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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,Effective Diagnosis, Treatment, and Control of Tuberculosis,World Health Organization,Regional Office for South-East Asia,New Delhi,1,Effective Diagnosis, Treatment,South-East Asia accounts for nearly40% of all tuberculosis cases,2,South-East Asia accounts for n,TB is the leading single infectious cause of death in South-East Asia,Number of deaths (1000s),Deaths from infectious,agents in South-East Asia,3,TB is the leading single infec,TB is a Leading Killer of Women,Deaths among women,4,TB is a Leading Killer of Wome,Tuberculosis,A Global Emergency,TB kills 5,000 people a day 2-3 million each year,One third of the worlds population is infected with TB,TB kills more young women than any other disease,More than 100,000 children will die needlessly from TB this year,Hundreds of thousands of children will become TB orphans this year,5,Tuberculosis A Global Emergen,TB and AIDS,Lifetime Risk,of TB,6,TB and AIDSLifetime Risk6,TB Control:,The 5 components of DOTS,TB Register,Political commitment,Diagnosis by microscopy,Adequate supply of SCC drugs,Directly observed treatment,Accountability,7,TB Control:TB RegisterPolitica,Diagnosis of pulmonary tuberculosis,Patients with TB feel ill and seek care promptly,Active 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 amplification technologies (PCR, etc.) currently of no proven value in TB control,8,Diagnosis of pulmonary tubercu,Diagnosis of Pulmonary Tuberculosis,Three specimens optimal,Spot specimen on first visit; sputum container given to patient,Early morning collection by patient on next day,Spot specimen during second visit,9,Diagnosis of Pulmonary Tubercu,Three sputum smears,are optimal,10,Three sputum smears 10,Reporting on AFB Microscopy,Number of bacilli seen,Result reported,None per 100 oil immersion fields,Negative,1-9 per 100 oil immersion fields,Scanty, report,exact number,10-99 per 100 oil immersion fields,1+,1-10 per oil immersion field,2+, 10 per oil immersion field,3+,11,Reporting on AFB MicroscopyNum,Diagnosis of Pulmonary TB,Cough 3 weeks,AFB X 3,Broad-spectrum antibiotic 10-14 days,If symptoms persist, repeat AFB smears, X-ray,If consistent with TB,Anti-TB Treatment,If 1,positive,X-ray and,evaluation,If 2/3,positive,:,Anti-TB Rx,If,negative,:,12,Diagnosis of Pulmonary TBCough,Microscopy is more objective,and reliable than X-ray,Inter-observer,agreement,13,Microscopy is more objective I,Microscopy is a more specific test than X-ray for TB diagnosis,Specificity,14,Microscopy is a more specific,X-ray-based evaluation causes over-diagnosis of TB,NTI, Ind J Tuberc, 1974,Over-,diagnosis,15,X-ray-based evaluation causes,Role of Chest X-ray,No chest X-ray pattern is absolutely typical of TB,10-15% of culture-positive TB patients not diagnosed by X-ray,40% 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, 1979,X-ray is unreliable for diagnosing and monitoring treatment of tuberculosis,16,Role of Chest X-rayNo chest X-,Proportion of patients with pulmonary,TB who have positive AFB smears,0,10,20,30,40,50,60,70,HIV,Negative,Early HIV,Late HIV,AFB positivity in,TB patients,17,Proportion of patients with pu,X-ray findings in TB patients,with HIV infection,Early HIV,Late HIV,(severe immuno-compromise),18,X-ray findings in TB patients,DOTS more than doubles accuracy of diagnosis of TB in SEAR,Expected range,19,DOTS more than doubles accurac,Prompt treatment of infectious cases reduces spread of tuberculosis,Smear-positive patients usually seek care,Smear-positive patients are 4-20 times more infectious,Untreated, a smear-positive patient may infect 10-15 persons/year,Smear-positive patients are much more likely to die if untreated,Rouillon A. Tubercle 1976;57:275-99,20,Prompt treatment of infectious,Treatment Categories,TB treatment,category,TB Patients,I,l,New smear-positive pulmonary TB,l,New smear-negative pulmonary TB with extensive,parenchymal involvement,l,New cases of severe forms of extra-pulmonary TB,II,l,Sputum smear-positive relapses,l,Sputum smear-positive t,reatment failure cases,l,Sputum smear-positive cases requiring treatment,after interruption,III,l,New smear-negative pulmonary TB,l,New less severe forms of extra-pulmonary TB,21,Treatment CategoriesTB treatme,Severe and less severe forms of extra-pulmonary TB,Severe,Meningitis,Less Severe,Lymph nodes,Miliary,Pericarditis,Bone (excluding spine),Bilateral or extensive,pleural effusion,Spinal,Intestinal,TB/HIV, A Clinical Manual, World Health Organization 1996,Pleural effusion (unilateral),Peripheral joint,22,Severe and less severe forms o,4 H,R,I,2 HRZE(2 HRZS),2 H,3,R,3,Z,3,E,3,(2 H,3,R,3,Z,3,S,3,),6 HE,4 HR,3,3,Recommended treatment regimens,Direct observation is recommended