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DOTS MANAGEMENT IN TUBERCULOSIS

Minilecture. DOTS MANAGEMENT IN TUBERCULOSIS. Zul Dahlan Subdivision Pulmonology Dep artment of Internal Medicine Medical Faculty of Padjadjaran University Hasan Sadikin Hospital , BANDUNG. Female 40 yrs Cough for >3 months 3 x to GP, only presciption No sputum or CXR

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DOTS MANAGEMENT IN TUBERCULOSIS

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  1. Minilecture DOTS MANAGEMENT IN TUBERCULOSIS Zul Dahlan Subdivision Pulmonology Department of Internal Medicine Medical Faculty of Padjadjaran University Hasan Sadikin Hospital , BANDUNG

  2. Female 40 yrs • Cough for >3 months • 3 x to GP, only presciption • No sputum or CXR • She did CXR on her initiative • Her sputum AFB pos

  3. INTRODUCTION • Tuberculosis is an infectious disease that remain to be a major health problem in the world including Indonesia. • Indonesia like other countries had adapted WHO DOTS strategy for national TB control and had succeed in variety of setting. • This presentation will disclose a few aspect in the implementation of DOTS in the management tuberculosis, in pulmonary and extrapulmonary sites.

  4. DIAGNOSIS • SPUTUM EXAMINATION : . 3 times, Ziehl Neelsen smear • POSITIVE RESULT : • Positive In 2 of 3 AFB smears, or • Positive in 1 AFB smear and chest x- ray (+)

  5. MICROSCOPIC EXAMINATION More objective and reliable than chest x ray Agreement of medical Practitioner 98% 70%

  6. CHEST X-RAY EXAMINATION Causing over- diagnosis of TB OVER DIAGNOSIS Suspect with positive Chest x-ray True positive TB case

  7. FACTORS THAT PLAY ROLE IN THE MANAGEMENT OF TB INTERACTION • 1.MYCOBACTERIUM: • . SPECIES • . VIRULENCE 2. HOST : . IMMUNITY . ADHERENCE 3. MANAGEMENT & MEDICINE CURED

  8. ASPECTOF TREATMENT FAILURE IN TUBERCULOSIS 1. ETIOLOGIC DIAGNOSIS : - TB MANIFESTATION MICOBACTERIOSIS 2. HOST : - IMMUNITY DEFICIENCY 3. DRUG ASPECT : - RESISTANT MYCOBACTERIUM - ADHERENCE TO THERAPY 4. SOURCE OF INFECTION : - EASIER TRANSPORTATION BETWEEN COUNTRIES AFB/ PA/ DNA EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY – DOTS METHOD

  9. TB MANIFESTATION AT HASAN SADIKIN HOSPITAL • PULMONARY TB 55 % . Pleura : 16,2 % . Meningeal : 9,9 % . Peritonitis : 8,3% . Spondylitis : 4,0 % . Limphadenitis: 2,2 % . Pericarditis : 1,0% • EXTRAPULMONARY TB 45 % . Coxitis : 1.0 % . Supracondylus : 0.7 % . Skin : 0,4 % . Sinovitis : 0,3 % . Hepar : 0,1 % . Renal : 0,1 %

  10. 1. ETIOLOGYTABLE - GROUP OF MYCOBACTERIUM FOUND IN PATIENT DIAGNOSED TUBERCULOSIS FAST GROWING 16,9% MTC 49,3% MNTB 50,7% 83,1% SLOW GROWING

  11. Table – Frequency Species of Mycobacterium Found in Various Organs Organ Mycobact’rium Species Lung Pleura Gland Peritoneum Total I.M. NonTuberculosis -MNTB 1. M. gordonae 2. M. alvei 3. M. ratisbonen 4. M. concordense 5. M.mucogenicum 6. M. avium 7. M. fortuitum 8. Uncultured Mycob. 9. M.peregrinum 10. M.septicum 11. M.paratuberculosis Total II. M. Tuberculosis Complex 1. M. africanum 2. M. tuberculosis 3. M. canetti Total 4 3 1 2 1 1 1 1 0 0 0 14 6 4 0 10 3 1 3 1 1 0 1 0 1 1 0 12 4 3 1 8 3 0 0 0 0 2 0 1 0 0 1 7 12 5 0 17 1 1 0 0 1 0 0 0 0 0 0 3 0 0 0 0 11 5 4 3 3 3 2 2 1 1 1 36 (50,7%) 22 12 1 35 (49,3%)

