Revised Technical Guidelines for Implementing DOTS Strategies in Jails and Prisons

July 20, 2015

DOH ADMINISTRATIVE ORDER NO. 2015-0032

 

I. Background/Rationale

In 2009, the Department issued Administrative Order No. 2009-0003, entitled "Technical Guidelines for Implementing DOTS Strategy in Jails and Prisons", to strengthen the implementation of the Comprehensive and Unified Policy (CUP) for TB control in the Philippines (Executive Order 187 s. 2003) by integrating DOTS strategy within jails and prisons. Both the Bureau of Jail Management and Penology (BJMP) and the Bureau of Corrections-New Bilibid Prison (BuCor-NBP) issued their respective institutional policies for TB control in prisons and jails in accordance with these guidelines in the Department of Health. The initial policies covered the NBP and Correctional Institute for Women (CIW) as well as five (5) BJMP jail facilities in NCR, Region 4A, Region 7 and Region 11. Capacity building and implementation of the guidelines has since been expanded in phases to the remaining BJMP jails in Regions 1, 3, 4A, 6, 7, 8, 9, 10 11, 13 and NCR and to the rest of the 5 penal colonies.

In August of 2013, the revised Manual of Procedures for the NTP, 5th edition was launched stipulating the changes in NTP policies and procedures in accordance with both global and local developments. Capacity building and roll-out to all regions nationwide began in 2014. It is expected to be implemented nationwide by January 2015. In addition to the revised NTP MOP, observations during the Joint Program Review done in August 2013 provided recommendations to strengthen the implementation of TB control program in jails and prisons.

Given the new technical policies and procedures of the NTP and considering expansion of the TB in jails implementation nationwide, these guidelines are being issued to guide jail and prison facilities in implementing the TB control program.

II Objectives

The objective of this Order is to provide guidance to all jails and prisons nationwide on the proper policies and procedures for implementing TB control in the jail/prison setting. It shall be the basis for the development of specific operational guidelines by the Bureau of Corrections (BuCor), Bureau of Jail Management and Penology (BJMP), Philippine National Police (PNP), National Bureau of Investigation (NBI) and the local government units (LGUs).

III. Scope and Coverage

These guidelines shall cover all jails and prisons being managed by the DILG (BJMP, PNP, LGU), DOJ (BuCor, NBI) and other detention authorities. Implementation shall be coordinated with the respective local government units and Regional Offices of DOH. HSAcaE

IV. Definition of Terms

1. Jails — a place for confinement for city, municipal or provincial prisoners, any fugitive from justice, detainee awaiting trial or under investigation or transfer to a National Penitentiary/Mental Institution. It caters to detainees and inmates serving up to 3 years of imprisonment. Jails are managed by the BJMP, PNP, NBI or LGU.

2. Prisons — refer to a penal establishment under the control of BuCor. It caters to prisoners (i.e., an inmates who is convicted by final judgment) serving more than 3 years.

3. DOTS Facility — a health care facility, whether public or private, that provides TB-DOTS services in accordance with the policies and guidelines of the National TB Control Program (NTP), DOH.

4. Presumptive TB — any person with any signs and/or symptoms suggestive of TB whether pulmonary or extrapulmonary, or those with CXR findings suggestive of active TB.

5. Case Finding — the identification and diagnosis of TB cases among individuals with signs and symptoms presumptive of tuberculosis.

6. Case Holding — the set of procedures which ensures that patients complete their treatment.

7. DOH Regional Offices (ROs) — refer to the regional office of the Department of Health.

8. Local Government Units (LGU) — refer to municipalities, cities or provincial governments.

9. Programmatic Management of Drug-Resistant TB (PMDT) services — refer to the services for diagnosis and treatment of DRTB cases.

10. Xpert MTB/RIF — a rapid test that detects Mycobacterium tuberculosis and rifampicin resistance.

11. Fit testing — is a test protocol conducted to verify that a respirator is both comfortable and correctly fits the user.

12. Close Contacts — A person who shared an enclosed space for extended periods within the day with the index case during the 3 months before commencement of the current treatment episode. For inmates, this can include people identified by the TB patient as his constant companions in the facility; inmates with frequent contact with TB patient (e.g., sleeping near patient, eating with patient, sharing other activities like playing, studying).

