You are on page 1of 154



 
   





  

  
 



 
   





 









  

 
2 (  !
 !
) ".#. 2551
$ 2,000 %&'

 

"* "+   -

%/
-'!
%#3



 
   



 

       !  ! 
#$%&  $' ( $) & *   %+
& ! ,( 
  
- -% +-!./ ( 0 &%&    $
   !!
& *
 )
& *1$$- $ 22$  
   %& !$ $ ( 
 -%& 3/ 
 %+
&2 $!/ 22$ 45  # $ / 22$  *672
'
  -$ 2 $   *.6 22$ -  %- '
'-'% 
$ + % $ $8 % 
' 4 9- $  -%!45  !( 32 
2 /  -
--3%& '3 -$&
0 7 0  ' %&  -  2 
 
- +3 (4 5 # $ ! 8.   2 :$ %& 6 
  - % &- &0 +2.2 
 - (
$  ,

) &(    -- 7 % !$, DOTS %&$* ,3 )
 $! $ :+ &$
$ 4-4   -%& , %& 

  !$ $  %&  3!
$ '3 -$& ( -+3/ % & % 
$
    -%4 %
'  &  - ;21;  $ -5   - 8 6&!   %&   - & -4     & ;
 +3 1 5
%1!  $
- &0 + 5-
3 %   -%
' 
:  / 2!./ +3 (' % (   %&  <   ! 2    !
( 1  -%   - 7  $& %&  &$',5 

( $'  2 $,)


 - -

  
 



 
   




 
   


" %
 1
   
1.1 3&1
1.2 %+
&2 $$
1
1.3 8  ,
1.4   EF & 3/$ ( & *1$

&
1
1
1
1
3

 2       (National Tuberculosis Programme : NTP)


2.1 $,(  -
2.2  !%4   -%
' 
2.3 %4   -%
' 
2.4  !
$ %
&&
2.5  !   %
&&
2.6  !    !3 )
2.7  -
--3 
$   !3 )
2.8  (' K K2  (%4   -%
' 

4
4
5
7
11
12
14
14
14

 3        ! " 


(International Standards for Tuberculosis Care : ISTC)
3.1 - 7  2:$
3.2 - 7  6
3.3 - 7  - 4'     !

16

 4   # # $


4.1    $ #$
4.1.1   % /  (Passive case finding)
4.1.2   ' (Active case finding)
4.2   $
4.3  2 :$
4.3.1  2 -& +3  '3/ 
4.3.2  3 ) ' 
$( 2 :$

22
22
22
22
22
23
23
23

  
 

16
17
18



 
   


 5    '&' %


5.1  2% & 0!4 5 # $
5.2  ($ 6 45 #$
5.3 $ %&& $ - 7 
5.4 %405-   6 (DOT)
5.5   -%& & -4 6
5.6 %  5%6 (
-  :+ &
5.7   %K!
5.8   1-
+. &,2  ('$
 6       ! '   # 
&   *  &+ 
 "",& -  . DOT
6.1 DOT %& DOTS 3&1
6.2  2  6 4 5 # $ (Organization of tuberculosis treatment service)
6.3 %     DOT

&
31
31
33
34
38
39
46
47
48

53
53
54
55

 7  / ""   


 /+ "0
7.1  --+,&
 ,%&
7.2  2&   
 45 #$
7.3  (    .6 %&2 '1  4 5 # $ (Provide HIV counseling
and testing)
7.4 %  5%(45  '3/ '1345  # $ ,

60
60
61

 8     9+.   ; 


8.1 $ 8.2 ! !  %& -! 3/ $  $! ( & *1$
8.3   45 #$$
- 3/$  $! 
8.4  !./ & $6 45  # $ MDR-TB
8.5 $  % 1 %& 2 ( '( 6 4 5 # $ $%&/3- 3/ $
 $!  %&! $ 

8.6 & $ ( '( 6 45  # $-   52 &  3/ $ ' MDR-TB
8.7   -%& & -4 6 ( $ )
8.8  2%4 6 (Treatment outcome)

59
59
70
70
73

65
66

74
74
75
75



 
   


8.9   - 6 


8.10    2  45  - 4 45  # $ MDR-TB
8.11 %     +3   - !
$ %&  (& 
)
%&   (Programme Monitoring Evaluation and Support )

&
77
77
77
78

 9  '/ =


- ( ; (Tuberculosis in Children)
-  2 :$
- %  <  

84
84
84
88

 10    ? 
# /9+.  '"* ?  
- !    %+
&2 $%&  '3/
- 22$-4
 %+
&2 $ '3/
- 22$-4
  '3/
- 22$ $ !45   '3/ 2& $ 
  #$ 
- $,  - %+
&2 $ '3/(8 +$ 
1.    2  (Administrative control )
2.   -0 +%3.   - F& 

91
91
91
92
92
92
92
94
95

 11     '?9. ?


 / @
 /" 
11.1   -( ! -3
11.2   -( 32
11.3   -(% 
 %&%' $%

97
97
100
102

 12      
,
/
12.1 & $%& $ 
12.2   *  -  

106
106
110

A  
1. $
%& -- $
2. % ],-%& $ 
3. Check lists    * 

113
117
135

  
 



 
   




 
   


1.1 

 (Tuberculosis 
TB) 
   
  Mycobacterium 

!"#  $%& # '* 
M. tuberculosis !+ M. africanum *,&-
.
! M. bovis /
&, &!0 123

/-23*,4/*/*,56  


 
  
Mycobacterium !/7,3,, 
 Mycobacterium 
 8 *,&9/
123 /*/
 &,  
   /  Atypical Mycobacterium 
Mycobacterium other than tuberculosis
(MOTT) & $"  Nontuberculous Mycobacteria (NTM)
3*:/  

&,
/#/ %
$ & 
 3;, 8 *  Mycobacterium Auium Complex (MAC)  &5<,  


*

1.2  
  

 ##
7
35< , =  /
 5< , = *
, / 
  #
<& ?
#

3
(Droplets) #& 7,!<
7
3"* ,* #
<&  

 & 23 
Primary focus  

* !<
/+ 
37
 +&,
/+ 
372 /  Primary
focus #
/+ 
3 72  Primary complex
3*:// 3 10% 7
35<,   
   # = 
 123
 43 
 &*/!  0 

 20-30 J 
/:*, !" 
5<,  
 
/!"74#4</, :#*/ =  &337,/5<,  
/4</,3 ( 
4#7!
  KK) 
! = :/72   !   "# $"% 
&%"'(&"%  ) *$
1.3 "+#
 
 
!+%3  $%!9!"7 ! "7
3 =#& 8
# '  ! " +&,
 // %
$ &/  
 3#7
3
!0 / #
  
 



 
   



,- #33 
 , !35&,#7
3//"3 / /72 #3  

/; .'.2536
30
/ :*, #'&,
 
<& 4#Q" Q! #,
3,*7
3 3
!-0
 7
3& $"
30
/3 1 & 3 7
3 #   

, /" (Prevalence) 7
35<, =/ #/ 14-15 ,  #/2323 "/
+3 
 (Highly infectious) ## J/5 <, = &/ (Incidence) #/ 9.2 ,  95%
<& 
# ' +3W 5< , =  ! J# #/ 1.7 , (98%
<&  # ' )
37
3
30
/ /
 J .'.2008 &"/ 22 # '/  %
$   #/
80% 7
35< , =  
<&  22 # '3 #*,/ 
 # '/  +5< , = //+ 123 3
# '/ 5 <, = /! " &
<& 
 *, # '
  