  12. 2. HOST FACTOR . GENETIC SENSITIVITY TO TB : - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN FUNCTION . INADEQUATE DRUGS DOSAGE . COMPLIANCE EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY –> DOTS METHOD

  13. COMPLIANCE TB Patient frequently did not have their medicine regularly and continuously because of : • Limited effort because of false understanding : . Stopping medicine halfway because they are feeling better TB relapse again . “Taking the medicine too long “ . “Medicine too much” • High cost of therapy • Drug side effect/ untoward effect

  14. WITH TUBERCULOSIS :- Treatment is more than treatment- Treatment is prevention of :. further spreading of infection . further process of disease

  15. DOTSDirect Observed Treatment Short-Course POLITICAL COMMITMENT INCLUDING FINANCIAL SUPPORT ACCURATE DIAGNOSIS,ADEQUATE PERIOD FREE ANTI TB DRUGS TAKING DRUGS UNDER SUPERVISING MONITORING AND EVALUATION TAKING COMBINATION DRUGS ON SUFFICIENT DOSAGE, REGULARLY, AND CONTINOUSLY CURED

  16. BASIC PRINCIPLES OF ANTI TUBERCULOSIS DRUGS • Drug is effective during active multiplication phase of mycobacterium, not in dormant phase • Use combination of 4 – 5 drugs, for 6 mo. or more • Use of still effective drug for etiologic mycobacterium • Patient has to take the medicine regularly, continuously in adequate dosage and period

  17. CLASSIFICATION TB : Related to 4 aspects : - Organ involved in TB process : lung/ extra-lung - result of sputum examination : AFB (+)/ AFB (-) - Previous history of TB therapy : . New/ exacerbation, relapse, migration/ drop out, failure - Degree of severity of disease: mild or severe DECISION ON CATEGORY OF THERAPY

  18. IMPLEMENTATION OF TB THERAPY Aspect–aspect : • Decision on the category of TB therapy • Therapy supervising : . Healthcare officer, family, friend, etc Monitoring of sputum ACB, during : - intensive period - the end of therapy/ 1 month before the - follow up of sputum conversion Monitoring of therapy : - cured, drop out, not cure

  19. THE CHOICE OF ANTITUBERCULOSIS DRUG BASED ON CATEGORIES

  20. MULTI DRUG RESISTANCE TB(MDR TB)

  21. DEFINITION OF RESISTANCE • Mono Resistant: Resistant to 1 drug:: OAT:H/ R/ S/ E • Multi Drug Resistance (MDR) : Minimally resistant to INH and Rifampisin: H+R/ H+R+S/ H+R+E. • Poly Resistant : Resistant to a few OAT exept INH & Rifampisin: H+S+E/ S+E/ H+E. • Extensive Drug Resistance (XDR): MDR resistant also to fluoroquinolon and kanamicin/ amikacin/ capreomicyn:MDR+Cipro+kana/ MDR+cipro+ami.

  22. Causes of Drug resistant TB • Due to physician– inappropriate drug, dosage and duration • Due to patient – compliance, malabsorption, financial, • Due to drug – substandard formulation, poor bioavailability • Due to health care – non availability source was MDR TB

  23. DOTS Plus Treatment of Poli/ MDR : • More difficult, costly, and more side effect • Individualized : - “tailor made” - Package

  24. MANAGEMENT OF MDR DOTS Plus Strategy Base on : • Anamnesis. • Diagnosis berdasarkanlaboratorium. • Pengobatan berdasarkan laboratorium. • Evaluasi pengobatan berdasarkan laboratorium. • Evaluasi efek samping, faal hati, faal ginjal, dll berdasarkan laboratorium. • Lama pengobatan min. 18 bln, dg tahap intensif 6 bln paduan mengandung OAT suntik.

