TECHNICAL GUIDELINES FOR IMPLEMENTING DOTS STRATEGY IN JAILS AND PRISONS
In 2008, it was estimated that of the total of about 130,000 prison
inmates in the country, 28% or 36,000 had symptoms of TB. In a study of
7,282 inmates in five (5) jails and one (1) prison in Davao Region[1],
the prevalence of sputum smear positive among inmates was 8.7/1,000
compared to the 2/1,000 for the general population based on the result
of the 2007 National TB Prevalence Survey[2]. Globally, the estimated number of people detained on any given day is over 9 million[3] and the prevalence rate of TB in prisons usually exceeds that of the civilian population[4].
The increased vulnerability of this group to TB can be attributed to
several factors: (1) overcrowding and lack of ventilation in many
jails/prison facilities, (2) late case detection secondary to lack of
access to health services and stigma, (3) lack of health human resource
and trained staff servicing inmates and (4) presence of other risk
factors such as malnutrition and co-morbidities.
Considering that more than half of the inmate population are
detainees awaiting case resolution and that a large majority of them
shall be re-integrated with the society at large, the Department of
Health (DOH) intends to implement Directly Observed Treatment
Short-Course (DOTS) Strategy to this captive population in order to
reduce TB transmission, morbidity and mortality within jails and prisons
and to render inmates non-infectious by the time they are released to
mainstream society.
The controlled, supervised situation of the inmates in jails and
prisons, on the other hand, is also expected to yield success rates and
cure rates that are higher than those for the civilian population. Thus,
implementing DOTS Strategy in jails and prisons has the potential of
significantly expediting the achievement of national and Millennium
Development Goal (MDG) target related to TB control.
II. OBJECTIVES
These guidelines aim to strengthen the implementation of the
Comprehensive and Unified Policy (CUP) for TB Control in the Philippines
(Executive Order 187 s. 2003), by providing minimum standard guidelines
for integrating (DOTS) Strategy within jails/prisons. These guidelines
shall become the basis for the development of specific operational
guidelines by the Bureau of Corrections (BuCor) and Bureau of Jail
Management and Penology (BJMP) in collaboration with concerned Local
Government Units (LGUs).
III. SCOPE/COVERAGE
The guidelines are to be used by jail and prison authorities who can comply with minimum DOTS Service requirements of the DOH.
The implementation shall initially cover four (4) city jails, one (1)
district jail and one (1) prison namely: Manila, Cebu, Davao and
Antipolo City Jails, Metro Manila District Jail and New Bilibid Prison.
Expansion shall be done in phases.
IV. DEFINITION OF TERMS
a. Casefinding – an activity to discover or find TB cases.
b. Caseholding – an activity to treat TB cases through proper treatment regimen and health education.
c. Detainee – a person accused before a court or competent
authority and is temporarily confined in a jail while undergoing or
awaiting investigation, trial, or final judgment[5].d. DOTS Referring Jails/Prisons – jails/prison providing Directly
Observed Treatment (DOT) except sputum microscopy which is linked
outside.e. DOTS Service Providing Jails/Prisons – jails/prisons providing DOTS services including sputum microscopy.
f. Droplet nuclei – microscopic particles which are estimated at
1-5 microns in diameter and are produced when a person coughs, sneezes,
shouts or sings. Such particles may contain the M. tuberculosis bacilli and remain suspended in the air for hours[6].g. Direct Sputum Smear Microscopy (DSSM) – is the primary
diagnostic tool in NTP case finding. It serves as basis for categorizing
TB symptomatics according to standard case definition, used to monitor
progress of patients with sputum smear positive TB while they are
receiving anti-TB treatment and confirm cure at the end of treatment.h. Environmental Control Measures – these are measures that can be
used in jails/prisons to reduce the concentration of droplet nuclei in
the air (e.g., maximizing natural ventilation or controlling the
direction of airflow)[6].i. Health Promotion – a process of enabling people to take action to improve health.
j. Infection Control – specific measures and work practices that reduce the likelihood of transmitting M. tuberculosis [6].
k. Inmates – is a generic term used to refer to a prisoner or a detainee[5].