 1 !+ # '*

<& 
 18 +3#&37
3
30
/ 0 # '*#/
5< , = &/" # 4 J# 90,000  (142 
! #) # #/ 40,000  5< , =   !/#
(62 
! #)
!+7
3 # '* #7
3 # ' 25-30%  
 , 3 506 7
3
!+# &
5  / /
 /;/  #!94 # '*!/-"/
*, +5<, = !/#/33  / 
/#7
3
!0 & J .'.2547 /
5< , =  / 72   
 & !/# #/ 50 
! #

"+#)  ,
 "#
#  11 ,  
 3 

!0 # 
 / &"/ 5< , = /
 " #
3 15-49 J  9%  

!0 /, &7#& 
./  #7
3
!0/! " !<3
-23 31% #5<, = !3/  

!0/,-23 12% !5<, =
!0 !3/
  11%
!+!-0
!0& # '* 3  / /#7
3
!0 7,/& # '*&
J .'.2527  7 #/!#!/-23 J .'.2547 #/5<,  

*
3! #/ 1 , ';
!* , 5 ! 33/5<,  

*
/
< 5 ! '; #5<, =
!0/&37
3!+
# /
 /, 
,
# 30
&"/5<, =
!0/  
Q
! Z   
Q
!/!"
"/ !+
!0  #
3 '!/90 #!+3 [
3"/" 7 /
;5< , =  /"/ *,+ ?[#3 

!0&5< , = &/ &
3#7
3
!0
  

!0&5<, =/,/!<3   Q#& 7 10 123

"/ #&334 

/  #7
3
!0/! " /! !7
3 


!0&5< , = !<3! " #/ 2 7
3 Q 7
33 # ' '2;&37&% 15
3 # # '* & J 2550 
 

*
 &5< , = &/ #/ 20%



 
   


1.4 -/
  
&0 &
!+ /"/ *,+  ?[#3
 
# # ' 3 3 !"/ 
3 !/#
5< , = / ; 33 8  "4& # '* 5 ?[#33  1
123 + & J .'.2540 - 2541 &5< , = &/ / 
 
 ;7&723
25.4% #  
 
 
7 (MDR-TB) 2.01% # /
  + 3  2 & J
.'.2544-2545 / 
 
 ;7&723 3  14.8% #  
 
 

7 (MDR-TB) 0.93% & ?[#3
 3  3 /
 7&5< , = * / ;/

 1.65% !3 # '* $%
 &5< , = */ ;/
3*/!3< / 
3*:/
'2;&"/ # '; *, 5< , = 
 <&  
+ 3& 7 /
3&%  #
   /  #7
3
!0!3< 123 "/ #/  %
$ &"/ 

  ]/4</
!<3-23 5-7% #&5< , =   *, /
 (Acquired drug resistance) :

 !<35< , = 
&/ 

 " 5 
1. #3!9!"7. 3# : "9'!05!/5!+ 3#
!0#

!0  
"/# [
3&5,<  

*
& # '* /03 2 "3 K :
3/0'! !+3#"9'!3, 2546.
2. 3 ?[#33#, !+#.
3. Global tuberculosis control: surveillance, planning, financing. WHO report 2005. Geneva,
World Health organization (WHO/HTM/TB/2005.349.)
4. Payanandana V., Rienthong D., Rienthong S. et al. Surveillance for anti tuberculosis drug resistance in
Thailand : Results from a national Survey. Thai J Tuber. Chest Dis. 2000 ; 21 : 1-8.

  
 



 
   


2.1 ,&6#7
", (Global TB Control Strategies)
"90 DOTS "90
 30
/ *, !
#&, # '3 8  +* + 
"/ 
 / #!94&;# 
 [
3
 
 7#/  # '3 8 +"90*
&,/ 150 # ' !+ # '**,+"90/&,3 .'.2539 /& 8
+ 4
+
3
#7!/-
"/   3 # '& J .'.2545
& J .'.2548
30
/ *, !
"90" (Stop TB Strategies) #+ 
123 /
7,372 #/ 
  / 72 #
,
1. Pursue quality DOTS expansion and enhancement 32-
"90 DOTS  
"/
#
/72 #,3733 72
30 #
3 5 *,
 Political commitment with increase sustained financing ,&,/!+% /
3 #/ / 72 # 3
&+ 3"/&,/  #!94
 Case detection through quality-assured bacteriology , =&, 

&,
3 Z  /  # #"4  !/#,,
3"'0 # # 

&3! /-+ *,
 Standardized treatment with supervision and patient support &,;5< , = ,##
 /] /3/<#!!";  
&,5<, =*,
3


 3+
 Effective drug supply and management system /
3 ##!!"
/ #!94# 3

 Monitoring and evaluation system and impact measurement /+#/ # /5

3 ## #0 


 5#  72
2. Address TB/HIV, MDR-TB and other challenges (5!/5!3#
!0 

 7 # # :,
 8)



 
   


 <3#3
!0
  [
3#"/
 7
 "/&5<,
, 373 5<
,  #"/ ! 3
 8
3. Contribute to health system strengthening (!!"#!"74&, 7,/7:3)
 &,///

 5&, 7,/7:3  / " 3 #/ 
 W
&, #  "3#7,
/<7!
 
 /33"/ 7,<5< , = 

 8
 3 7,* &3!9!"7  ]
 8 &"/ 3
//# : ,
4. Engage all care providers ( #!3"3   7,
3!"74)
 #!3#337
34], ##337
34]
 (Publicpublic and Public-private Mix : PPM)
 /]<5< , = #!" (International Standards for TB care : ISTC) +
72 3 Z&Q#;5<, = 123#!/-!3 !/<
!+ ,,! 9!"77
333 8 3 4]#

5. Empower people with TB and communities
 #", &,/!+%!
 !"/#!3/ 
 &,/ /<, # /##
/! /&"/  Q#&5<, *, /-237/3 7
3!3/

5< , =  (Advocacy, Communication and Social Mobilization :ACSM)
 Community participation in TB Care "//! /&<5< , =  *, &,/<, 5 <, = 
#% &,/<, /"  !3 !/
!!/&    3
6. Enable and promote research (!3 !/'2; *,  3 Z  &+ 3
"/ '2; 
 9 &/ 8 & Q
#&/ #W1 ,
2.2 "5)  :7 ;!
53"/3
  /  533 (National Tuberculosis
Programme : NTP) !+ # '* *,+72 3/!+,# 3 
#3 J.'.2503-2507  !3
 
 #
< 3 & 7 /
3#
# ' 533//337
3#5,< %7
3
30

/Q 8 /
 J .'.2507 (.'.1964)  #,
373<3"/ 7,
!9!"7  ]/
 < , 
 &,
"/ #*, # ' 3  / # 53- 
 /
&,9  30 3  &,*,5*, #5, < = #
" 7 2 3 # 

 
< ,*,
 #! +%
7,
23 :
,
3 
/# 7,-23//,
3 7
3
#, #3!9!"723*,+ /5333  J 2510 123 Z 
5!+ :&<Q1 1  !9!"77
3#3!9!"7&33 8 123
        !"#$%!& '()*+,(&$-#- .+$/+!00* 1 '.2