13. Adverse Drug Reactions — A response to a drug which is noxious and unintended, and which occurs at doses normally used for the treatment of tuberculosis.

V. General Guidelines

1. Inmates are among the populations at high risk for tuberculosis. Specific interventions that are necessary for early detection and treatment of TB among inmates to reduce morbidity and mortality shall be implemented.

2. The inherent worth, dignity, and safety of inmates shall be respected at all times. Inmates have the right to the same standard of health care as the people in the general community (principle of equity of care).

3  Tuberculosis in an inmate shall never be used to delay trial or release. Likewise, it shall not bring any extra advantage, in terms of special treatment, to the patient compared to other inmates. Inmates diagnosed with TB shall not be deprived or discriminated of social and livelihood privileges.

4. Inmates are partners in the implementation of TB control strategies. They shall be empowered to actively participate in prevention and control efforts.

5. Implementation of TB control in jails and prisons shall be a coordinated effort among the implementing institutions BJMP, PNP, BuCor, NBI, LGUs and the DOH.

6. Implementation of TB control in jails/prisons, including the provision of a package of TB services, shall be in accordance with NTP policies and shall be integrated into the health services of facilities managed by BJMP, PNP, BuCor, NBI and LGUs.

7. Case finding shall be systematically implemented in jails/prisons during the routine procedures that inmates undergo upon entry, during detention, prior to transfer of inmates to another facility, and, prior to release of inmates back to the community. All jails and prisons shall ensure that all detected TB patients are promptly diagnosed and treated, either by the jail/prison health unit/facility or referred to a nearby DOTS facility.

8. Management of TB cases shall follow the standard treatment regimens in accordance with the Manual of Procedures for the NTP.

9. The Department of Health, in coordination with BJMP, PNP, BuCor, NBI and LGUs, shall ensure supply of TB drugs and other logistical requirements. HESIcT

10. Infection Control measures shall be implemented in all jails/prisons to reduce the transmission of TB.

11. All implementing units shall maintain standard NTP records and submit the necessary reports through channels.

VI. Implementing Guidelines

A. Case Finding

1. Upon entry, all inmates shall be subjected to entry screening by a trained personnel. Screening shall be done by symptomatology and Chest X-ray.

2. During detention, identification of presumptive TB shall be carried out through:

i. TB symptom surveillance by trained health aide

ii. Screening when an inmate consults the health staff

iii. Evaluation of contacts of diagnosed TB cases

iv. Annual mass screening using symptomatology and Chest X-ray of entire inmate population and staff, with priority to jails/prisons with high congestion rate (>300%).

3. Prior to transfer or release, all inmates shall be subjected to exit screening by the trained health staff. Patients who are identified as presumptive TB or on TB treatment shall be referred accordingly.

4. All presumptive TB shall undergo direct sputum smear microscopy (DSSM).

i. Two sputum specimens shall be collected from the patient (spot specimen and early morning specimen).

ii. Results of DSSM shall be made available to the patient within 5 working days from the time of screening.

5. Presumptive extrapulmonary TB cases shall be referred to hospitals for appropriate diagnostic examinations.

6. TB microscopy laboratories jails and prisons shall participate in the External Quality Assessment (EQA) being administered by the Provincial/City Health Office.

7. Presumptive TB who have smear negative results shall undergo Xpert MTB/RIF.

8. In the absence of bacteriological confirmation (whether DSSM or Xpert MTB/RIF), a DOTS trained physician shall evaluate the patient and decide on diagnosis based on his best clinical judgment.

9. Inmates who are presumptive DR-TB shall undergo or be referred for Xpert MTB/RIF. These include the following:

i. Previously treated TB cases (i.e., presumptive DRTB)

ii. Non-converter of Category 1 or Category 2 (at 3rd month follow-up)

iii. PLHIV with TB symptoms

iv. Inmates with TB symptoms who are close contacts of diagnosed DRTB case

10. Jails/Prisons that refer for DSSM or Xpert MTB/RIF shall establish a system for collection and transport of specimens to the laboratory.

