Exercise C: Written Exercise

Giving supervised treatment

Individual work on written exercise

The purpose of this exercise is to document supervised treatment in the Category IV Treatment Cards of patients receiving MDR-TB treatment. In this exercise you will practice recording treatment on a Category IV Treatment Card for Mr. Ambrosio Amador. Fold out the Category IV Treatment Card for Mr. Amador provided to you.

1.

2. Write your three letter initials on the days that you supervised treatment. Write your three letter initials: __ __ __ Use the information provided below to update the patient’s Category IV Treatment Card.

For Treatment Site staff

a. b.

Update Mr Amador’s Category IV Treatment Card using the information provided in boxes.

Update page 3 of his treatment card starting on the date of patient endorsement to your facility.

Assume that you are a staff of Jasmine Health Center providing supervised treatment to the patient.

For Treatment Center staff

Update Mr. Amador’s Category IV Treatment Card, pages 1-4, using all the information below.

Ambrosio submitted baseline specimens on May 14 and 15, 2008. The DSSM results were 1+ and 2+. Baseline CXR done on May 14, 2008 showed progression of the bilateral infiltrates and increase in the right upper lung cavity.

Ambrosio began his treatment on Monday, May 19, 2008. He came and received directly observed treatment on the following days: May 19, 20, 21, 22, 23, 24.

Ambrosio complained about dizziness for a week which seemed manageable and he continued with his treatment. May 25 was Sunday. He received directly observed treatment on May 26, 27, 28, 29, 30, 31. June 1 was Sunday. He received directly observed treatment on June 2, 2008. He did not come on June 3, 4, and 5. The TC staff found out from his cousin through phone call that he had transferred to the house of another relative, also in Manila because of a family conflict. The TC staff coordinated with the nearest DOTS facility, Jasmine Health Center for default follow-up. Early in the morning on June 6, the Jasmine Health Center worker visited the patient’s home and found that Ambrosio had been sick and complaining of severe nausea and dizziness. The health worker was able to convince Ambrosio to report at the Treatment Center that same day.

On June 6, because of his severe symptoms, the TC physician gave ancillary medicines and revised the regimen, replaced prothionamide with PASER 4 grams/sachet, 2 sachets per day, with a plan to present it to the Consilium. Ambrosio received supervised treatment, took PASER instead of prothionamide along with the other drugs. The TC physician emphasized to Ambrosio the importance of not missing treatment and Ambrosio promised to continue taking his drugs. He also expressed willingness to be decentralized to Jasmine Health Center. * For Treatment Site staff, update page 2 of the Category IV Treatment Card.

Ambrosio received directly observed treatment on June 7, 9, 10, 11, 12, 13, and 14. June 8 was Sunday.

On June 11, the Consilium approved the change in regimen made by the TC physician. He will no longer be taking prothionamide and instead be given PASER continuously. * For Treatment Site staff, update page 1 of the Category IV Treatment Card.

June 15 was Sunday. Ambrosio received directly observed treatment on June 16, 17, 18, 19, 20, 21. His weight was 51 kg. June 22 was Sunday. He received supervised treatment on June 23, 24, 25, 26, 27.

On June 25, 2008 the facility received the first sputum follow-up DSSM results. The specimen was collected on June 18, 2008 and the result was negative.

After taking his drugs on June 28, he told the TC nurse that he plans on a trip to visit her mother for 4 days. The TC nurse explained to him the possible consequences of interrupted treatment and that he will not be given any medicines for self-administration. Ambrosio went ahead with his plan to visit his mother in the province. He returned to the TC and received supervised treatment on July 4 and 5.

July 6 was Sunday. Ambrosio received treatment on July 7, 8, 9, 10, 11, 12. July 13 was Sunday. He received directly observed treatment on July 14, 15, 16, 17, 18, 19. His weight was 52.8 kg.

