TB PREVENTIVE

TREATMENT (TPT)
Module 10 - TB Preventive Treatment (TPT)

Learning Outcomes

At the end of this module, you should be able to:

1. Identify persons eligible for TB Preventive Treatment

2. Determine which patients should undergo tuberculin
skin test to confirm LTBI prior to TB preventive
treatment
3. Perform the necessary screening to rule out active TB
prior to TB Preventive treatment
4. Prescribe the appropriate regimen for adults and
children
5. Monitor patients during treatment and assign the
treatment outcome
Module 10 - TB Preventive Treatment (TPT)

Definition of Terms

• Contact investigation: systematic process of identifying -

▪ people with previously undiagnosed TB among the
contacts of an index person with TB
▪ the source person with TB if the index person with TB is
a child
▪ candidates for preventive treatment
• Household contact: A person who shared the same enclosed
living space as the index person with TB.
• Close contact: A person who is not in the household but
shared an enclosed space with the index person with TB
during the 3 months before commencement of the current
treatment episode.
• Index case (index patient) of TB: the initially-identified
people with TB of any age in a specific household or other
comparable setting
• Source case: A person with infectious TB (usually
bacteriologically positive pulmonary TB) who transmits
infection to one or more other individuals.
• Latent tuberculosis infection (LTBI): A state of persistent
immune response to stimulation by Mycobacterium
tuberculosis antigens with no evidence of clinical
manifestations of active TB disease.
• TB Preventive treatment (TPT): Treatment offered to
individuals who are at risk of developing active TB disease
to reduce that risk. Also referred to as LTBI treatment or TB
preventive therapy.
Module 10 - TB Preventive Treatment (TPT)

Why is Preventive Treatment important?

New tools:
including
treatment of
latent
infection
 Module 10 - TB Preventive Treatment (TPT)

Risks and Benefits of LTBI

ADR to LTBI
Treatment
Prevent
Develop DR progression
(undetected to active TB
active TB)

Increased risk if:

> Individuals with medical conditions Benefits increased in:
that predispose to drug reactions > Individuals with high risk of
> Active TB not ruled out Progression to active TB
> Individuals with positive test
For LTBI
Module 10 - TB Preventive Treatment (TPT)

Policies

1. TB contacts (1,2), PLHIV (3) and TB risk groups(4) should

be evaluated for eligibility to receive TB preventive
treatment.

TB TB Risk
PLHIV
Contacts Groups

2. Tuberculin skin test (TST) or interferon-gamma release

assays (IGRA) shall not be required prior to initiation of
TPT preventive treatment in the following eligible
individuals:

▪ People living with HIV

▪ Children less than 5 years old, HH contacts of BCTB
▪ Individuals aged 5 years and older, HH contacts of BCTB, with
other TB risk factors

3. TST (or IGRA) shall be performed in other individuals prior

to TPT (5-TU or 2-TU).

▪ Children <5 yo, HH contact of CDTB

▪ Individuals aged 5 years and older, HH
contacts of BCTB, with NO OTHER TB risk
factors
▪ Close contacts of BCTB
▪ Other risk groups
Module 10 - TB Preventive Treatment (TPT)

Risk of active TB: (+) TST/IGRA Vs. TST/IGRA not done

4. Active TB shall be excluded by symptom and/or CXR

screening prior to initiation of TPT.

5. TPT shall not be given to contacts of RR/MDR-TB

6. All health care providers shall ensure completion of

treatment.
Module 10 - TB Preventive Treatment (TPT)

Procedures

A. Identification of individuals eligible for TB preventive

treatment

1. Identify individuals who require further evaluation to

assess eligibility for TPT.

