Flowchart for notification and reporting of TB Cases Among Health Care Workers to OHU, JKNS. Picture 12.5: Flowchart for notification and reporting of TB Cases Among Health Care Workers to OHU, JKNS *team under supervision of KPAS officer, consist of but not limited to, KPAS officer, MO trained in OH, OH nurse, PPKP 151
Treatment Of Active And Latent TB, TB Prophylaxis Therapy (TPT) Treatment Of Active And Latent TB Refer Chapter 4 and 5 for clinical management. TB Prophylaxis Therapy This is mainly given to this 2 groups of people if there are no contraindications i. children under 5 years old and ii. HIV patients if no contraindications. TB Prophylaxis Therapy is also given to children > 5 years old and above for the treament of LTBI after diagnosis of active TB is ruled out and mantoux test or IGRA is positive. Refer chapter 6. Standard precautions - cough etiquette/mask/isolation i. Cough Etiquette Patients should be educated about M. tuberculosis transmission and the importance of cough etiquette (i.e. to minimize the generation of infectious droplet nuclei). Coughing patients should be instructed to turn their heads and cover their mouth and nose with their hands and preferably with a cloth or tissue when coughing. If patients do not have a cloth or tissue, these should be provided by the institution. Posters emphasizing cough etiquette should be placed in the waiting areas. ii. Mask The use of PPE alone (i.e. respirator) should not be used as the main control measures since it can only work if standard work practice and environmental controls are in place. Ideally, all HCWs who are involved in the care of infectious TB patient should wear at least N95 disposable mask/respirator. However, in resource limited settings, N95 must be used at least by those working in the high risk areas in hospitals and referral centers as follows: i. TB wards and clinics ii. Isolation room iii. Procedure room (bronchoscopy suite, etc) iv. Operation room 152
BCG Bacillus Calmette–Guérin BCG vaccine are more protective against disseminated TB and TB Meningitis than pulmonary TB. *Source: GARIS PANDUAN PROGRAM IMUNISASI BCG, SEKTOR TIBI / KUSTA, BAHAGIAN KAWALAN PENYAKIT, KEMENTERIAN KESIHATAN MALAYSIA, EDISI KEDUA: 2019. Indication: Initial vaccination i. Newborn baby ii. All children under 7 years old that have not received BCG immmunisation Revaccination iii. Baby at 3 months old that have received BCG immunisation but has no scar or has pintpoint scar (≤2mm). Forms required: 1. Rekod Kesihatan Bayi dan Kanak-Kanak (0 – 6 Tahun) 2. Buku Daftar Jagaan Kanak-kanak KKK 101 3. Buku Daftar Imunisasi BCG TBIS 103C 4. Rekod Imunisasi di Klinik Kesihatan Kanak-kanak KKK 103 Pind.2/2007 5. Rekod Vaksin KKK 104 Pind.2/2007 6. Buku Daftar Kelahiran KIB103 Pind.2/2007 Monthly reporting forms to be sent to District BCG Coordinator, subsequently State BCG Coordinator and to KKM. 1. TBIS 103A Daftar Bayi Baru Lahir Tercicir Imunisasi BCG & Ringkasan Laporan Bulanan Kelahiran Hidup dan Liputan Imunisasi BCG Mengikut Tempat Kelahiran (TBIS 103A) 2. TBIS 103B Daftar Imunisasi BCG KKK 205 Laporan Bulanan/ Tahunan Dalam Penggunaan Dan Kawalan Stok Vaksin 153
Health Education For Patients/Public Points for Health Education on TB for the patient/ community i. Cause and mode of transmission of TB ii. High risk groups of TB iii. Symptoms and signs iv. Diagnosis with basic investigation tests v. Treatment - regime, duration, side effects, importance of compliance to treatment and Directly Observed Therapy (DOT). vi. Basic preventive steps - BCG vaccination, Isonizide prophylaxis therapy (IPT), seek medical help if suspect TB, keep a healthy lifestyle such as no smoking, regular exercise, balanced diet, adequate rest and good personal hygiene (cough etiquettes). vii. LTBI 154