for,all,patients and is particularly essential when intermittent regimens are used,Continuation Phase,Alternative treatment regimens,(if smear + at end of initial phase of Cat I or Cat II,one more month of initial phase is given),TB,treatment,category,Initial phase,III,2 HRZ,2 H,3,R,3,Z,3,6 HE,4 HR,R,4 H,3,3,3,3,3,(2 S,H,R,Z,E,/1 H,R,Z,E,5 H,R,E,II,2 SHRZE/1 HRZE,3,3,3,3,3,3,3,3,3,),5 HRE,23,4 HRI2 HRZE(2 HRZS)2 H3R3Z3E3,Doses of first-line anti-TB drugs,Pyrazinamide (Z),25,(20-30),35,(30-40),Ethambutol (E),15,(15-20),30,(25-35),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 is not effective when given intermittently and is not recommended for use in high HIV prevalence areas.,Isoniazid (H),5,(4-6),10,(8-12),Recommended Dose (mg/kg),Anti-TB Drug,(Abbreviation),Daily,Intermittent,3x/wk,Rifampicin (R),10,(8-12),10,(8-12),Streptomycin (S),15,(12-18),15,(12-18),Thiacetazone (T),2.5,Not applicable,24,Doses of first-line anti-TB dr,Role of Isoniazid,Mainstay of anti-TB treatment,Life saving in TB meningitis,Bactericidal for rapidly dividing organisms,Prevents emergence of resistance to other drugs,Intermittent treatment more effective than daily treatment in animal model and equally effective in clinical trials,Safe and effective for preventive treatment,25,Role of IsoniazidMainstay of a,Role of Rifampicin,Necessary for short-course treatment,Essential for at least first 2 months of regimens of 6-9 month duration,Bactericidal for rapidly dividing and slow-growing organisms,Prevents emergence of resistance to other drugs,Intermittent treatment more effective than daily treatment in animal model and equally effective in clinical trials,26,Role of RifampicinNecessary fo,Role of Pyrazinamide,Essential for 6- and 8-month regimens,No benefit if given for more than 2 months,Relatively ineffective at preventing emergence of resistance to other drugs,27,Role of PyrazinamideEssential,Pyrazinamide is essential for the first two months of 6/8-month treatment,Am Rev Respir Dis 1987;136:1339-42,Relapses,28,Pyrazinamide is essential for,Pyrazinamide does not give any,additional benefit if given beyond two,months in short-course treatment,Am Rev Respir Dis 1991;143:700-6,Cure Rate (%),29,Pyrazinamide does not give any,Role of Ethambutol/ Streptomycin,Prevent emergence of resistance to other drugs given,Hasten sputum conversion,Bacteriostatic or weakly bactericidal against rapidly dividing organisms,30,Role of Ethambutol/ Streptomyc,Role of Thiacetazone,Prevent emergence of resistance to other drugs given,Bacteriostatic,Should not be given to HIV+ patients because of risk of fatal skin reactions,31,Role of ThiacetazonePrevent em,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 (%),32,Relapse rates are low with dir,Adverse reactions to anti-TB drugs,Isoniazid,l,Peripheral neuropathy,l,Hepatitis,Drugs,Adverse reactions,Pyrazinamide,l,Joint pains,l,Hepatitis,Rifampicin,l,Gastroentestinal (anorexia, nausea,vomiting, abdominal pain),l,Hepatitis,l,Reduced effectiveness of oral,contraceptive pill,Ethambutol,l,Optic neuritis,Streptomycin,l,Auditory &,vestibular nerve damage,(also to,foetus),l,Renal damage,33,Adverse reactions to anti-TB d,Management of Logistics,Management,of Stocks,CHOICE,USE,PURCHASE,DISTRIBUTION,STORAGE,Quantification,Financing,Tender bids,Order,Quality Control,Re-packaging,Transportation,Information,for user &,for consumer,Adequate buffer stocks must be maintained at,national, state/regional, and local levels,34,Management of LogisticsManagem,Drug requirements are determined based on:,Number of cases in different treatment categories treated in previous year,Standardized regimens used,Existing stocks,Ensuring reserve (buffer) stocks at each level,35,Drug requirements are determin,Keys for effective distribution and storage of anti-TB drugs,Storage conditions (temperature and humidity),Management inside the stores:,appropriate space,implementation of FEFO principle (First-Expired, First-Out),reserve stocks,Conditions of handling and transportation to the peripheral level,Implementation of drug accounting system at all levels where drugs are stored or administered,36,Keys for effective distributio,D,irectly,O,bserved,T,reatment,Treatment observer must be,accessible,and,acceptable,to the patient and,accountable,to the health system,Observation is a service to patients and providers,Many patients do not take medicines regularly, even if excellent health education is provided,Impossible to predict which patient will take medicine,37,Directly Observed TreatmentTre,D,irectly,O,bserved,T,reatment,(DOT),vs,DOTS,Directly observed treatment (DOT) is one element of the DOTS strategy,An observer watches and helps the patient swallow the tablets,Direct observation ensures treatment for the entire course,with the right