 
   


*,5&3/
"/ # [/
:
 7,3 #
/*,7
 "/
# : ,
3 &, &, 
   Q#&

!+, =#;,5,< =
  /<3&,!-

/&33 8 !3 ,,* #+!-


/ 23 
 +  !/#5,< / 7

123 /
!3!,,
3"'0 #&,;,5 ,< =   
  123 ## 

 5, < = 
 *, !!"&,  '3 !" 40'<0
  7 5
+ 3&#3 J .'.2510-2519 3*/*,5 
& 
 3*/
73*,
 /
 #3 !9
!"7/ &3 3&#
+ 4
(
/ 3"/) 3,  =
#;:*, #!/,,&73 +&,5, < = #&,;5, < = *, /72

  3"/:*,+,  +7


35, < =  #;#
+ 4

3/ #!94 #


*, ///
3 * #3'<0 3 /

"/& #;237/72 +/*, Z/, 2-3  & $"
! -
/ # ' 9,738 3 / 7,//! /&53
 #0 /&,, =#;& J 2547 !+
#'<0
  7+ !/# #/ 20% + !/#3 /- <  # ' 123 !/5< , = &## 
 *,-32 38% +5< , = &## 
 3 / # ' #33;5< , = 
-23 #/ 13% +5<, =3/72# ; # ' !! 
7
3/7,3,
+ 3 '././.  # ' !-!3"3 /, 3/, #3
/, !+3+3 (.+), /0, /<9 #4
3 8



 
   


2.3 &60"#7) 


&0 &
2.3.1 +
"# :7 ;!
 
 ;#. .<!7" 47
35< , =  
 5 <, = #*,+/& #+*, #!/
<  /
#"/*,
 
 # 
 &"/ 123 #/5+&,7 $% #/"37
3
3*/  $%3,!9!"7
2.3.2 6 ;,)  :7 ;! 
 Q #;5< , = &,7  Q#5< , = &## 
 #5< , = 
 
3&# 
 5< , =  #/,
# 50 # ! 4& 2-3 J */*, ;

3*:5 <, = * /


< ## 
 #,
3*, ;  /7
, 3 &##"/
(Active TB)

        !"#$%!& '()*+,(&$-#- .+$/+!00* 1 '.2



 
   


2.3.3 7 ;7) '7 :7 ;! 



 =
 # 
 7
3 #3 */  $%3,!9!"7
7
3 # '
2.3.4 /;7'  % ;5, 7 ;7
9 + 3 
 &,"" /"3 /
1. ;5< , = ## 
 &,/
  5!+ :&; (Success rate) 

; (Cure rate) #; (Complete rate) /*/
,  ,
# 85
2. / /
"/# 3,5< , = &/## 
 */
,  ,
# 70 7
3+
5< , = &/## 
  #/
<& "/
2.3.5 &60"#'=5 :7 ;!
"9'!0 1 !,3 !// 7,/7:3+ 3/]3"/3 
/! /7
3"/#
30   7,
3"4!
"9'!0 2  3+ 35!/5!#
!0
"9'!0 3 !,3*///
+ 3& #"/ ! 3 ';#
   
"9'!0 4  ?[#3 [
3#"/ 
7#W 
7
,
3 Z  !<
"9'!0 5 W'4"
3 #
"9'!0 6 !3 !/!!"'2; #W3"/
2.3.6 7;,=5 :7 ;!
 ;5< , = ",/  #!94&3##   3

  Q5< , = &## 


   8  !/#,,
3"'0
 3 
77
3,,
3"'0 #/#"/"4
 3 ;&##7
3#!9!"7
 &,!!"#+/];
3
 
3/3/#"/
"47
3
 &,/ #2#3  /]/3
30
/
 /  #057
353K  #05;5< , = 
 &,/  '#?
/!+ ,,! 9!"7&"#
3

 3 &,/ &,
/<, #!"7'2;- < ,
3/" 
3

 3
 #! NTP 3 &4]#3
  3

30
 KK
 /+ 
 W NTP
3

 3



 
   


2.3.7 !  &% !5


7 :7 ;!
 5;5< , = &/&## 
 5< , =   1+ 5< , =  ;,/  /-235< , = 


#
* /
<& ## 


 !/# ' 
 (Conversion rate) /
 ! !"## 7,/7,7
35< , = &/&## 

5< , =   1+ #5< , =  ;,/ 
 /
"/7
3, =&/   


7
35< , = &/ !/# 
 +/
" # '

!7
3+5< , = &/ !/# 
 
5/7
3+5< , = &/ !/#*/ 

#5< , = 



 
 & !/#7
35<, ! 3! = 
1. 5@ 3/5;3
1.1
5!+ :&; (Success rate)   ! +%! " & , # /53"/
 
; (Cure rate) #; (Complete rate) /*/
,  85% 
   &/
 ;+ 85% !
5;
 / %
$  " &

%,

     % ()


X 100
    ! 
 ()

1.2
  7
3 !/# (Conversion rate)   ! +%
33/
; 
!/-3
!-0*, :  ,
   7
3 !/#&5, < = &/# 1+ 
*/+ 85% !+5, < =  # 4
 8 */+ 80%
 "#$% =     #$% & 
$' #* ! #+,$ () X 100
    ! 
 ()

1.3
; (Completion rate)
 

      
()
    ! 
 ()

X 100

        !"#$%!& '()*+,(&$-#- .+$/+!00* 1 '.2



 
   


1.4
7 (Default rate) / [/+ 33
, 3*/
,  5%

,

    , ()


    ! 
 ()

X 100

1.5
,/  (Failure rate)  
 ,/ &;5, < = &/ !/# 
 */  3%

$%

     $% ()


X 100
    ! 
 ()

1.6
 (Death rate)

-

     %"-. ()


X 100
    ! 
 ()

1.7



 (Transfer out rate)

. 

   .  5$


 ()
X 100
    ! 
 ()

;7; * 
    ,  , ,  !,
"! #$ 

2. 55;*
2.1 /
"/7
3, = (Case detection rate) !+%
23&
53"/ WHO +;/ #!94
, /
"/7
3,
 =&/*/,
 70% 7
3+5,< =
 !/#  
#/
<&"/ (123 $"&,
 +*,!<7
3 WHO)
$ 
+$"  % =    -. ,#$%
/%$  2
/ 
3 X 100
   -. ,#$%
/%$"! %$,
  , $/ 
3

10



 
   


2.2
 J (Case notification rate)    3 
-23,/7
3, =
/
  #0 3  ( 
,  J) #3 
/100,000 #

 2
3/100,000

   -. ,#$%


  2
/ 
3
 8"! %$,/ 2' !   ! 9 ("3)

2.3
 +//"
"# '    3 
-23,/7
3!-0
 
 
&/" #
 "*///,/3# 3 -23# 
 
, 3 &7#
 7
3
& #! 3<
"#, # #! 3<
"! &%# 
 / J

! J, / ,
& '#%3*/3/ !! /
%3/ 8 #/&,&!
*/ 7,/7:3 3
  &7,
! /-+*,
3, =
 4 

2.4 !!7
35, < =  !/#&5, < = 3 / / 3,
!&7,
 # #/
1 : 1 /! !  !/#/ 8 #-23 Q5 (Over diagnosis)
#,# "  #$%