11. All patients found to have Rifampicin resistant TB (RRTB) shall be started on second line anti-TB drugs or referred to a PMDT Treatment Facility if such services are not available in the jail/prison facility.

B. Case Holding (Treatment)

1. Directly Observed Treatment (DOT) shall be performed every time treatment is administered during the entire course of treatment. A patient-centered approach in determining when and how to do DOT shall be ensured.

2. All inmates diagnosed with TB that can be treated with first line anti-TB drugs shall start treatment within 24 hours. Likewise, DRTB treatment shall start within 7 days of diagnosis. 

3. All patients identified to be undergoing TB treatment at entry shall be evaluated by the trained health staff. The treatment shall be continued, modified, restarted or discontinued based on best clinical judgment of a DOTS-trained physician and on assessment of patient's previous compliance. All efforts shall be exerted to inform the referring facility that the patient has continued treatment in the jail. caITAC

4. All retreatment TB cases shall be referred for DR-TB screening prior to initiating treatment. In areas with no access to PMDT services or an Xpert MTB/RIF, Category 2 shall be initiated.

5. Food supplementation, or the provision of additional caloric intake for inmates with TB above their usual daily intake, shall be given to inmates diagnosed with tuberculosis.

6. Response to treatment shall be monitored clinically and through sputum follow-up examination in accordance with the prescribed NTP schedule.

7. Monitoring and management of adverse drug reactions (ADRs) shall be the responsibility of the DOTS team. All ADRs shall be reported to the next higher level.

8. All TB patients in jails/prisons shall be offered Provider-Initiated HIV Counseling and Testing (PICT) in accordance with RA 8504 (AIDS Law).

9. All TB patients diagnosed with HIV co-infection shall be referred to HIV treatment hubs/satellite treatment hubs and shall be managed according to guidelines of the National AIDS STI Prevention and Control Program (NASPCP) of DOH.

10. Inmates who are undergoing treatment at the time of release or transfer shall be referred to another DOTS facility for continuation of treatment using the proper referral forms and documents.

C. Infection Control

1. Managerial activities for infection control shall be conducted in all jails/prisons, including:

i. Designation of an Infection Control point person

ii. Risk assessment for each jails and prisons

iii. Development of an infection control plan based on risk

2. Work practice and administrative control shall be instituted in all jails/prisons as the primary infection control measure. This may include, but are not limited to:

i. Isolate bacteriologically confirmed TB cases in a designated holding area until they are no longer infectious (i.e., smear negative). DSSM may be done after 1 month of treatment to determine infectiousness.

ii. Designated jails may be developed as special treatment facilities for TB or DRTB treatment to prevent exposure of other inmates and to ensure quality TB care. A holistic and multidisciplinary approach should be done taking into consideration administrative, logistical, social and judicial implications.

iii. Face masks shall be worn by inmates in the following situations:

• For bacteriologically confirmed PTB cases, while still infectious or persistently coughing

• For clinically diagnosed PTB who are persistently coughing

• For presumptive TB while awaiting diagnosis

• During transfer or court hearings of TB patients who are deemed still infectious

iv. All TB patients shall be educated on cough etiquette.

v. Visitors of TB patients shall be advised on precautionary measures to prevent TB transmission.

vi. Hazardous waste (e.g., sputum cups, N95 masks and face masks) shall be segregated from domestic waste and disposed according to government regulations.

vii. For early detection and treatment, annual medical examination and chest x-ray shall be done for all personnel of the jail/prison. All jail/prison staff who develop TB symptoms anytime shall be screened based on the case finding policies.

3. Environmental control measures shall likewise be implemented and may include the following: ICHDca

i. Ensuring adequate ventilation

ii. Directional airflow

iii. Use of UV irradiation and Hepa filters

iv. Exhaust fan, blowing potentially contaminated air to the outside, where resources permit

4. Personal Protective Equipment. Respirators that meet international standards (e.g., N95) shall be used by health workers in high risk areas. Proper fit testing shall be done every year in coordination with the DOH regional office.

