Pulmonary Tuberculosis: Knowledge, Attitudes and Practices
of Selected Physicians in a Tertiary-Care Hospital

Catherine T. Yu, M.D., Ryan Ralph R. Zantua, M.D. and Linus John H. Sto. Tomas, M.D.

ABSTRACT

Pulmonary tuberculosis (PTB) remains to be a major concern for the Philippines, being one of countries with
the highest prevalence, incidence and mortality rates for PTB as of 1997, and the economic aspect has always been
blamed. Because more symptomatic TB patients consult the private practitioner this study therefore evaluates the
physicians' knowledge and approach to tuberculosis.
This study was conducted at the St. Luke's Medical Center over a period of one month to evaluate the
physicians' knowledge, attitudes, and practices and their approach in the diagnosis and management of pulmonary
tuberculosis and to determine if there are deviations from the guidelines in TB management. Respondents were
researcher-selected from a list of specialists of the institution and included general practitioners, internists,
pulmonologists, and infectious disease specialists. The study used a structured questionnaire and was conducted in an
assisted format. Frequencies were determined from responses to the questions and answers apart from the choices were
given consideration.
From a list of 1040 physicians in St. Luke’s Medical Center, 59 physicians were included in this study.
However, only 38 (4% of total) were interviewed. Fifty three percent of the respondents (n = 20) were male; the mean
age was 41 years. Pulmonologists comprised the majority of respondents (63.1%; n=24). Thirty four percent of
physicians (n=13) graduated between 1980 and 1989. Ninety five percent (n=36) realized the serious magnitude of the
TB problem in the country. As a means of avoiding TB infection while performing examination, majority (39%, n=16)
open their windows while no measures were taken by 19.5% (n=8) of physicians interviewed. Physicians would
suspect TB among patients who present with respiratory symptoms (87%; n=33) and 92% (n=35) among those who are
in contact with other TB patients. The National Tuberculosis Program (NTP) was rated fair by 39.5% (n=15) and had a
generally poor performance to 29% (n=11). The Directly-Observed Therapy (DOT) likewise rated fair to 23.7% (n=9).
Eighty seven percent (n=33) of the physicians interviewed would not rely on history and physical examination alone or
chest x-ray in the diagnosis of pulmonary tuberculosis. Ninety two percent of respondents (n=35) use 4-drug regimen in
the treatment of PTB. The duration of treatment usually lasts 6-8 months. Physicians educate their patients on the
importance of treatment and compliance and adverse events are explained by 97% (n=37). Monthly follow-ups are

Physicians play a key role in the diagnosis and management of patients with tuberculosis
and more PTB symptomatic patients consult the private health sector as compared to the public
health sector.
4
In an institution dominated by specialists, this study therefore evaluates the
physicians' knowledge, attitudes, practices and their approach to tuberculosis management.

General Objective

It is the general objective of the study to determine the knowledge, attitudes and practices
of specialist physicians in a tertiary–care hospital as to:
a. their idea of the magnitude of TB problem in the Philippines
b. their opinion of the National TB Program as well as the Directly-observed Therapy
(DOT).
c. the measures taken by physicians to avoid TB infection
d. diagnosis
e. treatment regimens
f. health education of patients
g. treatment monitoring of patients with pulmonary tuberculosis
h. MDR-TB cases
i. manner of gaining know-ledge of tuberculosis

Specific Objectives

1. To evaluate the physicians' approach in the diagnosis and management of pulmonary
tuberculosis.
2. To determine if there are deviations from the guidelines in TB management.

MATERIALS AND METHODS



n %
Gender male 20 53.0
female 18 47.0
Age 30-39
20
52.6
40-49 9 23.7
50-59 4 10.5
60-69 1 2.6
70 and above 1 2.6
Not stated 3 7.9
n %
Year graduated from Medical School 1950-1959 2 5.3
1960-1969 0 0
1970-1979 6 15.8
1980-1989 13 34.0
1990 to present 12 31.6
Not stated 5 13.1

Specialty training Pulmonology 24 63.1
Internal Medicine 10 26.3
Infectious Diseases 4 10.5

When asked about the magnitude of the PTB problem in the Philippines, 95% (n=36)
considered it serious. Performing examinations on PTB patients pose a risk of getting infected
and 76% (n=29) are worried; the remaining 24% (n=9) are not.
Most doctors open their windows (39%; n=16) as a measure to avoid getting infection
while 24.4% (n=10) keep distance and 12.2% (n=5) wear masks. Despite the worry of getting
infected while performing examination on their patients, no measures were taken by 19.5% (n=8).