PLHIV HH contacts Close contacts Other risk

groups
> All PLHIV aged ➢ All HH > All close ➢ Patients on
1 yo and above contacts (all contacts (all dialysis
ages) of ages) of BCTB ➢ Patients
BCTB case preparing for
➢ less than 5 yo organ or
HH contacts hematologic
of CDTB transplant
➢ Patients
initiating anti-
TNF treatment
➢ Patients with
silicosis

2. For contacts, check if the index case is RR (rifampicin

resistant) or MDR-TB. TB Preventive Treatment should
not be given to contacts of RR/MDRTB. They need to be
followed up with symptom screening, CXR screening or
Xpert test every 6 months for at least 2 years.

3. Assess presence of TB signs and symptoms. If present,

evaluate appropriately following procedures in screening
and diagnosis. EXCLUDE ACTIVE TB.
B. Excluding active TB prior to initiation of TB Preventive
Treatment

• Ask for TB signs and symptoms

- (+) S/Sx, should be evaluated further for active TB.

▪ (No S/Sx) Perform chest x-ray

- (+)findings suggesting TB, evaluate further for active TB
- less than 5 yo contacts, exception to CXR screening prior
to TPT

▪ What if CxR not accessible?

- Physician may still decide to give TPT but avoid
rifamycin-containing regimen.
Module 10 - TB Preventive Treatment (TPT)

B. Excluding active TB prior to initiation of TB Preventive

Treatment

TPT algorithm in adults and children with HIV ≥ 5 years old

 Module 10 - TB Preventive Treatment (TPT)

B. Excluding active TB prior to initiation of TB Preventive

Treatment

TPT algorithm in children with HIV age 1 – 4 years

B. Excluding Active TB prior to initiation of TB Preventive
Treatment
 Module 10 - TB Preventive Treatment (TPT)

B. Excluding active TB prior to initiation of TB Preventive

Treatment

TPT algorithm in HIV-negative child contacts < 5 years old

B. Excluding Active TB prior to initiation of TB Preventive Treatment

Module 10 - TB Preventive Treatment (TPT)

B. Excluding active TB prior to initiation of TB Preventive

Treatment

TPT algorithm in HIV-negative at-risk individuals > 5 years old

B. Excluding Active TB prior to initiation of TB Preventive
Treatment
Module 10 - TB Preventive Treatment (TPT)

Procedures

4. The following eligible groups do not require TST:

a) PLHIV
b) <5 years old, HH contact of BCTB
c) >=5yo, HH contact of BCTB WITH other TB risk
PROCEDURESfactors
Module 10 - TB Preventive Treatment (TPT)

OTHER RISK FACTORS FOR >=5 YO, HH CONTACTS OF BCTB:

1. PLHIV
2. Diabetics
3. Smokers
4. Those with immunosuppressive medical conditions
5. Malnourished
6. With multiple people with TB in same household

NO NEED to do TST, eligible for TPT (“multiple risks”)

Module 10 - TB Preventive Treatment (TPT)

Procedures

5. Perform TST in the following individuals.

▪ Less than 5 years old, HH contacts, CDTB
▪ 5 years and older, HH contacts, BCTB but with no risk
factor for TB
▪ All ages, Close contacts, BCTB
PROCEDURES
▪ Other risk factors: dialysis, patients preparing for an
organ or hematological transplantation, anti-TNF
treatment, silicosis

(If TST is not available, it is not recommended to

offer TB Preventive Treatment to these individuals)
Module 10 - TB Preventive Treatment (TPT)

Checking Eligibility of Different Risk Groups for TB

Preventive Treatment Using Tst.

TST NOT TST REQUIRED NOT ELIGIBLE

REQUIRED
(Eligible ONLY if positive) For TPT
(Eligible for TPT)

<5yo, BCTB index < 5yo, CDTB index ---

HH contacts >=5yo, BCTB

>=5yo, BCTB index, no >=5 yo, CDTB
index, with TB
TB risk index
risk*
Close All ages, CDTB
--- All ages, BCTB index
contacts index
Age<1 yo

PLHIV Ages >= 1yo --- (if not contact of

a person with
TB)
▪ Patients receiving
dialysis,
▪ Patients preparing
for an organ or
Other Risk hematological
--- ---
Groups transplantation
▪ Patients initiating
anti-TNF treatment
▪ Patients with
silicosis

*TB risk - PLHIV, diabetes, smokers, those with immune-suppressive medical

conditions, malnourished, with multiple people with TB in same household
Module 10 - TB Preventive Treatment (TPT)

Procedures

5. If TST positive or if eligible even without TST, exclude

active TB prior to giving TPT.