D. Health Education

1. Health promotion and education activities shall be conducted to include inmates, their visitors and family, and jail/prison staff. The head of the jail/prison (i.e., warden or superintendent) shall ensure that all staff are oriented on the TB program.

2. A jail/prison staff shall be designated as health education and promotion officer to lead the activities on health education and promotion.

3. Information, education, communication (IEC) materials for TB shall be developed by the detention authorities (BJMP, BuCor, PNP, LGU) in consultation with DOH and disseminated for use in jails and prisons.

E. Recording and Reporting

1. Jails/Prisons implementing DOTS shall maintain the prescribed NTP recording forms as stipulated in the NTP Manual of Procedures, as applicable depending on services available in the facility.

2. Jails/Prison who register their TB patients in the RHU shall maintain their own list of TB patients for monitoring purposes using the TB register as template.

3. If the jail/prison facility is a DOTS reporting unit, quarterly NTP reports, as stipulated in the NTP Manual of Procedures, shall be submitted to the NTP, DOH through channels.

4. All jails/prisons shall be encouraged to submit their regular institutional reports to the BJMP/BuCor/LGU to document their agency's contribution to the program.

5. Jails/Prisons shall utilize the integrated TB Information System (iTIS).

F. Monitoring, Supervision and Evaluation

1. The institutional TB program coordinators (BJMP, PNP, LGU, BuCor, NBI) shall be the technical supervisors in the implementation of the TB control program in jails/prisons. They shall lead the conduct of MSE in jails/prisons in coordination with the NTP Coordinators at the national, regional and provincial/city levels.

2. The DOTS team of the respective jail/prison shall regularly analyze data from quarterly reports before submission to the next higher level.

3. Quarterly monitoring visits to jails/prisons shall be conducted. Areas to be visited will depend on need and objectives of the visit.

4. Program implementation review and planning shall be done at least once a year in coordination with the DOH-RO.

5. Standard monitoring tools shall be used and standard indicators shall be measured and analyzed in monitoring and evaluating program implementation. The core NTP indicators to be monitored in jails/prisons include:

i. Case notification rate (TB, all forms)

ii. Percentage of TB cases, all forms, diagnosed at entry, during cough surveillance, by self-referral and upon exit/release

iii. Notification rate of MDRTB

iv. Percentage of MDR-TB cases enrolled

v. Treatment outcomes of TB, all forms (Cured, Treatment completed, lost-to follow-up, death, not evaluated)

vi. Cure rate (new bacteriologically confirmed TB)

vii. Interim outcome of MDR-TB

viii. Final treatment outcome of MDRTB (Cured, Treatment completed, lost-to follow-up, death, not evaluated)

ix. Percentage of TB cases counseled and tested for HIV

x. Number of TB patients who tests positive for HIV

xi. Percentage of TB-HIV given ART/CPT

6. Depending on the needs of the specific institutions (BJMP, PNP, LGU, BuCor, NBI), additional indicators shall be monitored and analyzed. TCAScE

G. Logistics Management

1. The development and dissemination of policies and guidelines for management of TB drugs and diagnostic supplies shall be the responsibility of the DOH-NTP. Jails and prisons shall ensure that these policies and guidelines are implemented properly at their level.

2. Jails/prisons shall coordinate with their respective DOH-RO/local government units for anti-TB drug supply as well as other NTP commodities (laboratory supplies and recording/reporting forms).

3. Jails/prisons shall submit to the LGU a quarterly report on drug and supply inventory and request.

4. Jails/prisons, in coordination with the respective LGUs or ROs, shall maintain buffer stocks of anti-TB drugs equivalent to 1 quarter's number of cases. If there are only few TB cases, link with the LGU or nearby jail/prison shall be clearly established to immediately secure drugs for timely treatment.

5. The DOTS team in each jail/prison shall be responsible for adequate and appropriate storage of TB drugs and supplies as well as ensuring good inventory control and record keeping.