l. Jail – a place for confinement for city and municipal prisoners,
any fugitive from justice, detainee awaiting trial or under
investigation or transfer to a National Penitentiary/Mental Institution[5]. It caters to detainees and inmates serving up to 3 years of imprisonment. Jails are managed by the BJMP and/or LGUs.m. Prison – refers to a penal establishment under the control of the BuCor[7]. It caters to prisoner serving more than 3 years.
n. Prisoner – an inmate who is convicted by final judgement[5].
o. TB Symptomatic – any person with cough for two (2) weeks or more
with or without the following symptoms: fever; chest and/or back pains
not referable to any musculo-skeletal disorders; hemoptysis or
recurrent blood-streaked sputum; significant weight loss; and other
symptoms such as sweating, fatigue body malaise, shortness of breath.p. Work Practice and Administrative Control Measures – managerial
or administrative measures which guide work practices to reduce
significantly the risk of TB transmission by preventing the generation
of droplet nuclei. These include early diagnosis, prompt isolation or
separation of infectious TB patients and prompt initiation of
appropriate anti-TB treatment[6].
V. GUIDING PRINCIPLES
a. TB cannot be managed effectively in a country if the TB reservoir in jails/prisons is not dealt with correctly[4].
b. Jails/prisons are reservoirs of TB infection that receive TB
disease; concentrate the disease; make it worse by not providing
adequate case finding and treatment; create resistance through erratic
or non-supervised treatment; disseminate it amongst inmates and export
TB through visits and other contacts such as jail/prison staff[4].c. A comprehensive package of medical and administrative interventions is necessary to control TB in prisons[8].
d. TB control in jails/prisons must be incorporated into the
existing programmatic TB control strategies thru the NTP, with DOTS
Strategy as the overarching framework[8].e. Inmates have the right to the same standard of health care as
the people in the general community (principle of equity of care)[8].f. Inmates have the right to avail of medical, dental and other health services[5].
g. The inherent worth, dignity, health and safety of inmates must be respected at all times[5].
h. The community is a partner in the developmental processes of inmates[5].
i. A diagnosis of TB or incomplete TB treatment must never be used
to delay trial, release or amnesty. It should not also bring any extra
advantage to the patient compared to other inmates[4].
VI. GENERAL GUIDELINES
A. Administrative
a. The DOTS Strategy shall be integrated within the jails/prisons
health services and these services shall be decentralized in accordance
to their respective system whenever possible (Annex A)[*].b. Engagement and partnership of the DOH-NTP with national
authorities in charge of jails/prisons in the country shall be
formalized thru the signing of a Memorandum of Understanding (MOU) at
the national level. The MOU shall then be adopted at the local level
prior to the implementation of the program.c. Operational Guidelines for BuCor prisons and BJMP jails shall be developed and disseminated.
d. Jails and prisons shall upgrade their facilities in order to be
classified as a DOTS Referring Unit or DOTS Service Providing Units.e. A point person from the BJMP and BuCor shall be designated to
ensure effective implementation of this program from the national down
to the jail/prison level. The point person shall initiate the
organization of DOTS Team for each jail/prison.f. The Jail/Prison DOTS Team shall be responsible for the following:
– develop written work plans. The plan shall cover:
a. routine NTP activities and procedures
b. infection control
c. health promotion
d. comprehensive discharge/release plan that will ensure continuity of care
e. reporting of treatment outcome of transferred or released inmates.– Manage and implement the program in coordination with the LGUs and CHDs.
g. The basic composition of the DOTS team are:
– health staff that will manage and oversee the implementation
– treatment partner
– specimen transporter (for DOTS Referring Units)
– sputum collectorh. Training courses or program shall be provided by DOH to jail/prison staff and DOTS team that are specific to their task.