6. Explain the rationale for TPT and need for further

evaluation. Evaluate the presence of other risk factors
and pregnancy.

C. Initiation of treatment

1. Inform the patient that he/she is eligible for TPT.

Provide key messages for the person and his/her

families, as necessary:

▪ Rationale for TB preventive treatment

▪ Duration of treatment
▪ The reasons and schedule of regular clinical and
laboratory follow up for treatment monitoring
▪ Potential adverse event
Module 10 - TB Preventive Treatment (TPT)

▪ Tracing mechanism in case of treatment interruption

▪ Availability of free of charge services

▪ Discuss with him/her their social and financial needs

and offer possible sources of social support to
enable adherence to treatment.

DSWD

LGU Patient SSS/GSI

S/ ECC

Others
Module 10 - TB Preventive Treatment (TPT)

C. Initiation of treatment

2. Determine baseline weight.

3. Assign the appropriate TPT regimen.
▪ The currently available regimen under the program is
6 months of Isoniazid (6H)

Once available under the program,

▪ weekly dosing with Isoniazid and Rifapentine for 3
months (3HP) (except for pregnant and <2 yo)
▪ Alternative: 3HR for children
▪ Alternative: 4R for adults.
Module 10 - TB Preventive Treatment (TPT)

C. Initiation of treatment

4. Instruct on proper dosage based on weight

Dosage (in ml)
Rifampicin 200mg/
Body Weight (Kg) Isoniazid 200mg/ 5ml
5ml
(at 10mg/kg)
(at 15mg/kg)
2.1-3 0.75 1.0
3.1-4 1.0 1.5
4.1-5 1.25 2.0
5.1-6 1.5 2.25
6.1-7 1.75 2.5
7.1-8 2.0 3.0
8.1-9 2.25 3.5
9.1-10 2.5 3.75
10.1-11 2.75 4.0
11.1-12 3.0 4.5
12.1-13 3.25 5.0
13.1-14 3.5 5.25
14.1-15 3.75 5.5
15.1-16 4.0 6.0
16.1-17 4.25 6.5
17.1-18 4.5 6.75
18.1-19 4.75 7.0
19.1-20 5.0 7.5
20.1-21 5.25 8.0
21.1-22 5.5 8.25
22.1-23 5.75 8.5
23.1-24 6.0 9.0
24.1-25 6.25 9.5
25.1-26 6.5 9.75
26.1-27 6.75 10.0
27.1-28 7.0 10.5
28.1-29 7.25 11.0
29.1-30 7.5 11.25
Module 10 - TB Preventive Treatment (TPT)

Table 29. Dosing for 6H, 3HR, and 4R in adults.

Drug Dosing in Adults

5 mg/kg (range: 4-6 mg/kg)
Isoniazid (H)
Not to exceed 300mg daily
10 mg/kg (range: 8-12mg/kg)
Rifampicin (R)
Not to exceed 600mg daily

Table 30. Dosing for 3-month weekly rifapentine and

isoniazid in adults and children
Age >= 2 yo 2-11 yo >=12yo
Isoniazid Isoniazid
Body Weight Rifapentine 200mg/5ml 200mg/5ml
(in Kgs) 100mg/tab
(at 25mg/kg) (at 15mg/kg)
No. of tablets in ml in ml
10-12 2 tabs 7 ml --
12.1-14 2 8.5 --
14.1-16 3 10.0 --
16.1-18 3 11.0 --
18.1-20 3 12.0 --
20.1-22 3 13.0 --
22.1-24 3 14.5 --
24.1-25 3 15.0 --
25.1-27 4 16.0 10.0 ml
27.1-30 4 18.0 11.0
30.1-32 4 19.0 12.0
32.1-35 5 21.0 13.0
35.1-37 5 14.0
37.1-40 5 15.0
40.1-42 5 16.0
42.1-45 5 17.0
22.5
45.1-50 5 18.0
50.1-55 6 20.0
55.1-58 6 21.0
>=58.1 6 22.5
Module 10 - TB Preventive Treatment (TPT)