   #$%
/ 
3
   -. "! %$,/ 
3

2.5 "47
3 !/# !
"47
33&!<  ,
!/#5, < = /
 !3!#&,5 #/ 10% (8-12%)


" #$%

   #$%
  2

X 100
 $  #"#  #$%

2.4 &&) ; ,




&&) "'
 + "9'!0 35#+3 #/!+ NTP
 + &  
353W"#?
/&, ,,!9!"7
 5,< #!3 ?[#3&# # '
  '3&, !+3 [
3"/ 7 (!.)
 5, < #!3 NTP &,
304]#
 8
 + W< #+/] 
 !!" NTP
 3&
,3
3,#!<
        !"#$%!& '()*+,(&$-#- .+$/+!00* 1 '.2

11



 
   


&&) "'/ 7)


 #!3"/& 7
  '#?
/"!9!"7   7,
33"/&# 7 3 #
+ 4

 + W< + 3"/&#    


 !!" NTP
 /# # /53"/& 7
 #!3"/#33]#
 8
 3&
,3
3,#!<
 ?[#3 / #0 %
$ &#  
&&)   !./  &./  0./ CUP
1. 55;*
 ,5,< =/
!3!/ ././'.
  !/#&5, < = /
 !3!
3,
 3 3
 ! + Q5< , = &##*/ 
 (-43!3
)#



2. 5@
 &,/,<#+ 2;5,< =",&
#/ #0
;7
35,< =
 ;5, < = ,#  /#!/ (//<
) ,9 DOT
 
5, < = &  :* ;3 !
.
PCU &,, 
 25;&25;# DOT card !+5, < =   ; 3
  !/#&#3;/7,
+
 /5,< =7;&, :!"
 ;5, < = 
 !
.
PCU #,
/
1,

3. 
" ,
;5777 '7
 '= ,&%
%)5 &

2.5 &&) ,5 ,


&&) :5E 
"
; (Provincial Tuberculosis Coordinator : PTC)
1. , '"/+5+ 3#3
  ' ./ ./ './ CUP !!
. #3
3,
" 4 

3
 &,?!
"!9!"7&7#  ' (On the Job training)
2. ,/ # /5 2#3
 +# #3
 +3
 3 
 4 3
3, = (.
0/ TB07) 35
!/# ' 
 /
 ! !"## 7,/7, (.
0/ TB07/1) 35; (.
0/

12



 
   


TB08) #3+ 35!/5!#


!0 (TB-HIV01) 7
33#!3
&,5,< #!3# 7
3. ?[#3/!-0#3
&&) :5E 
"
 '= (District Tuberculosis Coordinator : DTC)
1. , '"/+5+ 3#
+ 4

  ' !
. #3
3,
" 4 

3
 &,?!
"!9!"7&7#  ' (On the Job training)
2. ,/ # /5 2#3
 +# #
+ 4

 /+3
 3 
 4 3
3, = 35 !/# '

 /
 ! !"## 7,/7, 35; #3+ 35!/5!#

!07
3
+ 4
#!3&,5 ,< #!3#3
3. ?[#3/!-0#
+ 4

&&) 5;5&%"+ 7/PCU


1. ,, =
 ,5, < = /
 !3!/  !
./PCU
 /
 5, < = /
 !3!,
+ *,3 
1. !35, < = ,
/ : !/#
 ,*  ./ ./ './ CUP
2. !3 !/#* 
3. &/  /,
/
 [!*0 !/#!3 ./ ./ './ CUP
2. ,;
 &,;5,< =Q /#0#+
 2;# DOT !+5, < = #  ; !
./ PCU
 &,/ 3&;!+5,< =#
;
 : !/#7
35, < = &#3;!3
 /5,< =7;/;
&, :!" #+*,
 !35,< =/
,* ;
 ././'.
3. , [
3
 &, 1 1   "
 &, 1 1   :  .1 * // 5  1 
4. ,!"7'2;
 &,/, < 
 35 ,< =  % #"/
5. , '#?
/
  '#?
/ 
 3&,
!/. 5,< +"/
        !"#$%!& '()*+,(&$-#- .+$/+!00* 1 '.2

13



 
   


2.6 &&) ,"6") % I


&&) ="!
 3 40#&,&;
 +/]#"!/7
3&,&;
 /# ?[#357,3 37
3
  :;# /  Daily drug packet
 &,+ 2;#/, <  
&&) 5;5&%!"E
 !*0 !/#
3-<,
3# 33
 /2#
7
35, < = #53&# !< (Laboratory register)
 :!*0 !/#& ,5#"5 
 "/"4
*
&&:5E ;5'J@ ( Counselor )
5 "#
 &,+ 2; 7,
/< /,<  "/ [
3;
 
35,/<
 !3!&5,<  

!0 #!3*  !/# 
 ,5, < = 
 !35,<  

!0  =  * 72 # ;  4&,9 DOTS
5
 &,+ 2;
 
 "
/" (VCT) 
,/,&, 5< , =  

(PICT)
 !
# 

*
/!/&
 ,35 
#35 
&, /#!/
 !35, < =  
*
 /,* 7
 
!0 
 &,/
! 7,-23,*!
2.7 777 ;"6") % I

30/!/&+#7
353"/3

30+ 3/37
353"/3
 !<!
?
/ + 
30   * /7
353
"/3#&,/!+%!
#?
/  
3
 53"/3#3
30 #!3#3 53"/
3
30  3 &##4</4 
2.8 !5 L L   :7 ;!
 &, 1  1   &, :! "  #+*,
 &, 1  1     /  
 HIV 3*//
 7
3 AIDS
 &, 1  1   : .1 * // 5   1  #*//  #  *, 1 1  /
 */
,
3!
" 
0< 

14



 
   


 " 5 
1. #3!9!"7. 3+ 3"/3. 3/0"/"/!0 ;3
# '* +. 2541
2. !+
* . 3!
</
!,3 !/4</,"/ : 3/0!+33/0
30
!3 #05'2, 2548
3. Compendium of Indicators for Monitoring and Evaluating National Tuberculosis Programs. WHO, August
2004 (WHO/HTM/TB/2004)
4. Expanded DOTS Framework for Effective TB Control, WHO : 2002.
5. The Stop TB Strategy.World Health Organization, 2006 (WHO/HTM/STB/2006)

        !"#$%!& '()*+,(&$-#- .+$/+!00* 1 '.2

15



 
   


/]!  
<; *,W72/"3/  
!!"/!#7
3
5< , Z  3 &4]#4
 #*,&,<;5<,  =  
!3!# = &"/

"
3/
" 4 123 /3 5< , = 5  !/#,,
3"'0 #  


   
 
 
; #  / 

*
 3 5<,  Z  

<&53"/# Q#5<, Z/*,


<&53"/, #  
&,5<, =
#"/*,//<, / 7,&  
&,!/-!"47
3*, #<;

"#/  
  
/ 5
 "/,
3.1 7M N
7M&% 1 5</,
 *
!/# 2-3 ! 0 
 * /
9! "*, 

7M&% 2 5</,
 !3! 3 5<&, %# :  : !/#
3,
 2 
3
-,*, 3 
3:3  
3,
 1 
3 :3  
 ,
7M&% 3 5< , = ! 3!
 !3 
 ! 3!  
 ,
,
3"'0 # #  3 
 #39  -,#+*,
7M&% 4 5<,  43!3
  35   #  !33,
3
Z  ,
7M&% 5  Q
  !/# /-23 5 !/#,,
3"'0

3,
 3 
3 (/3
3,
 1 
3 :
 ,) #&,5
43!3
 35  7,*,  123 */!35
!
3

;, Z# (/ " :  
3 # 4 fluroquinolones /9

 

/5+&,5<, =72 23*/&,) &5<, =
3 -,#+*,!3 !/# #  3 
 &" 
!3!