  25. China 15% Indonesia 10% Bangladesh 4% Pakistan 4% India 30% Philippines 3% Nigeria 3% South Africa 2% Other 28% Russia 1% Indonesia : 22 High Burden Countries • India • China • Indonesia • Bangladesh • Nigeria • Pakistan • South Africa • Philippines • Russia • Ethiopia • Kenya • DR Congo • Viet Nam • UR Tanzania • Brazil • Thailand • Zimbabwe • Cambodia • Myanmar • Uganda • Afghanistan • Mozambique • Penyebab kematian terbanyak penyakit infeksi (SKRT 1995) • 583.000 kasus baru/tahun, 140.000 kematian /tahun (WHO)

  26. BACKGROUND OF TB PROBLEM IN DEVELOPING COUNTRIES * HIGH MORBIDITY AND MORTALITY RATE • Annually there are 1 millions new TB patients • And TB is responsible for an annual 3 millions death • 97 % patients located in developing c’ tries  25% can be • avoided • In Indonesia : TB is third major cause of mortality ( SKRT ‘95) MANAGEMENT OF TB IS BASED ON : • Species of causal mycobacterium • Infected organs • Advanced and progression of diseases THE STRATEGY IS TO MORBIDITY & MORTALITY

  27. World Health Organization Estimated Annual Incidence of TB in Selected High Burden Countries, 2000 Population (thousands) Cases (thousands) Rate x105 Country 1. India 2. China 3. Indonesia 7. Philippines 8. Pakistan 10. Russia 13. Viet Nam 22. Afghanistan 1,008,937 1,275,133 212,092 75,653 141,256 145,491 78,137 21,765 1,856 1,365 595 249 247 193 148 70 184 107 280 330 175 132 189 321

  28. Background • Indonesian situation : - population : 222,781,000 - global rank : 3 - incidence : 239 (239/100,000/year) - incidence of new cases : 108 (108/100,000/year) - prevalence : 262 (262/100,000/year) - mortality : 41 (41/100,000/year) - co-infection TB/HIV : 0,8% - MDR-TB : 1,6%

  29. The Global Plan • The Regional Plan • Country Plans A pessimist sees the difficulty in every opportunity: an optimist sees the opportunity in every difficulty. Sir Winston Churchill

  30. Global Strategy to Stop TB 2006-2015 1. Pursuing quality DOTS expansion and enhancement • Government commitment with long-term planning and adequate resources to reach targets • Case detection : bacteriology and strengthening of laboratory network • Standardised treatment, under proper case management conditions including DOT and patient support • Effective and regular drug supply system • Monitoring system for supervision and evaluation, including impact measurement 2. Additional components1 Addressing TB/HIV and MDR-TB2. Contributing to health system strengthening3. Engaging all care providers 4. Empowering patients and communities 5. Enabling and promoting research Stop TB Department

  31. The new Stop TB Strategy and the Regional Strategic Plan, 2006-2015 • Sustaining and enhancing DOTS to reach all TB patients, improve case detection and treatment success • Establishing interventions to address TB/HIV and MDR-TB • Forging partnerships, including with communities, to ensure equitable access to international standards of TB care for all • Contributing to strengthening health systems

  32. DOTS Success Story • DOTS the internationally recommended control strategy was launched in 1994 • The DOTS framework has subsequently been expanded and implemented in 182 countries. • DOTS implementation has helped countries to improve national TB control programmes (NTPs) and make major progress in TB control • By 2004, more than 20 million patients had been treated in DOTS programmes worldwide and more than 16 million of them had been cured.

  33. Puskesmas yg melaksanakan DOTS

  34. Hospital distribution (absolute numbers)

  35. Coverage of DOTS Services in National TB Program Source of Thy failure, MDR-TB, TB-HIV, XDR GPs etc ?? HOSPITAL, LUNG CLINICS (N 1316) 37% PUSKESMAS (N 7489) 98.5%

  36. The practices of TB care among doctors in private sector • Over diagnosis and under diagnosis • Over treatment and under treatment • Chest X-ray regarded as the most important diagnostic tool • Sputum smear is mostly neglected • Non standard tests gaining popularity (serology, PCR etc) • Incorrect use of anti TB drugs (regimen, doses, duration, compliance) Lead to substandard care and failure Eur Respir J 2006; 28: 687–690