Fair 15 39.5 9 23.7
Generally poor 11 29 10 26.3
Does not concern me 0 0 1 2.6
Other: No idea 1 2.6 Respondents were asked regarding their approach to the diagnosis of pulmonary PTB
(Table 4). A standard 4-drug regimen was used by most of the respondents (n=35; 92%) and the
remaining 8% (n=3) use a 3-drug regimen consisting of rifampicin, isoniazid and pyrazinamide.
The duration of treatment usually lasts 6-8 months [(n=36; 95%) (Table 5)].

Table 4. Physicians’ approach in the diagnosis of PTB

Yes No Other: depends on symptoms
n % n % n %
CXR alone 14 36.8 23 60.5 1 2.6
Sputum AFB exam 36 94.7 2 5.3
Sputum TB culture 27 71 11 29
History and PE alone 5 13 33 87

Table 5. Treatment regimen and duration for PTB

Treatment Regimen N %
3-drug 3 8.0
4-drug 35 92.0
Duration of Treatment N %
< 6 months 0 0
6-8 months 36 94.8
9-11 months 1 2.6
12-18 months 1 2.6

current anti-TB regimen they are giving and reevaluate; 17.5% (n=7) will refer to an ID specialist
for management and 7.5% (n=3) will refer to a pulmonologist. Fifteen percent; n=6) will add just
1 drug to the regimen and reevaluate. One physician did not answer this particular question, as
there had been no encounter of drug resistance (Table 8).

Table 8. Course of action of respondents to suspected drug-resistance*

Course of action n %
Add 2 drugs and re-evaluate 23 57.5
Add 1 drug and re-evaluate 6 15
Refer to Pulmonologist 3 7.5
Refer to ID specialist 5 17.5
No answer 1 2.5
* 2 respondents had multiple answers

A great deal of information can be contributed to the national surveillance data on
tuberculosis but unfortunately, 95% (n=35) of the physicians interviewed fail to notify the health
authority; as much as 53% (n=20) are not aware of the reportability of tuberculosis and 26%
(n=10) decline because of too much paperwork involved. Ten percent (n=4) do not know where
to report cases; 5% (n=2) say that no ready forms were available and 3% (n=1) was not conscious
of any surveillance being done.
In order to gain knowledge or information on tuberculosis, physicians rely on periodicals
and academic meetings attended; the Internet is also one access from which our respondents gain
information on tuberculosis.
Clinical

n

%


of disease and presents with a variety of symptoms. Almost 90% (n=33) suspect TB among
patients with respiratory symptoms and especially since cough is its most common symptom.
7

In the presence of symptoms of prolonged duration, tuberculosis is almost always one of
the considerations. Apart from respiratory symptoms, tuberculosis may also present with
prolonged fever, weight loss and body weakness. The presence of intrathoracic or extra thoracic
lymphadenopathies, anemia and leukocytosis may also increase our suspicion of tuberculosis.
7

The National Tuberculosis Program (NTP) of the government as well as the DOT were
rated unfavorably by our respondents and only 26.3% (n=10) rated the DOT as good. Manalo et
al
8
commented that this could be due to the unfamiliarity of the program by private physicians or
they do not quite agree with the NTP of the government.
Sputum microscopy has a high rate of specificity and low rate of false negatives.
3
Ninety
five percent of the respondents follow the National TB Program by requesting for sputum
microscopy as a diagnostic tool for tuberculosis. However, the diagnosis of PTB becomes definite
when Mtb is isolated by culture. As cited in the Philippine Clinical Practice Guidelines,
3
it is ideal
to confirm all smear positive cases by culture but is not recommended as part of routine
evaluation because of its cost and areas of limited technical facilities. The problem of cost of TB
culture may be the reason why only 48% of pulmonary specimens submitted to the laboratory for
TB work-up, have TB culture requests. With the emergence of multiple drug-resist-ant
tuberculosis, isolation of the organism as well as performing drug susceptibility testing is
imperative for appropriate manage-ment.