B. Management of TB patients in Jails/Prisons
1. Casefinding and caseholding shall be systematically implemented
in respective jails and prisons during the routine procedures that
inmates undergo:– upon entry (or commitment/admission)
– during incarceration (or confinement)
– prior to transfer of inmates to another jail or prison
– prior to release of inmates back to the community2. General Guidelines on Casefinding:
a. DSSM shall be the primary diagnostic tool in casefinding.
b. Casefinding shall prioritize the early diagnosis of inmates
with infectious TB (i.e pulmonary smear-positive) and treat them until
cure.c. The main strategies for casefinding are through:
– screening for signs and symptoms of TB
– surveillanced. A screening form shall be used to identify the following:
– TB symptomatic inmates (upon entry and before release or transfer)
– detainees with history of anti-TB treatment and those undergoing treatment for TB (upon entry)e. All TB symptomatics identified shall undergo DSSM for
diagnosis before start of treatment, regardless of whether or not they
have available X-ray result or whether or not they are suspected of
having extra-pulmonary TB. The only contraindication for sputum
collection is hemoptysis; in which case, DSSM will be requested after
control of hemoptysis.f. All sputum collection shall be supervised by the Sputum
Collector. Collection, storage and transport shall follow the NTP
guidelines.g. A cough surveillance shall be put in place to ensure early identification of incarcerated inmates who are TB symptomatics.
h. All sputum collection shall be supervised by the Sputum
Collector. A proper area for sputum collection shall be designated in
well ventilated area outside the cell and away from other people. Sputum
collection, storage and transport shall follow the NTP guidelines.i. For DOTS Referring Units where DSSM is not available, DSSM
shall be done in a designated microscopy center near the jail/prison.
Proper coordination with the LGUs managing the microscopy centers shall
be done by the Center for Health Development (CHD)-NTP Coordinators in
collaboration with the Department of the Interior and Local Government
(DILG). The arrangement shall be stipulated in the MOU.j. Results of DSSM must be available within 5 working days.
k. TB symptomatic shall be asked to undergo other diagnostic
tests (X-ray and/ or culture), if necessary, only after they have
undergone DSSM for diagnosis with three sputum specimens yielding
negative results.l. The TBDC will evaluate the results of the chest X-ray,
together with the clinical history and findings, and will recommend
whether or not the case will be started on treatment.3. General Guidelines on Case holding:
a. All inmates diagnosed as sputum smear positive shall start treatment within 24 hours.
b. Management of smear negative patients shall follow NTP protocol.
c. After screening, admitted/committed inmates (after arrest or
transfer) who are on TB treatment shall be ensured for continuation of
treatment. The DOTS Facility where the inmate was registered shall be
notified by jail/prison staff or DOTS team within two (2) days.d. Short-course regimens following the NTP guidelines shall be
the mode of treatment for the different classifications and types of
TB.e. Directly Observed Treatment (DOT) shall be performed every
time treatment is administered during the entire course of treatment.
DOT is non-negotiable.f. Only trained jail/prison staff shall act as treatment partner.
g. Monitoring response to treatment thru sputum follow-up shall follow the NTP schedule.
h. Management of possible adverse drug reactions shall be the responsibility of the DOTS team.
4. Transfer and Release of Inmates
a. Transfer of inmates undergoing treatment shall be coordinated
and properly endorsed by the DOTS Team to the receiving jail/prison. To
ensure continuation of treatment, remaining drugs shall also be
endorsed to the receiving jail/prison.A properly filled out referral
form shall be used.b. Whenever possible, transfer should be delayed:
– while inmate is still infectious
– until inmate is cured if the destination does not have services for continuation of treatmentc. Release of inmates who are on treatment shall also be
coordinated by the point person and properly endorsed to the receiving
DOTS Facility for continuation of treatment. A properly filled out
referral form shall be used. Inmates shall be given drugs good for at
least 10 days to allow time to locate the receiving DOTS Facility.d. Released or transferred patients shall be recorded as “transfer out” in the TB register and “trans-in” in the receiving DOTS Facility
5. Infection Control
a. Infection control measures shall be adopted in two (2) main ways[6]:
1. Work practice and administrative control measures which shall include:
– Written infection control plan
– Administrative support for procedures in the plan, including quality assurance
– Training of staff
– Education of patients and increasing community awareness2. Environmental control measures
b. Separation of smear positive cases until no longer infectious
1. When feasible, a temporary holding area shall be designated for smear positive patients.
2. To prevent overcrowding in the holding area, a repeat DSSM
should be done after 2 weeks to check if the inmate has converted to
smear negative before returning to their designated cells.3. Smear positive patients shall remain in the holding area until the inmate has converted to smear negative.