  37. Involvement of All Health Personnel & health centers • Extension of DOTS Service in Hospital through Hospital DOTS • Extension of PPM (Public Private Mix) (DPS, Jail, Army/ Police Dept.) • Extended of working cooperation with LSM with Health Service • DOTS in Work Place • Extension of working cooperation with Medical Proffesion to facilitate DOTS • ISTC & PCTC (Patients’ charter for TB Care)

  38. Audience: all health care practitioners, public and private Scope:diagnosis, treatment, and public health responsibilities; intended to complement local and national guidelines Rationale:sound tuberculosis control requires the effective engagement of all providers in providing high quality care and in collaborating with TB control programs ISTC: Key Points ISTC TB Training Modules 2009

  39. ISTC Objectives • The Standards are intended that all care provider delivered high quality care: • for patients of all ages, those with sputum smear (+), sputum smear (-), and extra pulmonary TB • TB caused by drug-resistant M tuberculosis complex • TB + HIV

  40. ISTC: Key Points (Edition 1) 17 Standards Differ from existing guidelines:standards present what should be done, whereas, guidelines describe how the action is to be accomplished Evidence-based, living document Developed in tandem with Patients’ Charter for Tuberculosis Care Handbook for Using the International Standards for Tuberculosis Care ISTC TB Training Modules 2009

  41. ISTC: Key Points (Edit. 2- 2009) 21 Standards Original Standards were renumbered and new Standards were written Evidence-based, living document, will require future revisions as well ISTC Tuberculosis Training Modules and Facilitator’s Guide were updated and developed to be in agreement with Edition 2 of the ISTC ISTC TB Training Modules 2009

  42. ISTC Standard 1 All persons with otherwise unexplained productive cough lasting two-three weeks or more should be evaluated for tuberculosis ISTC TB Training Modules 2009

  43. The Indonesian Version of ISTC

  44. ISTC in IndonesiaIndonesian Standard for Tuberculosis Control • Is accepted and being endorsed by several profession organization • In socialization phase • Has been disseminated and implemented in Jakarta, West Java, East Java, and Central Java as pilot project

  45. Goals Equitable quality DOTS for all - To standardize the care of TB patients in variety of different providers - To provide high quality of care - Improve CDR, cure rate - Prevention of MDR - Reduce mortality - Cover co-infection TB/HIV The first priority is to endorse and implement ISTC among private physicians and hospitals

  46. RESPIROLOGY TEAM WORKING TEAM ON PULMONARY & EXTRAPULMONARY TB ERADICATION PROGRAM DOKTER/PERAWAT/ PARAMEDIS TRAINING PULMONARY & EXTRAPULMONARY TUBERCULOSIS CENTRAL CLINIC

  47. DOTS PROGRAM AT HASAN SADIKIN HOSPITAL BANDUNG TB PATIENTS INTERNAL MEDICINE CLINIC OTHER CLINICS NEURO CLINIC ORTHOPAEDIC CLINIC PEDIATRIC CLINIC TBP +/- TBE THERAPY TBP +/- TBE THERAPY TBE (+) THERAPY (+) DOTS CORNER

  48. MEDICAL PRACTITIONER SOCIAL WORKER FARMACY- OFFICER DOTS CORNER DATA COLLECTING REPORTING OFFICER LABORATORY OFFICER

  49. Conclusion 1 TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM IN INDONESIA WITH A HIGH MORBIDITY AND MORTALITY RATE . STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT MUST BE DONE NATIONALLY AND SUPPORTED BY WHOLE COMMUNITY WITH ADEQUATE PERSONNEL, MEDICINE, AND FINANCIAL. RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHER SPECIES MAY HAMPER THE ERADICATION OF TUBERCULOSIS AND MYCOBACTERIOSIS. ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC AGENT MUST BE DONE WHICH WILL BE HELPFUL IN TREATING THE RESISTANT SPECIES.

  50. Conclusion 2 • The result of Indonesian National TB Program was encouraging • However, Puskesmas gave the biggest contribution to successful outcome • The problems lie on Hospitals and Private providers • The Implementation of ISTC expected to be complimentary to existing DOTS program

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