*
 /&,*,5 Q

16



 
   


7M&% 6  Q& :/


  (*, 
 
 "/,
 
/+ 
37 
)
  !/#&,5  Q
' # !/5! 5
43!3
 7,*,  5!
 
   (
!
" 
0<  
!
 Interferon gamma release assay) !3 !/#


3-" #  3 
 -,#+*, ( : !/#7 Gastric
washing 
Induced sputem)
3.2 7M@
7M&% 7 5<&, ,<;5< , =  
/5
&,!9!"7
3!+%,

&,;,#/]  /#!/, 3,
3!/ # # / Z  /5;
3

 37
35< , = 
# #
,
3
,*7-, Z  /5;*/
 
 3#;*/ 

#&,5 <, = *, ;-,
7M&% 8 5< , = " (/3 /   

*
) * / *, ;/
 *,
;,# 23   
///]! ,/ 
 5 Bioavailability &## / ,!
3 
  #
,
Isoniazid Rifampicin Pyrazinamide # Ethambutol ##

 3 &,/
!" :
Isoniazid  Rifampicin  
!  
 77
3#7
&,7
, !
#! ##+&,&, /:/7 123 /3 !
37
!/7 #!7   Q#
33 5< , =   
3
7M&% 9 &,-
5< , =  '<03&; //,
37
35< , = 
#
/-
#35< , = #5<&, , ,
3/ 
 < !!"
"<  /3 &,/<, #&,+ 2;5 <, =  /3 !!"
;,  3&< 7
35<, = (Directly
Observed Treatment : DOT)
7M&% 10 /# # /5;5< , = 
 
 5 # /
 ! !";
/,-43!*/+  #+&, 55*, 5< , = 
5 !/#,,
3"'0 3 & 
 5 -
5;
,/  #  ; !5< , = 

#& :

/ # /5,
3
7M&% 11 2  
3
7,3 3 #53,
3 Z  
"3 3&5 # ;
7M&% 12 5< , = " ,
3*, &,+ 2; # 

*

7M&% 13 5< , =   

*
 *,  # / #-, 7, 0*, 
,*!&#3; :/!-  /#!/ -,#,
3&,
 3  
456   7 8 5
9%"*+%!"#$%!& :"!%;!+;- <$+ '()*+,(&$-#- =!+* 1 9:'=2

17



 
   


;/* ;,,*!123 //!11,


 
; /* *,  #&, Co-trimoxazole  
[
3  

Q
!
 ,
7M&% 14  # /40
  #+&5< , =   *, ;/
 
/
#! / 5!
  

<& "//  /"7


3
  5< , = 
/5;,/  
 = 
 3 ##
   !/#
#  3 
 #!
/*
 Isoniazid # Ethambutol  :
7M&% 15 5<, = 
7  Q# 
 Isoniazid # Rifampicin
(MDR-TB) *,;,#;!
3
<, 
#
, 
#3*,5
<
 3,
 4 7   18-24 

#,
3<
3 7,/3  
&,5<, =*,-, -,/ $% 2;
5< ,  %
3.3 7M7:! 5"6")
7M&% 16 5<,&,!9!"7 &,+#+#/5<,!/5!&,  Q#
:
"+ 5 J #5<,  

*
 
  
 # =
7M&% 17 5<&, ,!9!"7 ,
335< , =  3 5< , = &/ #   #
5;7
35< , = "* 3!+3!9!"7&   
 35#
+
*
75 5
&!7
3#W ISTC  / 7!7  "%!+% 
 3
, 3
 / /* ,+*,, 
3 ##'2; (123 3 
 3:+3+ 
<
7#) & 7!7  0#
&, ]!!"<;!/ "!/5#
/]7 2
<  ]#"/  & 7!7&, Z  #, #
!3 !/// +3+ 
< 123 3 :3 
 W 
 3/
&/ 8 
 "/
;" International Standards for Tuberculosis Care (ISTC)
 TBCTA (The Tuberculosis Coalition for Technical Assistance)
123/
30/

CDC
: Centers for Disease Control and Prevention (USA)
ATS
: American Thoracic Society
IUATLD : Interantional Union Against Tuberculosis and Lung Disease
KNCV : Tuberculosis Foundation (The Netherlands)
WHO
: World Health Organization

18



 
   


R) :E5 * "';E ,@


The Patients' Charter for Tuberculosis Care
The Patients' Charter for Tuberculosis Care (The Charters)  *,3 ,3!9 #/
5
7
3 (TB) &,
+/  3#"/7
353/< , 
 3
  / #W5< , = 
 3&,/!/90 

 #0132 #5<&, ,
<!"74
+-35<, = "/ 5<,&,<!"7434
 !9# #]
!/-#+3/
3 ", !&3#&/!/90   5 
  "3/]7
3
<; ## #!957
3#<!"74 
/&,", !3 /,
35

123 # !!" Z   /#3# " ", !&3"
W//<;//]! (1)  
!!"9
"&,'< 03
< 5 <, = "  2
<  7
3!"74#!97
3/";0 7
3! #
30
'2;'!0 #W9/3! # (UNESCO)
30
/ #!4" 
,
3- 3 ## 5
 8
3*, #/3  90/ 72 7
3 (GIPT : Greater Involvement
of People with TB)    &,
+/   #", +3/&, 5
5<&, ,<!"74# ,, #+ !+#&
!<  
 "3  123 /]
<;# "
+7
35<, =" #   
3/
3//


//
"  / 
 "/3 /
"&6) :E5*
1. E ,@
. !9& 7,-23<;
3 !#//"9 / 3  Q! !"
;*/+23-23 
  '
" 4; ]#3/ / 
 -
3'!  

+'3   ' W9/ 
]#3!"74
7. !9&#+30 #;  7,*,
3!/<0 /]!
&/!+<;  3 :3
<  /,
37
35< , =  /3 5< , =   
 
 7

  
 / 

*
#; 
 [
3!+ : : #5<
,   /  / ! 3!<3
. !9 #*, #034!"747  
 

* !< /"  &, 2; 30


[
3123 !7
353<!"74
3 : !:
2. 00W 
. !9&*, Z,/-
#!/  /3&,3 8 
',
 
 
  / 3 5<&, ,!"74# ,,
 3  
456   7 8 5
9%"*+%!"#$%!& :"!%;!+;- <$+ '()*+,(&$-#- =!+* 1 9:'=2

19



 
   


7. !9&*, <!"74/  
" 4!<3&!4#,
/! /  ,!!"
,+3&
 
  #"/
3. )5 7E,)"
. !9&*,7,
/<7! <;/
< #/5

/
#&, 3 33#3
,
/   7,
3
7. !9&*,3  # # /#!/ 7
3!4#30
,
/, Q + (/ :&+ 7
3  # &
) #7,
!
& 
 3
;-
&,-23/ !3/
#3 
 /#!/
. !9 #
 #7&,7
3& 8 
9 133 8 ! 3 ;5
 #57,3 3
 #/ #5#  *,
 !4##;
 8
3. !9& 7,-237,
/<30   7,
3!47
35< , = #; #!+ 
7
3330-, ,
35< , =  
"* , /