4. The purpose of separating smear positive is to prevent
transmission of TB to others. It shall be emphasized to the inmate that
the separation is a preventive measure and not as a form of punishment.c. Face Masks
1. Smear positive patients who are in the holding area shall also wear face masks.
2. TB symptomatics and smear negative patients will remain in their assigned cells.
3. TB symptomatics should be considered infectious until a
diagnostic investigation is completed therefore; they should wear mask
until result of the DSSM becomes available. If the DSSM is negative,
inmate shall no longer wear the mask except if persistently coughing.4. Smear positives and TB symptomatics/smear negative inmates
but coughing persistently shall wear face masks at all times while
inside the cell except during routine inmate count. The DOTS team should
inform them of the importance of wearing face masks.d. A proper area for sputum collection shall be designated in a well ventilated area outside the cell.
e. Infection control measures shall be included in the training of DOTS team members and other jail staff.
6. Health Promotion
a. Health promotion activities shall be conducted to include
inmates, their visitors (families and others) and jail/prison staff.b. Aside from providing information on TB, inmates shall be made aware of and understand the importance of the following:
– correct way of collecting sputum
– treatment using DOT and sputum follow-up
– respiratory hygiene/cough etiquette
– how to obtain treatment should immediate transfer or release occur
C. Program Management
1. Recording and Reporting:
a. Recording shall follow the NTP protocol
b. DOTS Service Providing Jails/Prisons shall maintain their own laboratory and TB Register for recording.
c. For DOTS Referring Units, ID cards shall be conferred with the
NTP Register at the City Health Office (CHO) for updating on the 2nd
week of each month.
d. DOTS Service Providing Jails shall maintain their own Laboratory
and NTP Register for recording. Quarterly reports on laboratory,
casefinding and cohort analysis shall be submitted to the Infectious
Disease Office (IDO) of the DOH using NTP schedule through the following
channels:– DOTS Service Providing Jails/Prison -> CHO -> CHDs -> IDO
– New Bilibid Prison (NBP) -> CHD -> NCR -> IDO2. Supervision, Monitoring and Evaluation
a. The LGU staff, CHD-NTP Coordinators and IDO staff shall
supervise the implementation of the program. Together with the
designated national/regional point person from BJMP and BuCor, shall
conduct at least a quarterly joint supervision and monitoring visit.b. The DOTS team shall regularly analyze data from quarterly
reports using standard program indicators and provide feedback of
findings with corresponding recommendations to the staff or authorities
concerned.c. Planning and evaluation shall be done twice a year.
d. There will be three (3) stages in evaluating the program:
– Case finding
– Cohort analysis of results of sputum smear conversion at 2/3 months
– Cohort analysis of results of treatment outcome
VII. IMPLEMENTING MECHANISM
Roles and Responsibilities:
A. Department of Health
1. Initiate partnership with other government agencies, NGOs,
private organizations and international communities involved with
prisons and TB control.
2. Assist partner agencies in developing their respective
operational plan vis-à-vis the CUP for TB Control in the Philippines.
3. Provide technical assistance, support for drugs, laboratory supplies (consumables) and NTP recording/reporting forms.
4. Ensure the implementation by key partners/agencies at the Regional and LGU levels.
5. Conduct joint monitoring, supervision and evaluation on the
implementation of the program with local and international experts.B. Department of Interior and Local Government (DILG)-BJMP
1. Ensure the issuance of a Department Order from the DILG for the adoption of these guidelines.
2. Designate a point person on TB activities in every jail.
3. Allocate the necessary resources as counterpart support (e.g.,
surgical masks, transportation expenses) for the
operationalization/implementation of the program.