H. Capacity-Building/Training

1. All jail/prison health staff shall be trained in TB control, including TB diagnosis, treatment and program management. This may include but not limited to:

i. DOTS Provider's Training for Jails and Prisons

ii. Direct Sputum Smear Microscopy (DSSM) training

iii. Training for informal laboratory workers (smearing)

iv. Programmatic Management of Drug-resistant TB (PMDT) training

v. Infection Control

vi. Provider-initiated HIV Counseling and Testing (PICT)

2. The institutional TB program coordinators (BJMP, PNP, BuCor, PNP, LGU) shall conduct and update a training needs assessment for their staff in the jails/prisons.

3. Training of jail/prison health staff shall be spearheaded by the detention authorities (BJMP, PNP, BuCor, NBI, LGU) in coordination with the DOH-RO.

VII. Roles and Responsibilities

A. The Department of Health shall:

1. Develop and disseminate plans, policies and guidelines for TB control in jails/prisons.

2. Provide technical assistance to BJMP/PNP/BuCor/LGUs in the implementation of TB control program.

3. Conduct capacity-building activities for TB in jails/prisons.

4. Harmonize technical and financial support from DOH and partners to jails/prisons.

5. Ensure availability of drugs, laboratory supplies and NTP recording/reporting forms.

6. Advocate to the respective BJMP regional offices/prisons/LGU to allocate funds and budget for the implementation of the TB control program in jails/prisons.

7. Collect, analyze and disseminate information on TB control in prisons and jails.

8. Conduct joint monitoring, supervision and evaluation on the implementation of the program with local and international experts. 

B. The Detention Authorities (BJMP, PNP, BuCor, NBI, LGU) shall:

1. Oversee the implementation of TB control program in jails/prisons.

2. Develop, disseminate and implement institutional guidelines for TB control in accordance with DOH policies.

3. Designate DOTS team in every jail/prison.

4. Provide technical support to jails/prisons in implementing TB control program.

5. Allocate the necessary resources as counterpart support (e.g., surgical masks, transportation expenses, etc.) for the operationalization/implementation of the program.

6. Coordinate with the LGU, through the Provincial/City Health Office with regards to all TB program activities.

7. Prepare, analyze and submit necessary reports, data and information thru channels.

8. Conduct monitoring and evaluation activities.

9. Allow DOH and partners access to health-related records for monitoring purposes.

C. The Jails and Prisons shall:

1. Implement this operational guidelines.

2. Organize DOTS team that will develop a written jail/prison specific work plans for TB.

3. Ensure the provision of diagnostic, treatment, counseling and referral services on TB in coordination with PHO/CHO, DOTS facilities and laboratory facilities.

4. Manage the logistics (e.g., drugs, laboratory supplies and reagents, recording and reporting forms, IEC materials) provided by DOH.

5. Allow DOH and partners access to the facility and other health-related records.

6. Provide additional support for NTP supplies and equipment when needed.

7. Prepare, analyze and submit necessary reports, data and information thru channels.

8. Coordinate with the concerned local government unit and other providers in the TB DOTS referral network.

9. Participate in monitoring, program reviews and planning activities.

D. The Local Government Unit, thru the Provincial/City Health Office shall:

1. Serve as technical assistance providers for the implementation of the TB in jails/prisons program.

2. Provide access to EQA for microscopy centers, Xpert/MTB-RIF, Chest X-ray and other hospital services for jails/prisons.

3. Distribute drugs, laboratory supplies, recording and reporting forms to jails/prisons.

4. Supervise and monitor the implementation of these guidelines.

5. Collate and submit reports thru channels as per NTP schedule.

E. The DOTS Facility shall:

l. Provide sputum microscopy services to referring Jails/Prisons.

2. Register TB cases from jails/prisons, as necessary.

3. Maintain records and submit reports on inmates with TB.

4. Provide drugs, laboratory supplies and recording/reporting forms to jails/prisons.

VIII. Repealing Clause

This Order hereby amends AO 2009-0003, "Technical Guidelines for Implementing DOTS Strategy in Jails and Prisons". Any other issuances with provisions that are inconsistent with the provision in this Order are hereby amended, modified, repealed or revoked accordingly.

IX. Effectivity

This Order shall take effect immediately.

(SGD.) JANETTE LORETO GARIN, MD, MBA-HSecretary