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Management of TB: Medical and Public Health considerations

Management of TB: Medical and Public Health considerations. Clydette Powell, MD, MPH, FAAP November 2012. Learning Objectives. Briefly review the basics of TB and its medical management

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Management of TB: Medical and Public Health considerations

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  1. Management of TB:Medical and Public Health considerations Clydette Powell, MD, MPH, FAAP November 2012

  2. Learning Objectives • Briefly review the basics of TB and its medical management • Describe the global TB situation and challenges: DOTS expansion, TB/HIV, M/XDR-TB, engaging all providers • Describe the need and approach for new drugs and diagnostics, with focus on Gene Xpert • Describe the priority settings for Xpert and its implications for patients, providers, and public health authorities

  3. Case Study

  4. MDR-TB patient • Migrant worker, South Asia • Battling TB for 8 years • Dx at 20 yo – Rx x 6 mos, “cured” • 3 yrs later- cough and weight loss • Rx- higher doses, for 8 mos • 2 yrs later – Rx for 4 mos • Finally dx’d with MDR-TB • Severe side effects, unable to work

  5. Child TB - Liberia

  6. Women bear a high burden of TB

  7. The Global Burden of TB Number of cases diagnosed, 2011 Estimated number of cases, 2011 5.8 million (67%) 8.7 million (8.3–9.0 million) All forms of TB ~600,000 (55%) HIV-associated TB 1.1 million (1.0–1.2 million) 60,000 (9%) 650,000 out of 12 million prevalent TB cases Multidrug-resistant TB Source: WHO Global Tuberculosis Control Report 2012

  8. Global Burden of TB

  9. TB Incidence (%) by WHO Region Most cases are in Asia

  10. Why is TB still a problem?

  11. What Needs to Be done to Control TB • Improve TB case detection (Prompt and early identification): to minimize TB transmission • Community education for early symptom recognition and action • Aggressive contact investigation and management • Minimize factors associated with delay in seeking medical care and establishing definitive TB diagnosis • Engage all health care providers, civil society organization and other sectors in TB control

  12. What Needs to Be done to Control TB • Improve TB prevention through scaling up of infection control and targeted treatment of a latent TB infection • Support development and deployment of new tools for TB diagnosis, treatment and prevention

  13. Global Plan to Stop TB 2011–2015 Launched 13 October 2010

  14. Basic clinical points

  15. Infection versus disease?

  16. LTBI vs. TB Disease TB Case NOT a TB Case

  17. Diagnostics

  18. Evolution in TB Diagnostics 2006 - 2010 1882 1895 1907 1936 1950 1980s Short-course chemotherapy; Liquid culture developed LED/fluorescence microscopy; Line Probe Assay First anti-TB drugs discovered Robert Koch: identified TB bacilli Tuberculin skin test developed Solid culture used to identify TB HIV & MDR-TB

  19. Diagnosis of Tuberculosis Disease • Identification of individuals with TB symptoms • Collection of specimen • Laboratory examination: • Microscopic Exam • Culture • Chest X-Ray • Molecular: • GeneXpert • Line Probe Assay

  20. Current Diagnostic Limitations

  21. Specimen Collection • Persons suspected of having pulmonary or laryngeal TB should have at least three sputum specimens examined by acid-fast bacilli and culture • It is best to obtain a series of early-morning specimens collected on 3 consecutive days. • Specimens should be obtained in an isolated, well-ventilated area or sputum collection booth.

  22. Specimen Collection: Gastric Aspiration • Gastric aspiration can also be used to obtain specimens of swallowed sputum. • It is the best way to obtain specimens from infants and some young children who cannot produce sputum.

  23. Laboratory Examination: Smear Microscopy • Detection of Acid Fast Bacilli in stained smears examined microscopically may provide the first bacteriologic clue of TB. • Smear examination is a quick procedure; results should be available within 24 hours of specimen collection.

  24. Culture techniques

  25. Laboratory Examination: Cultures • Positive cultures for M. tuberculosis confirm the diagnosis of TB disease • Conventional culture on solid medium (egg or agar): Labor intensive and provides results in 1-8 weeks • The BACTEC Radiometric System and other recently developed liquid medium systems allow detection of most mycobacterial growth in 4 to 14 days compared to 3 to 6 weeks for solid media

  26. Laboratory Examination: Molecular • Line Probe Assay • GeneXpert: A fully-automated diagnostic molecular test that simultaneously detects TB and rifampicin drug resistance and provides results in less than 2 hours

  27. Treatment

  28. Treatment of TB disease: Goals • The overall goals for the treatment of TB are to: • Cure the individual patient, minimizing death and disability from TB • Interrupt the transmission of M. tuberculosis to other persons

  29. Treatment Regimens • TB treatment regimen consists of two phases: • Initial phase: 2 months of 4 drugs (isoniazid, rifampicin, pyrazinamide and ethambutol or streptomycin) aimed at rapidly killing actively dividing bacteria, resulting in the negativization of sputum • Continuation phase: 4 to 7 months of at least 2 drugs (isoniazid and rifampicin) aimed at killing any remaining or dormant bacilli and preventing recurrence

  30. Why monitor TB treatment ?

  31. Treatment monitoring • Monitor for adherence • Monitor for Adverse Drugs Events • Monitor response to treatment: • Smear Microscopy at 2, 5, 6 months

  32. Drug supplies - Libya

  33. Community-based DOTS

  34. Community Health Workers

  35. TB suspect referral

  36. Drug sellers as DOT workers

  37. Patient education

  38. Afghan treatment supporters

  39. Supervision of DOT workers

  40. TB/HIV

  41. Estimated HIV prevalence in new TB cases, 2009

  42. HIV testing for TB patients expanding Although more needed to reach 100% targets in Global Plan Several countries show very high testing rates achievable Percentage of TB patients Africa Rwanda: 97% Kenya: 88% Tanzania: 88% Malawi: 86% Mozambique: 84% World

  43. CPT and ART for HIV-positive TB patients also expanding Although more needed to reach 100% targets in Global Plan Several countries show higher rates of enrolment are possible Percentage of HIV+ TB patients CPT CPT 86%–97% in 2009 Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda ART close to 50% in 2009 Rwanda, Malawi ART

  44. Multi-drug resistant TB

  45. 18/36 HBCs* have insufficient capacity to diagnose MDR-TB ≥1 <1 Culture laboratories per 5M and DST laboratories per 10M population, 2009 *HBC= high-burden country Countries = Afghanistan, Armenia, Azerbaijan, Bangladesh, Belarus, Brazil, Bulgaria, Cambodia, China, DR Congo, Estonia, Ethiopia, Georgia, India, Indonesia, Kazakhstan, Kenya, Kyrgyzstan, Latvia, Lithuania, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, Republic of Moldova, Russian Federation, South Africa, Tajikistan, Tanzania, Thailand, Uganda, Ukraine, Uzbekistan, Viet Nam, Zimbabwe

  46. What is GeneXpert MTD/RIF? • A fully-automated diagnostic molecular test that simultaneously detects TB and rifampicin drug resistance • Can provide results in less than 2 hours • Specially designed for use at the district or sub-district level of the health system

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