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1、Effective Diagnosis,Treatment,and Control of Tuberculosis,World Health Organization Regional Office for South-East AsiaNew Delhi,2,South-East Asia accounts for nearly40%of all tuberculosis cases,3,TB is the leading single infectious cause of death in South-East Asia,Number of deaths(1000s),Deaths fr
2、om infectiousagents in South-East Asia,4,TB is a Leading Killer of Women,Deaths among women,5,Tuberculosis A Global Emergency,TB kills 5,000 people a day 2-3 million each yearOne third of the worlds population is infected with TBTB kills more young women than any other diseaseMore than 100,000 child
3、ren will die needlessly from TB this yearHundreds of thousands of children will become TB orphans this year,6,TB and AIDS,Lifetime Risk of TB,7,TB Control:The 5 components of DOTS,Political commitment,Diagnosis by microscopy,Adequate supply of SCC drugs,Directly observed treatment,Accountability,8,D
4、iagnosis of pulmonary tuberculosis,Patients with TB feel ill and seek care promptlyActive case finding is unnecessary and unproductive Microscopy is appropriate technology,indicating infectiousness,risk of death,and priority for treatment X-ray is non-specific for TB diagnosis Serological and amplif
5、ication technologies(PCR,etc.)currently of no proven value in TB control,9,Diagnosis of Pulmonary Tuberculosis,Three specimens optimalSpot specimen on first visit;sputum container given to patientEarly morning collection by patient on next daySpot specimen during second visit,10,Three sputum smears
6、are optimal,11,Reporting on AFB Microscopy,12,Diagnosis of Pulmonary TB,13,Microscopy is more objective and reliable than X-ray,Inter-observeragreement,14,Microscopy is a more specific test than X-ray for TB diagnosis,Specificity,15,X-ray-based evaluation causes over-diagnosis of TB,NTI,Ind J Tuberc
7、,1974,Over-diagnosis,16,Role of Chest X-ray,No chest X-ray pattern is absolutely typical of TB10-15%of culture-positive TB patients not diagnosed by X-ray40%of patients diagnosed as having TB on the basis of x-ray alone do not have active TB,Toman K.Tuberculosis case finding and chemotherapy.WHO,197
8、9,X-ray is unreliable for diagnosing and monitoring treatment of tuberculosis,17,Proportion of patients with pulmonaryTB who have positive AFB smears,AFB positivity in TB patients,18,X-ray findings in TB patients with HIV infection,Early HIV,Late HIV(severe immuno-compromise),19,DOTS more than doubl
9、es accuracy of diagnosis of TB in SEAR,Expected range,20,Prompt treatment of infectious cases reduces spread of tuberculosis,Smear-positive patients usually seek careSmear-positive patients are 4-20 times more infectiousUntreated,a smear-positive patient may infect 10-15 persons/yearSmear-positive p
10、atients are much more likely to die if untreated,Rouillon A.Tubercle 1976;57:275-99,21,Treatment Categories,22,Severe and less severe forms of extra-pulmonary TB,TB/HIV,A Clinical Manual,World Health Organization 1996,23,Recommended treatment regimens,Direct observation is recommended for all patien
11、ts and is particularly essential when intermittent regimens are used,24,Doses of first-line anti-TB drugs,All these anti-TB drugs should be given as a single daily dose.Direct observation is recommended for all patients and is particularly essential when intermittent regimens are used.Thiacetazone i
12、s not effective when given intermittently and is not recommended for use in high HIV prevalence areas.,25,Role of Isoniazid,Mainstay of anti-TB treatmentLife saving in TB meningitis Bactericidal for rapidly dividing organismsPrevents emergence of resistance to other drugsIntermittent treatment more
13、effective than daily treatment in animal model and equally effective in clinical trialsSafe and effective for preventive treatment,26,Role of Rifampicin,Necessary for short-course treatmentEssential for at least first 2 months of regimens of 6-9 month durationBactericidal for rapidly dividing and sl
14、ow-growing organismsPrevents emergence of resistance to other drugsIntermittent treatment more effective than daily treatment in animal model and equally effective in clinical trials,27,Role of Pyrazinamide,Essential for 6-and 8-month regimensNo benefit if given for more than 2 monthsRelatively inef
15、fective at preventing emergence of resistance to other drugs,28,Pyrazinamide is essential for the first two months of 6/8-month treatment,Am Rev Respir Dis 1987;136:1339-42,Relapses,29,Pyrazinamide does not give any additional benefit if given beyond two months in short-course treatment,Am Rev Respi
16、r Dis 1991;143:700-6,Cure Rate(%),30,Role of Ethambutol/Streptomycin,Prevent emergence of resistance to other drugs givenHasten sputum conversionBacteriostatic or weakly bactericidal against rapidly dividing organisms,31,Role of Thiacetazone,Prevent emergence of resistance to other drugs givenBacter