drugs,in the right doses,at the right intervals,38,Directly Observed Treatment(D,DOT is necessary even when,drug supply ensured,Chaulk CP. JAMA 1998;279:943-8,Treatment Success,DOT,No DOT,39,DOT is necessary even whenChau,D,irectly,O,bserved,T,reatment,is the Standard of Care,“DOT 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),40,Directly Observed Treatment i,Why is it necessary to directly observe treatment?,At least one third of patients receiving self-administered treatment do not adhere to treatment,Impossible to predict which patients will take medicines,DOT necessary at least in the initial phase of treatment to ensure adherence and achieve sputum smear conversion,A TB patient missing one attendance can be traced immediately and counseled,41,Why is it necessary to directl,Modes of Observation,Health care workers,Non-governmental organizations,Community volunteers,Religious leaders,Child survival workers, lay midwives, etc.,DOT is feasible in each community by identifying and involving the strengths of the community.,42,Modes of ObservationDOT is fea,DOT prolongs survival of,HIV-infected TB patients,SCC with DOT,SCC without DOT,43,DOT prolongs survival ofSCC wi,Systematic Monitoringand Accountability,Good record-keeping is the,cornerstone of success,The DOTS recording system enables,Monitoring of patient outcomes,Evaluation of programme performance,Analysis of epidemiologic data,Operational research,Every level of health system accountable for patient diagnosis and cure,44,Systematic Monitoringand Acco,Treatment outcomes in sputum smear-positive patients,Cure,Patient who is smear negative at (or,one month prior to) completion of,treatment and on at least one,previous occasion,Treatment,completed,Completed treatment but follow-up smear,results are not available,Treatment failure,Remains or becomes again smear,positive 5 months or more after starting,treatment,Died,Patient who dies for any reason during,treatment,Transferred out,Patient who has been transferred to,another treatment,centre and whose,treatment results are not known,Defaulted,(treatment,interrupted),Patient whose treatment has been,interrupted for more than 2 consecutive months before the end of treatment,45,Treatment outcomes in sputum,Supervision,Effective supervision at all levels is key to success,Supervision is the process of helping staff improve their performance,Key areas:,laboratory work,patient categorization,direct observation,drug storage and stock,record keeping,reporting,46,SupervisionEffective supervisi,DOTS can reduce the burden of TB,Annual percentage decline in incidence/prevalence,47,DOTS can reduce the burden of,DOTS can reduce drug resistance,Decline (percent),48,DOTS can reduce drug resistanc,Results of DOTS in 112,842 patients with smear-positive pulmonary TB in China,Lancet 1996;347:358-62,Cure rate,Cure rate (%),New Patients,2 H,3,R,3,Z,3,S,3,/ 4 H,3,R,3,Previously treated patients,2 H,3,R,3,Z,3,S,3,E,3,/ 6 H,3,R,3,E,3,49,Results of DOTS in 112,842 pat,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 1,873,50,Treatment outcomes, DOTS areas,DOTS triples treatment success in South East Asia,51,DOTS triples treatment success,DOTS is succeeding in South East Asia,More than 500,000 TB patients treated with DOTS in South-East Asia,More than 50,000 lives saved,More than 2 million TB infections prevented,More than 200,000 TB cases prevented,More than US$150 million saved,52,DOTS is succeeding in South E,DOTS in the context of HIV,DOTS can:,Prolong life and improve its quality,Stop the spread of TB,Prevent emergence of MDRTB,Reverse the trend of MDRTB,Failure to use DOTS in the face of HIV can lead to explosive spread of TB, with cases tripling and drug resistance increasing rapidly,53,DOTS in the context of HIVDOTS,Economic benefits of DOTS:,Indonesia,Sawert, WHO, 1998,0,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,Years of implementation,0,20,40,60,80,Return on each dollar invested in DOTS,$55 saved for every $1 invested,54,Economic benefits of DOTS: Saw,DOTS is Expandingin South East Asia,0,300,50,100,150,200,1994,1995,1996,1997,1998,1999,0,100,200,400,500,600,(Thousands),Cases treated,Pop. Covered (million),Population covered,Total Cases treated,New SS+,55,DOTS is Expandingin South Eas,The Sooner DOTS is Implemented, the Faster,TB Will be Controlled in South-East Asia,0,1,9,9,5,2,0,0,0,2,0,0,5,2,0,1,0,2,0,1,5,0,2,0,2,Year,G,T,B,/,W,H,O,5,0,0,1,0,0,0,1,5,0,0,2,0,0,0,2,5,0,0,3,0,0,0,3,5,0,0,4,0,0,0,56,The Sooner DOTS is Implemented,Deaths from TB (thousands),Deaths from TB with and without rapid,DOTS expansion, SE Asia, 2000-2020,57,Deaths from TB (thousands)Deat,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,58,DOTS is accelerating in South-,
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