requesting for sputum exam for smear-positive cases are followed by 89.7% (n=35).
Knowledge or information on tuberculosis is gained mainly through periodicals and
attending academic meetings. The internet is also a rich source of updated information on this
subject. Much effort is needed on the part of our doctors in notifying our health authorities
regarding TB patients. The unavailability of ready forms in the offices of our private
practitioners, the lack of information on the health authority to contact and not just the paperwork
that it entails may have contributed to a certain degree to the poor forwarding of information.
Definitely, the private sector has a role to share in the control of tuberculosis.

CONCLUSIONS

Selected physicians in a tertiary care hospital as St. Luke’s realize the magnitude of TB
problem in the country. However, the majority does not favorably rate the National TB Program
and DOT. The lack of awareness that TB is reportable and the paperwork it entails limits the data
on its surveillance. Report forms as well as the proper contact personnel should be made available
in the clinics of our private practitioners.
It has been found out that majority of our respondents follow the recommended guidelines in
the diagnosis, management and treatment monitoring for tuberculosis. Most would not rely solely
on chest x-ray or history and physical examination for its diagnosis. The use of sputum
microscopy and TB culture are still requested for proper diagnosis, however, because of the high
cost of TB cultures, this is not requested routinely.
A 4-drug regimen is given by 92% and 3-drug regimen given by 8% of respondents at the
initiation of treatment and the total duration of treating a PTB patient usually lasts 6-8 months.
Eighty two percent (n=31) of the total respondents have encountered MDR-TB and in their
approach to managing drug-resistant TB cases, although 2 drugs are added by 57.5% of
physicians, it may be of concern that 15% add just one drug. This may contribute to failure of TB
treatment and pose problems in the future.

Acknowledgement


Pulmonary Tuberculosis (PTB): Knowledge, Attitudes and Practices of Selected Physicians in a Tertiary Care
Hospital

Doctor’s Initials: ______ Age: ____ Sex:  male  female

Specialty:  General Practitioner  Internal Medicine
 Pulmonary  Infectious Disease

Year graduated from Medical School: __________

Please check one:

1. How do you see the magnitude of TB problem in the Philippines?

( ) serious ( ) not so serious
( ) not a problem ( ) don’t know

2. Are you concerned about getting TB infection while performing examination on your patient?

( ) Worried ( ) not worried

3. What measures do you take to avoid infection?

( ) keep distance ( ) open windows ( ) wear mask
( ) no measures taken

4. When do you suspect Tb in a patient?

4.1 Do you suspect TB in patients with respiratory symptoms? ( ) yes ( ) no
4.2 Do you suspect TB in patients with contact with TB patients? ( ) yes ( ) no

D. 2,3,4 drug, no Isoniazid < 6 6-8 9-11 12-18
E. RP with other < 6 6-8 9-11 12-18
F. monotherapy < 6 6-8 9-11 12-18

H: Isoniazid R: Rifampicin PZA: Pyrazinamide P: PAS

2. Do you advise patient on the importance of treatment and patient compliance?

( ) yes ( ) no

3. Do you explain adverse events of anti -TB medicines to patient prior to initiating treatment?

( ) yes ( ) no

4. Do you advise monthly follow-up to monitor patients?

( ) yes ( ) no

Treatment Monitoring

1. Do you monitor treatment by chest x-ray alone?
( ) yes ( ) no
2. Do you monitor treatment by requesting for sputum exam for those with (+) AFB smear?
( ) yes ( ) no

MDR-TB CASES:

1. When would you suspect MDR-TB in a patient?

1.1 Would you suspect MDR-TB in a patient who has history of treatment for TB?

( ) Refer to an Infectious disease Specialist for consult
( ) Refer to a Pulmonologist for consult

Case Notification

1. Do you notify the Health authority when you have a TB patient?

( ) yes ( ) no

If you answered no, why?

( ) not aware that Tb is reportable ( ) too much paperwork

2. What are the ways of gaining information/knowledge on TB? (you may check one
or more)

( ) textbook ( ) periodicals ( ) academic meetings ( ) I do not seek any info on TB