+5< , = 
. !9 # # /< , #!0 
  #5< , = 
 8 # 2;!/&
/ 
&:*,3Q* -23!!";
4. &, 
. !9&*, / :30 #!
3  7,-23330&

7. !9#
/
Z !9;'/ -,;&, !3 * *,
#&,*, -235/33/#30 # * *, 4&
7
3

. !9 # 
#/! &53 */ 5


<;
5. 7 5
. !9&*,  
/!"  / 
 -
3'! #W9/
7. !9&;/   7,
3!4#30 7,
/<   5
,,
   8
7 2
<  /
/7
35< , = 
6. 76 7
. !9& ,
35
33  &,/* ,!+-" #!303  ,,! 7" 4
#,
3&,+,
3 *,
3"9/
7. !9 #
"90
 ,, #! 3< 72 -, ,
33*/*,  #,
3
*,,35 ;0
;
7.  #
. !9& 7,/ 
3
307
3
  #!!"  

W!/!#!//7
3"/  535<&, ,!"74 ,, #!// 


20



 
   


7. !9& 7,/&]# "5<,  /  ,7


3" &W+  /#
# /5#53 ,,,
3-# # ,,!"74#
8. 
7, =
. !9& #&+33 43*,  Q 
. .<!7" 4
 /#!/ / 
; !:!,
7. !9& #34 

 !/ -,+ //,


37
3;
7:! ) :E5*
1. 7E)5 5 7E,)"
. /5
&7,
/<7!&,/!"#/*, &,5<,&,!"74
& 
 3!"74& $"  : =&

4</ ,& 8 ##
! +%
 8
7. /5
&7,
/<7!&,5<,&,!"74 &  
35<,!/5!7
3

5< , =  
  #
 8 123
# ! 3
 

#*,  
 ,
2. &'7@
. /5
&+/#;* ,!3 #3, #
/ Z  /
 #
3 
 [
3!"747
35< , = #
 8
7. /5
 #,35<&, ,!"74-23/+ # $%&+/
;
-,/;!&3*/ 7,&
3,/,3
3. !;, ")= ) !7!
. /5
& 

/
< 7
3"/ 5<
,   &,7
+#+3
0-,/
7
3
7. /5
 !3/
&&!
 !97
35< , = 
 8 #5<&, ,!"74 
7,&
 ]/ #]-
7
3"/
4. 7"7
. /5
39/ #!3/!/ 5< , = 
 8 / ,* ,
!<
7. /5
39/  / Q !37,
/<7!#/<, * , #3
;#/+%
 8 &"/ +&,/

+
#* *, :
. /5
39/#/&//#+&,"/ '
3 + &, /3 !!"5&,/+ &"/ &0&&%7
57+ LJ%  ,
 
"7+
77ME ,@

 3  
456   7 8 5
9%"*+%!"#$%!& :"!%;!+;- <$+ '()*+,(&$-#- =!+* 1 9:'=2

21



 
   



        
!"#$%

"#"&  ' () ""& $* & '+' ",!
 !-' .
 #
%'% 
   /* -"& $*

)/ # ' 


     '.0 
 *$ "& 
$* 1#  &-'&   2
"#-'/() &3
4 
4.1  
  
  
    
4.1.1 
 (Passive case finding)
0 $%!5 6 &&  "& $* %'
 $*

!$%
0  ',
 !56   $%-'& &   7%'
.
4.1.2 
"# (Active case finding)
0 $% %'
 -56  ! /6 30 , 
#
4()  
)0  &&56-'&  7
 *  - /
. ,8
+#  +- /& 
 *# ',
 ! 0     +' (Cure rate)

 /) 85 ()
/  ,8),'&($%0
 +'!
 /) 85
56    & ' #&* &&!& +/ ,
 * /-
. !"$=> *& 
 *  ,8!)/ *
7  / ?
/ !56  5%!)'    

4$% )* / %+,  '
  ' ()  ,8 '* 0)* /     '
0 HIV
4.2 $$ 
 ,8$%' 0 -
0  '// 2 '= 0 ?   &-'0
,)',
&0 , /
) - ( 
4&/
. 0)0) - 
)0' (Haemoptysis)

.&, !'

22



 
   


4.3   % & 


4.3.1 %$' *+, "+

0 $%')*)3= Direct microscopy 0 Direct smear
4  )
&* $% "& $** '&  "!/ & 
  ')*)3=

0 ! &  &)* %' "# /



) 
0 (Culture) ! >*& '#
 % &)/ ?
!6   ",-'()  8
> 0 " & '& -
0 /1#  ,
%! &
0 $%!
  # /6 & >/-
1. '$' 
!(/)  
.&/- // 5 )) )  ()  $
*  0 ) +$
4
0

 /*
 ) -'- - /!/),
2. '"+  $' 
 % &
0 $%%'')*)3= !
  1 ).  
0  $
10,000
1))=# -1# % &
0 (/ ) 50 (/" !
   $
0 /"6 # 500,000
1))= 0 /
% &
0  "# ) 99.95 " $
0 / 10,000
1))= % &')*)3=
 )  (/" !  %'

) 
0 . /!
 =%-'   #
3. %-  , %
!(/J &   3  ' 0
, 1 !56  
.&
   (Spot sputum) &!/ ()/
, 2 !
 -% &) !56  
.&
 
0 0 
/)
(L> &!/ (), / (Collection sputum)
, 3
4/
  Spot sputum 
 .&) ,/  2 /()
/$' 
 
 .&
  /"6  ,8
/ ? &  /"6!J &   "-'
"*/ (Specimen) '*$ . - %=!5)5 ' )'-' 0" ,"

/$'  !'0",' )  ( 0%) (/- /! '+*&


- (Paraffin) 0
, 
 
)/  '/&6  Smear
4  ())  '  Acid N fast 0,J   &
Non acid N fast bacteria ,!J
 0 Acid N fast -'   () )#  
0 !56 
&
  -' '  Q
)R'-'(/T -) '
5/36=) $ 3 1. . () )#
 $ 2 1. . 0  * $ 12 ). () //!56  R'7)0 ()
)    !

&/
 /$' %5
6  J &   ),'&'
1.  &!56  
!
/
*5)
.&
  ()  -  () &!"6 
2. !56  &! '/
0 - /!
 3+ 
  



23



 
   


3.
R'Q"()
.&Q- /
7  "!56  
4. &!56  - (!'R ()  6' '+
.'05
.'/) -" 6 
06'!)# ? ) ! /6 ()(-!
  # )')
0 -'
  ()!"#  '
 QW)// ? )/!
  -))!"
   /"/ 
1.