Chapter 13 : Referral Criteria Dr Ho Rong Lih There is lack of primary evidence in the recommendation for specialist referral of TB. However, various guidelines have certain referral criteria for the management of TB. Extrapolating from other parts of the CPG, certain TB cases or TB-related conditions would need to be referred to the specialists with substantial experience in treating the conditions. 155
Table 13.1: Referral criteria to the respective team 156 Phase Referral Criteria 1 Referral criteria from Pusat Rawatan 2 (PR 2) to Pusat Rawatan 1 (PR 1) * PR 1: diagnose TB, starts anti-TB treatment (ATT), performs follow-up examination and review for TB patients, ends TB treatment, TB contact screening * PR 2: continue TB treatment (DOTS) for TB patients • Suspected TB case • TB patients to start or end ATT • TB patients on ATT with suspected side effects • TB patients with relapse/ worsening symptoms • TB patients to continue TB follow-up review • TB patients detected to be pregnant • Defaulter TB patients • Patients for TB contact screening (clinics without medical officers) 2 Referral criteria to Family Medicine Specialist (FMS) • Unsure of TB diagnosis • Smear negative TB • Adverse events following antiTB drugs (Refer Chapter 7 & 9) • TB patients with uncontrolled co-morbids or that require shared care with tertiary center • Eg: uncontrolled diabetes / hypertension, HIV-TB co-infection, maternal TB • Long-term complications • Eg: bronchiectasis, chronic obstructive pulmonary disease, Hepatitis secondary to ATT, peripheral neuropathy, optic neuropathy
Table 13.2: Referral criteria to the respective team (cont.) 157 Phase Referral Criteria 3 Referral criteria to Tertiary Center Physicians (eg: Respiratory physician (Respi), Infectious Disease physician (ID) • Unsure of TB diagnosis - after discussing with FMS [Refer Respi] • Retreatment of TB [Refer Respi] • Multidrug-resistant and extremely drugresistant TB [Refer Respi] • Smear negative TB [Refer Respi] • Smear positive after two months of treatment [Refer Respi] • Extrapulmonary TB except for tuberculous lymphadenitis [Refer ID] • HIV-TB co-infection [Refer ID] • Adverse events following anti-TB drugs (Refer Chapter 9) • Renal and/or liver impairment with TB (Refer Chapter 7) • Maternal TB (Refer Chapter 6 & 10) • Complex TB cases requiring surgical intervention [Refer Surgeon] • Severe cutaneous adverse reaction (SCAR) [Refer Dermatologist] - Eg: drug-induced Stevens-Johnson Syndrome, Toxic epidermal necrolysis, Drug reaction with eosinophilia and systemic symptoms, Acute generalised exanthematous pustulosis
Table 13.3: Referral criteria to the respective team (cont.) 158 Phase Referral Criteria 4 Indications of Hospitalisation • Gravely ill patients with advanced disease or respiratory distress • Cases of acute disseminated TB - Eg: military TB, TB meningitis • TB involving central nervous system, pericardium, adrenals and spine • Multidrug-resistant and extremely drugresistant TB • Patients who default treatment frequently or whose compliance is suspected • Patients with complications such as hemoptysis, pneumothorax and empyema • Patients who develop severe side effects such as severe skin reactions or jaundice • Patients who need to be desensitised to anti-tuberculous drugs • Initial intensive chemotherapy – if daily ambulatory treatment proves difficult - Eg: homeless patients, drug addicts, alcoholics
Table 13.4: List of Pusat Rawatan (PR) in Sabah 159 No. District Pusat Rawatan 1 Pusat Rawatan 2 1 KOTA KINABALU PR1 QEH KK Likas PR1 Luyang KKOM Taman Canggih PR1 Inanam KKOM Sulaman PR1 Menggatal KKOM UTC PR1 Telipok KKOM Tanjung Aru PR1 HWKKS KKOM PCC KKIA Pekan 2 PENAMPANG PR1 Penampang KK Terian KKOM Cybercity KD Sungoi KD Moyog KD Babagon KD Limbanak KD Nosoob 3 PUTATAN PR1 Putatan KKOM Putatan Jaya KD Petagas 4 TUARAN PR1 Tuaran KK Tenghilan KK Serusop KKOM Rugading KKOM Taman Telipok Ria KKIA Tuaran PR1 Tamparuli KK Simpangan KK Kiulu