17、iostaticShould not be given to HIV+patients because of risk of fatal skin reactions,32,Relapse rates are low with directly observed intermittent treatment in both HIV-positive and HIV-negative patients,Am J Respir Crit Care Med 1996:154:1034-38,Relapse rates,Relapse(%),33,Adverse reactions to anti-T
18、B drugs,34,Management of Logistics,Adequate buffer stocks must be maintained at national,state/regional,and local levels,35,Drug requirements are determined based on:,Number of cases in different treatment categories treated in previous yearStandardized regimens usedExisting stocksEnsuring reserve(b
19、uffer)stocks at each level,36,Keys for effective distribution and storage of anti-TB drugs,Storage conditions(temperature and humidity)Management inside the stores:appropriate spaceimplementation of FEFO principle(First-Expired,First-Out)reserve stocksConditions of handling and transportation to the
20、 peripheral levelImplementation of drug accounting system at all levels where drugs are stored or administered,37,Directly Observed Treatment,Treatment observer must be accessible and acceptable to the patient and accountable to the health systemObservation is a service to patients and providersMany
21、 patients do not take medicines regularly,even if excellent health education is providedImpossible to predict which patient will take medicine,38,Directly Observed Treatment(DOT)vs DOTS,Directly observed treatment(DOT)is one element of the DOTS strategyAn observer watches and helps the patient swall
22、ow the tabletsDirect observation ensures treatment for the entire course with the right drugsin the right dosesat the right intervals,39,DOT is necessary even whendrug supply ensured,Chaulk CP.JAMA 1998;279:943-8,Treatment Success,DOT,No DOT,40,Directly Observed Treatment is the Standard of Care,“DO
23、T has emerged as the standard of care”(Bayer,Lancet,1995)“Every patient with TB in this country should receive DOT”(Iseman,NEJM,1993)“DOT seems imperative where the disease has become epidemic”(Chaulk,JAMA,1996),41,Why is it necessary to directly observe treatment?,At least one third of patients rec
24、eiving self-administered treatment do not adhere to treatmentImpossible to predict which patients will take medicinesDOT necessary at least in the initial phase of treatment to ensure adherence and achieve sputum smear conversionA TB patient missing one attendance can be traced immediately and couns
25、eled,42,Modes of Observation,Health care workersNon-governmental organizationsCommunity volunteersReligious leadersChild survival workers,lay midwives,etc.,DOT is feasible in each community by identifying and involving the strengths of the community.,43,DOT prolongs survival ofHIV-infected TB patien
26、ts,SCC with DOT,SCC without DOT,44,Systematic Monitoringand Accountability,Good record-keeping is the cornerstone of successThe DOTS recording system enablesMonitoring of patient outcomesEvaluation of programme performanceAnalysis of epidemiologic dataOperational researchEvery level of health system
27、 accountable for patient diagnosis and cure,45,Treatment outcomes in sputum smear-positive patients,46,Supervision,Effective supervision at all levels is key to successSupervision is the process of helping staff improve their performanceKey areas:laboratory work patient categorizationdirect observat
28、iondrug storage and stockrecord keepingreporting,47,DOTS can reduce the burden of TB,Annual percentage decline in incidence/prevalence,48,DOTS can reduce drug resistance,Decline(percent),49,Results of DOTS in 112,842 patients with smear-positive pulmonary TB in China,Lancet 1996;347:358-62,Cure rate
29、,Cure rate(%),50,Treatment outcomes,DOTS areas,South East Asia,New Smear+Patients 1997,25,871 308 7,708 19,492 94 9,014 2,303 3,506 1,873,51,DOTS triples treatment success in South East Asia,52,DOTS is succeeding in South East Asia,More than 500,000 TB patients treated with DOTS in South-East AsiaMo
30、re than 50,000 lives savedMore than 2 million TB infections preventedMore than 200,000 TB cases preventedMore than US$150 million saved,53,DOTS in the context of HIV,DOTS can:Prolong life and improve its qualityStop the spread of TBPrevent emergence of MDRTBReverse the trend of MDRTB,Failure to use
31、DOTS in the face of HIV can lead to explosive spread of TB,with cases tripling and drug resistance increasing rapidly,54,Economic benefits of DOTS:Indonesia,55,DOTS is Expandingin South East Asia,56,The Sooner DOTS is Implemented,the FasterTB Will be Controlled in South-East Asia,57,Deaths from TB(thousands),Deaths from TB with and without rapidDOTS expansion,SE Asia,2000-2020,58,DOTS is accelerating in South-East Asia,but needs to become more extensive and intensive,Target Zone,750,000 more new ss+patients need to be treated yearly,