XY   -'
 
/ 5 ).
5. '6
  
 .&-'
  ! -''  )  +$
4
0

4/*   
)0
0
 - /!/,)1#!0
4L " 
.&-'- /"60
 - !56
.&

() "56- / "--'! 2-3  !56   
06#/ 
  #/-! /
56  - /-0-()- /
   !' 0 ,  ? /(6 )-0!,
)/0,
)0) 0!
7') ,
)0
)') .  * !56  -/(() &
   -' '/!56  
,! *!3 + )!Q 0
 ')
& ? .,!56  &
   -'' #
6. R'Q"
  !(/()/J &   - / "/-' ! 
.&!
.
() /!"6 ((''/ 7 
   &6'
/ ) 
 . ((/.  % &
0 $%-' %'
')*)3=)  ) 0! ''&/6
 %$'  "+ 7
 
%# 8
 9 %$' 7  (Direct smear)
 %'!- 

  ()T)&(5/ -)'=
%' 
 4  ! 

4   /   ' () '
.  ",-'!"& $*
* '& 5) &
0 $%# /6 & ,
0 !
       
.  J &  0
 
0$%!
  - /
/ '
)0

  T& -)'=#,8 
"
 &
$- /
 0 0 
0 , T. - / &0 &
0 -' #,
4
)0
 / /
 
0  '*  0 /
 4
0
 /* 
 )  &
0 -'/ #
9 % $'  (Concentrated smear)
 %'5/  /
  '

 /,!
0  ,
 (), >\'
0>\


7   
  T&
(5/ -)'= ,! &
0 -'/ # (/ !
0 >\
   ( >\
 6"# 3000 xg # ,
!
0  '#
/
  %'!
 (  ,!!0 ,L5    ,/!)' -
/
Clorox  /5  Sodium hypochlorite  $) 5N10 %'5 )!
   $
/

/!
' $ 5  (), >\ !
0  Centrifuge 
. 3,000 &/0
&
4/
Relative Centrification Force (RCF) -'
/& 3,000 xg 0 /
4
) 15 
0 !
0 $%
!
   
,/!  (), 
  T& -)'=
0   ,! %  &

0 -' # () ,'  ' . - /   /56 J &  


 _ /
0 $%!
 
-'' #
  !
7    ')*)3=
/  ,-

0 - /-'
0 
0 $%  '

24



 
   



  ')*)3=
4 '*' !  7$%'
  
 ,!56 '-')/()  "#56/
4$%'
 /#
56  $%' 
4$%'/ ' %$'  %% :
 3 
 
/
 )'  756!  ( /
0&

  - /$' 
1. 
.&
   (
.& (Spot sputum)
0 56    ( %'!,( ,
!
.&
  " 6 (/56  ' : !56  6') !

.  ) !  # ()-  )
-'
  () &/
  - '
 0- / - /
 
.&
  ! / 
2. &)&
  !56  )&&
0
.&
  
 (Early morning sputum 0 Collection
sputum) "'  %',( ,
 0   ,&56  /
0 0 - /&
    /

.&
 
3. )56  )& /
  
()
.&
  56   %'  
'&
.&
 
 
4. !,( ," 6 !
.&
  (/56  ' : 
.&
  !  '  '0!   3
"/
'() ((''/"#
 "56  - / "
.&
  $  -' !
.&
  
 3 
 ,T
  )&-)'= 1 (5// 1 /
    -!(/#,-)'=
-5/&
)-L (Fix) 2 N 3 
 ,)
  
 )0%'
50Q> "- / ,

) 
0 ()
 (&&L= 6()/-)'=() (&&L= -/ )*)3=

0 ')*)3=/ -
 (5/ -)'=! !T
  
4-)'=! / () !
'  - /  ,)&
)!! /

   %'"&    )*)3= "-)'=
  / 2 -)'= !5)&
56 "6,(
456 
  &  ' 56()
  + /-.
 "   +$%/
  +
0 -'! &&"6/-
 %$'  "+ 7
 * "+
%#7$ 8

0 //- / "')*)3=-'

0
  $() 6 = '  0   
0 $% %''&*$ &
 () 
 

0 '& -
0 /+,&!
4(!+/    

0
QT '0
0$%!*  0! 0
3+
7 
/!
0,
('
4
  



25



 
   


" 7 :$:%*+,* "+


(&/
4 2 
 0
 Pulmonary specimens
/
  
 Extrapulmonary specimens
/ CSF, Gastric wash, Urine, Plural fluid () Tissue biopsy
%$:%* "+'+,7
  5
6  ':*+, %&
-
0 
  ')*)3=- / &
0 / 3  # -
-
0 -
0$%/!+
-
0    50!) '&56'0)
-
0 
QT '0+$%
  5
6  , -7'; +< =-
0   *' 
 
  ')*)3= &
0 AFB
-
0 
/56$%
-
0 5)+
  ')*)3= &
0 AFB !
'0*'+
  5
6 ,< =-
0 
  &
0 ')*)3=
-
0
4  ! /+
* "+
  

) 
0 $% "',
 -'    2&5 -/  
 4 '
Ogawa media () Lowenstein-Jensen media   # &  *$=  ! J &   1# -'(/

0 >\
 
.6(&&,
.-' %'  
.&- /,/ 3,000 xg /
0 
 ,'
0 
XY 0 ? !  !) ) 4% NaOH
 0 / Ogawa media !,&
',
    "Ogawa method"   ""/
0  ,'  
XY ())& Ogawa -'%'
(/,& Lowenstein-Jensen (LJ) ,/5 / ,'
0 
XY 0 ? () ->\ )',)
_/
0 0 , Phosphate buffer '
0 >\
 
.6 / "/
0  ,'  
XY ())
& LJ     "Petroff's Method" '   0 % &
0 -' #
 *"+  Ogawa method
J & '0
1. *$=
0 ! () ,
- , 4% NaOH _/
0 ()
- 
) 
0 3% Ogawa Medium
- Pasteur pipette _/
0 ()

26



 
   


- Transfer pipette _/


0 ()
- '( Mac-Cartney
- )' ) ,&>\ Q
)  * 50 )) ) 
2.   J &
- "/
  "
.&
  !/!'(0)' ) Q
)
-
 , 4% NaOH )! &*
  !/ 1:1
/  $
  "

   0'/
/ !
 / 4% NaOH
4 2
/  $
  R'Q'/
)'!(/
- 5 !
'&
0 
/5 vortex mixer ()   - 15  %'! 0
/
4  ?
-
0 &
)! Pasteur pipette 0 Transfer pipette '6'() !/
 
 ,'
0 
XY ()')& 3% Ogawa ' ? ) 100 ul ( $ 4 ')
- ,
6 &
0 *$6 37oC  8 '=
- /5)*'=  
 8
0
 '#
- )&#5)

0 () ',
 &0 '
0 $%/-
 *"+  Petroff's Method
J & '0
1. *$=
0 ! () ,
- , 4% NaOH _/
0 ()
- Pasteur pipette _/
0 ()
- Transfer pipette _/
0 ()
- '( Mac-Cartney
- )' ) ,&>\ Q
)  * 50 )) ) 
- 
) 
0 Lowenstein-Jensen medium
-
0 >\
 
.6 
.&- /,/ 3,000 xg /
2.   J &
- ',
    
'&  Ogawa method &,'
) ,'
0

XY ', 4% NaOH 15 
-
0 ,'
0 
XY 0 ? & 15 () !
 ,) # _/
0 ()) !)''&
"#'&  50 )) ) 
- ,->\ '
. 3,000 xg  15 
-
,!// &  %'!  ,
)0 ')''& $ 0.5 )) ) 
-
  ! ' ()! Pasteur pipette 0 Transfer pipette '6('()

