services; and social mobilization to engage society, especially the poor, and all allies and partners in the campaign to Stop TB. Learning & Growth Goal area/Perspectiv e G4 support development Objectives Baseline Measure to participate actively in both country-led and global efforts to improve action across all major areas of health systems, including policy, human resources, financing, management, service delivery (including infrastructure and supply systems) and information systems Measures Targets Number of service deliverers (community based support group 67 (2006) Number of Public-private Mix 100 Actual Initiatives 2,622 (92) GF: # of service deliverers (community based support group) trained cordinating body that includes TB and HIV patient support groups; 99