July 20 was Sunday. He received supervised treatment on July 21, 22, 23, 24, 25, 26.

The facility received the smear results for the July sputum follow-up. Sputum specimen was collected on July 19 and the result was negative.

July 27 was Sunday. From July 28 to September 27, 2008, the patient was adherent to supervised treatment at the Treatment Center.

The baseline culture result, released in August, turned out positive for M. TB. His DSSM results for August 19 and September 19 were all negative. The culture result for the specimen collected in June came out in September and was positive for TB. The culture result for the specimen collected in July came out in September and was negative.

His weight, taken on August 19, and September 19 were 54.2 kg and 55 kg, respectively. September 28, 2008 was Sunday.

Patient Decentralization. Refer to Module E: Ensure Continuation of MDR-TB Treatment.

**By this time, Ambrosio already has one negative culture and 4 negative monthly smears. He was eligible for decentralization to a Treatment Site after having at least one negative culture and 3 negative smears. The staff from Jasmine Health Center underwent training and after proper coordination, Ambrosio was endorsed to the staff of Jasmine Health Center, a Treatment Site, on September 29, 2008, Monday. He received treatment for the first time at the Treatment Site on September 29. The Treatment Site nurse will supervise the barangay health worker in providing supervised treatment to Ambrosio. He agreed to come to the DOTreatment Site facility from Mondays to Fridays and report weekly, every Saturday, for supervised treatment at the Treatment Center. He took drugs on September 30 to October 3 at the Treatment Site.

He received supervised treatment at the Treatment Center on October 4. October 5 was Sunday. He received treatment on October 6 to 10, 2008 at the Treatment Site. He received supervised treatment at the Treatment Center on October 11. October 12 was Sunday. He received directly observed treatment on October 13 to 17 at the Treatment Site. He received treatment at the Treatment Center on October 18 and submitted a sputum specimen. His weight was 55.3 kg.

October 19 was Sunday. He received directly observed treatment on October 20 at the Treatment Site. By a phone call, the Treatment Site nurse informed the Treatment Center staff that Ambrosio did not come for treatment at the Treatment Site on October 21 and 22. He came back the following day. He claimed that he originally planned to just stay overnight to attend the funeral of his close friend in a nearby province but floods and mud slides caused by heavy monsoon rains made transportation difficult.

He received treatment on October 23 and 24 at the Treatment Site.

The DSSM result for the specimen collected on October 18 was negative. His culture result for the specimen collected on August 19 was negative.

He received supervised treatment at the Treatment Center on October 25.

October 26 was Sunday. He received supervised treatment on October 27, 28, 29, 30, 31, 2008 at the Treatment Site. He received supervised treatment at the Treatment Center on November 1, 2008. November 2 was Sunday. He received treatment on November 3, 4, 5, 6, 7 at the Treatment Site.

On November 8, after taking his drugs, he told the Treatment Center staff he wanted to attend his brother’s birthday celebration in Cebu on November 14 and 15. The Treatment Center staff reiterated to Ambrosio the need to adhere to treatment and the possibility of relapse. He received supervised treatment at the Treatment Site on November 10, 11, 12, 13, and 14. On November 15, 2008, the patient came to the Treatment Center and received supervised treatment.

When you have finished this exercise, review your answers with a facilitator.

Discussion after Exercise C

Write your answers to the questions below. When everyone is ready, there will be a group discussion of these questions.

1. A health worker was very busy and a line of people were waiting. The health worker recognized an MDR-TB patient, Mary Galang, and did not want to keep her waiting long. She signaled to Mary to come ahead of the queue and handed her the day’s tablets. She told Mary to take the tablets home and swallow them when she found something to drink.

What could happen to the tablets? (List 5 different possibilities)

2. What should the health worker have done when handing the tablets to Mary?

3. If an MDR-TB patient does not take the anti-TB drugs correctly or on schedule over a period of time, what might be the consequences?

Then read until the nex t exercise.