C. Initiation of treatment

5. Perform baseline liver function tests in the following:

▪ Individuals with risk factors for hepatotoxicity
▪ History of liver disease
▪ Regular use of alcohol
INITIATION
▪ ChronicOF TREATMENT
liver disease
▪ HIV infection
▪ Age > 60 years
▪ Pregnancy or within 3 months of delivery.

Do not give TPT if LFTs cannot be done at baseline and

monthly during treatment.

Exception: PLHIV without other risk factors for hepatotoxicity

can still be given TPT even if LFTs cannot be done. The benefits
of treatment still outweighing harms.

For adolescents and adults (>= 15 yo):

▪ Give 3HP regimen if available, it can be given
even if LFT monitoring cannot be done.
▪ Perform baseline LFTs if 3HR or 6H will be used.

If only 3HR or 6H are available but LFT’s cannot be

done, TPT may be given based on clinical judgment
and informed decision of clients.
Module 10 - TB Preventive Treatment (TPT)

C. Initiation of treatment

6. Determine other co-morbidities (Diabetes, HIV,

malnutrition) and note other medications.
▪ Manage or refer accordingly.
▪ Adjust regimen if needed

Diabetes

TB
HIV Malnutrition

7. Prescribe 10-25mg/day of pyridoxine (vitamin B6) if given

INH and at risk for peripheral neuropathy
▪ Malnutrition
▪ chronic alcohol dependence
▪ HIV infection
▪ renal failure
▪ Diabetes
▪ are pregnant or breastfeeding.
▪ infant taking isoniazid or whose breastfeeding
mother is taking INH (5-10mg/day)
Module 10 - TB Preventive Treatment (TPT)

C. Initiation of treatment

8. Discuss the appropriate treatment adherence and

support mechanism with clients. Consider the most
suitable location of drug intake and treatment supporter
based on clients’ condition.

9. Accomplish Form_ TB Card and Form__ NTP ID Card.

Register the patient in Form __ LTBI Register and ITIS.

10. Ask if the patient requires any further social or financial

support. Refer accordingly to other programs providing
social protection.

D. Treatment considerations in special population

1. Pregnant women
Isoniazid and rifampicin can be used(including
breastfeeding)
Rifapentine should be avoided

For pregnant women with HIV who are already on ART

defer TPT until 3 months post-partum.

2. Breastfeeding
Isoniazid and or rifampicin can be safely given
Module 10 - TB Preventive Treatment (TPT)

D. Treatment considerations in special population

3. Oral Contraceptives
Rifampicin and rifapentine - risk of decreased
protective efficacy against pregnancy of oral
contraceptives.

Rifampicin/
Rifapentine

Oral
contraceptives

4. Liver disease or history of liver disease

Treatment (INH, Rifampicin, Rifapentine) should not
be initiated in individuals whose baseline liver
transaminases is more than three times elevated (or
not done)

TPT should not be given to individuals with end-stage

liver disease.
Module 10 - TB Preventive Treatment (TPT)

D. Treatment considerations in special population

5. Acute Hepatitis (e.g., Acute Viral Hepatitis)

Defer TPT until the acute hepatitis has been resolved.

6. Renal Failure
▪ Isoniazid and rifampicin/rifapentine (biliary
excretion) can be given in normal dosages to
patients with renal failure.
▪ Patients with severe renal failure should receive
isoniazid with pyridoxine to prevent peripheral
neuropathy.