Table 13.5: List of Pusat Rawatan (PR) in Sabah (cont.) 160 No. District Pusat Rawatan 1 Pusat Rawatan 2 5 KOTA BELUD PR1 Kota Belud KK Taginambur KK Jawi-Jawi KKOM Alap Baba KK Rosok KD Kiau KD Kaung KD Kebayau KD Pangkalan Abai KD Kelawat KD Losou KD Sayap KD Rampayan laut KD Payas-payas KD Tamau KD Pandasan KD Dudar KD Kuala Abai
Table 13.6: List of Pusat Rawatan (PR) in Sabah (cont.) 161 No. District Pusat Rawatan 1 Pusat Rawatan 2 6 KUDAT PR1 Kudat KK Karakit KK Sikuati KK Matunggong KK Tinangol KK Narandang KK Lotong KK Suangpai KK Indarason KD Milau KD Dualog KD Tambuluran 7 PITAS PR1 Pitas KK Pantai KK Telaga KK Bongkol KK Dandun KKOM Pinggan-Pinggan
Table 13.7: List of Pusat Rawatan (PR) in Sabah (cont.) 162 No. District Pusat Rawatan 1 Pusat Rawatan 2 8 BELURAN PR1 Beluran KK Nangoh PR1 Telupid KK Kuala Sapi KK Sungai-Sungai KK Tangkarason KK Telupid KK Paitan KK Jambongan KK Lingkabau KK Terusan Sugut KK Abuan KK Tagas Tagas 9 BEAUFORT PR1 Beaufort KK Padas Damit KK Kota Klias KK Weston KK Membakut KKOM Limbawang KKOM Pimping KD Gadong KD Kabajang KD Bangkalalak KD Rancangan Klias KD Lubak KD Takuli KD Lingkunga KD Bukau KD Sinoko KD Binsukok KD Pimping
Table 13.8: List of Pusat Rawatan (PR) in Sabah (cont.) 163 No. District Pusat Rawatan 1 Pusat Rawatan 2 10 RANAU PR1 Ranau KK Bundu Tuhan PR1 Kundasang KK Paginatan KK Lohan KK Perancangan KK Timbua KK Kaingaran KD Kinirasan KD Randagong KD Terolobou KD Nalapak KD Matupang KD Tampios KD Narawang KD Bongkud KD Pinawantai KD Malinsau
Table 13.9: List of Pusat Rawatan (PR) in Sabah (cont.) 164 No. District Pusat Rawatan 1 Pusat Rawatan 2 11 KUALA PENYU PR1 Kuala Penyu KK Kerukan KK Menumbok 12 SIPITANG PR1 Sipitang KK Sindumin KK Mendulong KK Meligan KK Long Pasia KD Melamam KD Mesapol KD Banting 13 PAPAR PR1 Papar KK Kuala PR1 Kinarut KK Ulu Kimanis KK Bongawan KD Gadung Kimanis KKOM Taman Pengalat Besar KD Pengalat KD Biau KD Simpudu KD Benoni KD Kelatuan KD Tibabar KD Kawang
Table 13.10: List of Pusat Rawatan (PR) in Sabah (cont.) 165 No. District Pusat Rawatan 1 Pusat Rawatan 2 14 TAMBUNAN PR1 Tambunan KK Sunsuron KK Patau KKOM Pekan Tambunan KD Lotong KD Nambayan KD Toboh KD Lumodou KD Kitokot KD Garas KD Tontobob Liwan 15 KENINGAU PR1 Keningau KK Apin-Apin PR1 Sook KK Bingkor KK Tulid KK Mansiat KD Baginda KD Kem PPH KD Ansip KD Bunga Raya KD Biah KD Senagang KD Merapok KD Kabatang Baru KD Karamatoi KD Bulu Silou KD Tuarid Taud
Table 12.11: List of Pusat Rawatan (PR) in Sabah (cont.) 166 No. District Pusat Rawatan 1 Pusat Rawatan 2 16 TENOM PR1 Tenom KK Melalap KK Kemanbong KK Kuala Tomani KD Pamilaan KD Lagud Seberang KD Mandalom KD Batu-Batu KD Sapong KD Paal KD Baru Jumpa KD Ulu Tomani 17 NABAWAN PR1 Nabawan KK Pensiangan KK Pagalungan KK Sepulut KD Pandiwan KD Bahagia 18 SANDAKAN PR1 Sandakan KK Ulu Dusun PR1 Sungai Manila KK Batu 10 19 KINABATANGAN PR1 Kinabatangan KK Bukit Garam KK Sukau KK Batu Putih KK Kuamut KK Suan Lamba
Table 12.12: List of Pusat Rawatan (PR) in Sabah (cont.) 167 No District Pusat Rawatan 1 Pusat Rawatan 2 20 TONGOD PR1 Tongod KK Entilibon KK Pinangah KK Minusoh KK Mengkawagu KD Keramuak 21 TAWAU PR1 Tawau KK Kalabakan PR1 Apas Balung KK Sungai Tamang PR1 Merotai Besar PR1 Felda Umas 22 KUNAK PR1 Kunak KK Pangi 23 SEMPORNA PR1 Semporna KK Pulau Bum Bum KD Egang KD Hampalan KD Sg Buaya KD Tg Kapor 24 LAHAD DATU PR1 Lahad Datu KK Silabukan PR1 Felda Sahabat KK Belacon PR1 Tungku KKOM Bandar Sri Perdana KKOM Layung KK Tambisan
Table 13.13: List of Pusat Rawatan (PR) in Sabah (cont.) 168 No. District Pusat Rawatan 1 Pusat Rawatan 2 25 KOTA MARUDU PR1 Kota Marudu KK Langkon PR1 Tandek KKom Simpang 3 KKom Hexan KK Marak Parak KD Samparita KD Gana KD Tanjung Batu KD Marudu KD Salimandut KD Timbang Batu KD Goshen KD Tagaroh KD Mosolog
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Respiratory Department, QEH & TB and Leprosy Sector, JKN Sabah 2022