4. Ensure continuation of the on-going coordination with the local health facilities of the LGUs.
5. Allow access to relevant health data in support to TB studies within prisons.C. DILG-Bureau of Local Government Development (BLGD)
1. Issue Memorandum Circular enjoining LGUs to pass a resolution
or issue an Executive Order adopting these guidelines through the Local
Health Offices and to include TB Control Program as a priority concern
to be incorporated in their Comprehensive Development Plans (CDP) and
Local Development Investment Programs (LDIP).
2. Coordinate and advocate with the League of Provinces, Cities and
Municipalities for their support relative to the nationwide adoption and
operationalization of these guidelines at the local level.
3. Assist the BJMP in advocating to the LGUs and district jails to provide support to the NT P.
4. Monitor LGU compliance on the adoption of these guidelines and integration of TB Control Program in the CDP/LDIP.D. Department of Justice (DOJ)-BuCor/NBP
1. Ensure the implementation of these guidelines in their operating unit which shall initially be the NBP.
2. Designate a full-time coordinator and staff for the TB control activities.
3. Manage the logistics (e.g., drugs, laboratory supplies and
reagents, recording and reporting forms, IEC materials) provided by DOH
through the Center for Health Development (CHD).
4. Allow DOH and partners to this MOU access to the NBP and health-related records.
5. Provide additional support for NTP supplies and equipment when needed.
6. Prepare, analyze and submit necessary reports, data and information thru channels.E. Philippine Tuberculosis Society, Inc. (PTSI)
1. To provide personnel assistance thru PTSI branches in implementing these guidelines in partnership with the LGUs.
2. To assist in the provision of training to BJMP and BuCor personnel on TB diagnosis treatment and DOTS strategy.
3. To serve as a research body that will conduct a survey to
determine and monitor the magnitude of TB among inmates and to do
operational researches to improve management of TB in jails/prisons.
4. Participate in the joint activities on monitoring, supervision and evaluationF. DOTS Referring Jails/Prisons and DOTS Service Providing Jails/Prisons
1. Implement their operational guidelines.
2. Organize DOTS team that will develop a written jail/prison specific work plans for TB
3. Designate a full-time point person who will be in-charge of the program.
4. Manage the logistics (e.g., drugs, laboratory supplies and
reagents, recording and reporting forms, IEC materials) provided by DOH
through the CHDs.
5. Allow DOH and partners to this MOU 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.G. City Health Office
1. Supervise and monitor the implementation of these guidelines,
provide technical assistance to DOTS Referring and DOTS Service
Providing Jails/ Prisons.
2. Provide sputum microscopy services to DOTS Referring Jails/Prisons.
3. Facilitate referrals to the TB Diagnostic Committee (TBDC).
4. Through the CHDs, provide drugs, recording and reporting forms and sputum caps to DOTS Referring Jails/Prisons.
5. Collate and submit reports thru channels as per NTP schedule.
VIII. REPEALING CLAUSE
Provision s from previous issuances that are inconsistent or contrary
to the provisions of this order are hereby rescinded and modified
accordingly
IX. EFFECTIVITY
This order shall take effect immediately.
Adopted: 8 Jan. 2009
(SGD). FRANCISCO T. DUQUE III, MD, MSc
Secretary of Health
[*] Text Available at Office of the National Administrative Register, U. P. Law Complex, Diliman, Quezon City
[1] TB Control in Prisons in Region XI, Mayor, E. et, al, FETP Scientific Papers vol. 19, No. 2, 2008: NEC-DOH
[2] 2007 Nationwide Tuberculosis Prevalence Survey, Philippines, Tupasi T. et. al
[3] International Centre for Prison Studies, King’s College London, World Prison Population List Seventh Edition http://www.kel.ac.ukdepsta/law/research/icps/downloads/worldprison-pop-seventh.pdf
[4] Guidelines for Control of Tuberculosis in Prison, ICRC-WHO 2008
[5] BJMP Manual, Revised 2007
[6] Tuberculosis
Infection-Control in the Era of Expanding HIV Care and Treatment:
Addendum to WHO Guidelines for the Prevention of Tuberculosis in Health
Care Facilities in Resource-Limited Settings
[7] BuCor Operating Manual
[8] Tuberculosis Control in Prisons: A Manual for Programme Managers, WHO-ICRC 2000