7. People living with HIV

▪ Rifampicin and rifapentine can be co-administered
with efavirenz
▪ Rifampicin or rifapentine cannot be co-administered
with protease inhibitors or nevirapine.

8. Baby born to mother with active TB disease (NOTE:

TPT not necessary if mother has taken more than 2
months treatment)
a) refer to a specialist/pediatrician if baby is not well
b) If well, do not give BCG first. Instead give TB
preventive treatment (with Pyridoxine at 5-10
mg/day)
c) At the end of treatment, perform TST. If TST is
negative or not available, give BCG.
d) If the mother is taking anti-TB drugs, she can
safely continue to breastfeed.
Module 10 - TB Preventive Treatment (TPT)

F. Monitoring Treatment

1. Ask patient to follow-up 2 weeks after initiation of

treatment and then at least monthly thereafter.
▪ clinical assessment during follow-up visits
▪ Monthly weight

2. Check for presence of signs or symptoms of TB. If

diagnosed with active TB disease, stop TPT and start
treatment for active TB disease.

3. Check for adverse reactions. Manage any adverse

drug reactions and refer if needed.

a) If there is a need to discontinue anti-TB drugs due

to major ADRs, do not re-introduce.

b) In case of a flu-like syndrome due to rifapentine,

consider a switch to daily rifampicin-containing
regimens or, if not possible, isoniazid alone. Drugs
can be started at a full dose but add one drug per
day.

c) Advise patient to contact their health care provider

if they become aware of symptoms.
Module 10 - TB Preventive Treatment (TPT)

F. Monitoring Treatment

4. Perform liver function tests monthly for :

▪ individuals with abnormal baseline test results
▪ adolescents and adults receiving 6H or 3HR
▪ Discontinue treatment if liver transaminases
(elevated 3X + symptoms) or (elevated 5X
regardless of symptoms)
5. Continue management of co-morbid conditions, and
refer if necessary.

6. Explain the importance of adherence and completion

at each encounter.

7. Record the visit, drug intake and all findings in Form __

NTP TB Card.
Module 10 - TB Preventive Treatment (TPT)

G. Assigning LTBI outcome

a) Completed –completed the prescribed duration of

treatment and remains well or asymptomatic
b) Lost to Follow-up –interrupted TB preventive treatment
for two (2) consecutive months or more.
c) Died – dies for any reason during treatment
d) Failed –developed active TB disease anytime while on
TPT
e) Not Evaluated –transferred to another health facility
but whose treatment outcome is not known; include
here discontinued by physician because patient cannot
tolerate (eg, severe ADR)
Module 10 - TB Preventive Treatment (TPT)

Talking points

Field implementation guides for Contact Investigation and

TB Preventive Treatment

In addition to the policy and procedures for contact investigation

(CI) and TB preventive treatment (TPT) detailed in the 6th MOP,
NTP has developed a field implementation guides for contact
investigation and TPT with two main objectives:
1) to enhance contact investigation and TPT coverage
2) to ensure the quality of CI and TPT services

The guides provide strategies and tools that will help address
barriers in the field implementation of contact investigation and
TPT. These strategies and tools are provided under the following
headings and the useful tools are provided in the annexes.
• General strategies in the provision of contact investigation
and TB preventive treatment
• Identifying persons potentially eligible for TPT
• Investigation for LTBI and procedure to rule out active TB
disease
• Preparation before starting TPT for a person eligible for TPT
• Initiation of TPT and follow-up during TPT course
• TPT Information management system
• Operational preparation at the health facility level for contact
investigation and TPT service delivery
Module 10 - TB Preventive Treatment (TPT)

Talking points

The tools provided in the annexes include:

ANNEX 1. FREQUENTLY ASKED QUESTIONS TO ADDRESS MYTHS ABOUT LTBI

AND TPT
ANNEX 2. IEC MATERIAL FOR INDEX CASE AND CONTACTS (AN INVITATION
CARD OR LEAFLET)
ANNEX 3. COUNSELING MESSAGES FOR CLIENTS BEFORE STARTING TPT
ANNEX 4A. CONTACT TRACING AND SYMPTOMATIC SCREENING FORM FOR
BHWS
ANNEX 4B. CONTACT INVESTIGATION SHEET FOR FACILITY-BASED HCWS
ANNEX 5. EXAMPLES OF TREATMENT CALENDAR FOR TPT CLIENTS
ANNEX 6. CHECKLIST FOR MONTHLY ADVERSE EVENT CHECKING BY PHONE
ANNEX 7. MONITORING AND MANAGEMENT FORM OF AES DURING TPT BY
HCWS IN HEALTH FACILITIES
ANNEX 8. FORM 6C. TPT REGISTER
ANNEX 9. MONITORING INDICATORS OF TPT IMPLEMENTATION
Annex 10. ESTIMATION OF COMMODITY REQUIREMENT
 Module 10 - TB Preventive Treatment (TPT)

Talking points

General strategies that will enhance the provision of contact

investigation and TB preventive treatment are outlined to address
issues/concerns at health facility level and from client’s perspective.

(A) At health facilities level

The constraints due to limited human resource to conduct contact
screening and investigation and delivery of TPT services and
difficulty in reaching clients can be overcome by the following
strategies:
• Use an integrated approach through immunization, nutrition, and
maternal and child health programs
• Engage BHWs, TB patients or peers, or CSOs in CI and delivery of
TPT
• Use telehealth in contact tracing and screening

The health workers’ concern over drug resistance amplification due

to TPT in settings with high levels of isoniazid resistance, toxicity
leading to discontinuation, requirement of directly observed
treatment (DOT), and lack of completion of TPT can be addressed by
the following strategies:
• Use information education and communication (IEC) materials and
conduct training to address these concerns, especially among
health care providers
• Use of shorter TPT regimen
• Ensure availability of alternative TPT regimens in case of
intolerance or risks of hepatotoxicity
• Use of alternative TPT adherence strategies instead of strict DOT
Module 10 - TB Preventive Treatment (TPT)

Talking points

B: Clients’ perspective
The issues that constraint complying to contact investigation and
TPT are:
• Stigma
• Limited understanding of TB and LTBI and benefits of TPT
• Long duration of previous TPT regimen
• Lack of time (work, school, long waiting time) and cost
involved with CI and taking TPT (e.g., travel cost, income
loss, other investigation costs if charged)
These issues can be addressed by the following strategies:
• Promote education and counseling to index/source cases
and close contacts and other at-risk populations potentially
eligible for TPT (e.g., PLHIV)
• Obtain verbal agreement with index case for contact tracing
and screening at the time of diagnosis
• Use of telehealth if possible
• Capacitate BHWs, TB patients or peers, or CSO
• Use a shorter TPT regimen
• Ensure all costs, including CI, screening, and TPT
medications are free
• Consider social support where needed (e.g., travel cost)
• Minimize the required number of visits by multi-month
dispensing

For detail contents of the field implementation guides for

contact investigation and TPT and to access/utilize the tools,
please download the guides through this link.
Module 10 - TB Preventive Treatment (TPT)

Talking points

A few sample tools are:

Module 10 - TB Preventive Treatment (TPT)
Module 10 - TB Preventive Treatment (TPT)
Module 10 - TB Preventive Treatment (TPT)
Module 10 - TB Preventive Treatment (TPT)

References

WHO. 2018. Latent Tuberculosis Infection: Updated and

Consolidated Guidelines for Programmatic Management.
Geneva: WHO.

WHO. 2018. BCG vaccines: WHO position paper – February

2018. Wkly Epidemiol Rec. 2018 Feb 23;93(8):73-96.
Mathad JS, Gupta A. Tuberculosis in pregnant and
postpartum women: epidemiology, management, and
research gaps. Clin Infect Dis. 2012 Dec;55(11):1532-49.