  -'')& Lowwnstein-Jensen medium 2 ' ? ) 100 ul ( $ 4 ')
  



27



 
   


- ,
6 &
0 *$6 37oC  8 '=
- /5)*'=  
 8
0
 '#
*"+ (Incubation)
&
0 Primary culture *$6  6 &%' - 6/  37oC ()  
.*$6
6 &
4 ,*
 %'  *'&#*$6 ! (/) 
0 &*  ,6 &
: 5*"+ (Culture reading)
/
0 Primary culture  ( 
  /
0 5/&
0 -() 3-5 
0 '6)* /
0
(Colony)  
4 
 8
. (Repid grower) () / /*'=
4 
)    8 '=
& (/
  &
0 !)&#5)

0 ! *'&#5) 

0 %'
7  "& 8 '=()- / 
)* /
0 !
.#/ "No growth"    &#!/5)-'(/
1.  (Growth rate)
0 (
0 
4 2 )* / 0
-
 8
 &%
. (Rapid grower)  / 7 
-
 8
 &% (Slow grower)  
 / 7 
2. ,)* /
0 (Colony)   &&

3. )* /
0 
  8
- Non pigmented 0 Nonchromogen )* /
0   (White), (
 (Buff),  (Cream)
- Pigmented 0 Chromogen )* /
0 
 )0 
)0/  ('  6 0,)/
- Scotochromogen )* /
0  
 4 Pigmented
0 &
0 - !  '0 ()  / () 

 #
0 "6(/
4
)
  2 '=
- Nonphotochromogen )*/
0
4 Non pigmented (  "6(/
4
)
 
2 '=
4. )+$ )* /
0
- Eugonic 0 (   ' 2-3 .
- Dysgonic 0 ) (&
& ' 1-2 .

28



 
   


4.3.2  + , ? ", :   % & 


 @: 0*$  %=- / !  7%
 ( (/( =
0( =  &$= ? .,($%!  )*) $%  &0%0-'- /'
  %=/)56 
5 ' -' /-.    7$%"/ 
() 
  &/-6 '* #   7$%'  ,
4!"/
 
 0
/ 5 6  $% (/
  ) ()- / &
0 
56  5% () '6 (10 ?
4
 7$68 6 
4'& '
0 $%  %=  !  7
$% 
!
'.- /
-'& 1 BCG 5)6
&=)6  & - /-'&/  
4$%!,
'&5)
)& .- / " ()5)/- /
4 $%-' '&6
&=)6    %=!
'.*,/ 5 W  
- /
-' BCG (/!5)'&
4 &   &/" # $='
0 $% 1#  %
4$%
!  )*) //5!6 8/ /-. ! 1 &1 .  ,!()5)6
&=)6  !
'.  #
   6   & /!56 '
0
-. ,!(5)(/-'
   7
3)
/
'&$%'  &
0$%#
4  7(/

0$% ' ,


0$% %  &
0# /  7%
/!8/3 
0  ,
 -' / ? / &() ('

-'& $%
4
0 /
B8 % &  7
1. 56 )  () 5)J & 
-'&$%'
2. 56    5 )   
-'& $%'
3. 56    5 )

0   / &
0 $%

  



29



 
   


$

1. 
 * 6 $%J &  ,   &$%(/
3- !  & 6" = % =(/
*)$=  ), 2529
2. (',
 '6$%(/ , ,%
'= $% () % '/
3 =
=  4,  2547 % =3 ISBN : 974N297N224N9
3. &88  8=, 
 * 6 ()   =
 8
0 $%!$%   &$%(/

3- !  & 6" = =  4  2542 % =(/*)$=  )
+ 2542 : ISBN 974-331N083N5
4. Kawai M., and A. Fujiki Minimum Essential of Laboratory Procedure for Tuberculosis Control. The Re
search Institute of Tuberculosis, JATA, 1988; p.53-54
5. Kubica GP., Dye WE., Cohn ML., and Middlebrook G. Sputum Digestion and Decontamination with NAcetyl-L-Cystein-Soduim Hydroxide for Culture of Mycobacteria. AM.Rev.Respir.Dis. 1963;87:
775-779.
6. Kubica GP., Kaufman AJ., and Dye WE. Comments on the Use of the New Mucolic Agent, N-Acetyl-LCystein, as a Sputum Digestant for the Isolation of Mycobacteria. AM.Rev.Respir.Dis. 1964;89:
284-286.
7.Petroff, SA. A New and Rapid Method for the Isolation and Cultivation of Tubercle bacilli Directly from the
Sputum and Fecae. J. Exp. Med. 1915;21:38-42.
8. Van Deun A. and F. Portaels. 1998. Limitation and Requirement for Quality Control of Sputum
Smear Microscopy for Acid-fast Bacilli. Int J Tuberc Lung Dis 2(9):756N765
9. Vestal A.L. Procedure for the Isolation of Mycobacteria DHEW publication No.(CDC) 79-8230 U.S. Dept of
Health Education and Welfare Public Health Service. Atlanta, Georgia. 1978. P.129-130.

30



 
   


5.1 %- 05


6 
  7$%0 56   
4$%  )*)
0  !+56  !()
*'( / 
0$%-/656!) '() * 
0!  7() ,(
56

0' &&+!
    
5)+
 && 2 1#  "&
 6)"& *(/!
4-!( 2
'
0 
5)  
3
,(56    4 (&& '/-
1. ,(  
4$%
2. ,( 5)
 
3. ,(  *(%
4. ,(   +!'
1. %- ' , < 
  7 (Pulmonary Tuberculosis : PTB) 0      $%!
0 ' " &
 5 '  / ,
)0 ' (Mediastinal and/or hilar) 0,!
0  * ' (Pleural effusion) %'- /
&(5)!
0 ' '/!6 
$%' (/" &$%
 0 '/ & 0 ?  ,(
4
$%'
  7 (Extrapulmonary Tuberculosis : EPTB) 0      $%  0 ? 
!/
0 '
/ 
 0  * ' / ,
)0 /  &&
' > 5   '6() 
0  *  
  7# &
0
0   ? ()
'!& 3) / &(')  1# ( =
'  !+' &&+$%
2. %- '5$' 

4,(
56$%'-'&
  () & 
1
='
/ '
0' &&!
  
      

31



 
   



 7, $'  (PTB+)  "#


 56    5 )
  '  Direct smear
4&/ 2 
 56    5 )
  '  Direct smear
4& 1  ()   &(5) 
 !
0 ' 1# ( =!  7/
4$%  )*)
 56    5 )
  '  Direct smear
4& 1  () 5)

0
4& 1 
  7 $'  (PTB-)  "#
 56    5 )
  '  Direct smear
4)&/ 3  (/  &(5)
  !
0 ' 1# ( =!  7/
4$%'  )*) - /&/!J  
() ( =' !!+'$%
 56    5 )
  '  Direct smear
4)&/ 3  (/5)

0
4&
 : !$- / 5 )
  1#  &-'!56  5!6 8/&    () - / "

.&
  -'0!56
'.
).
  /- /-' (This group includes cases without smear
result, which should be exceptional in adult but are relatively more frequent in children WHO/CDS/TB 2003.313)
%' -()! 0    /      ' /56  
  &/
65% 56  $%' ()  $ 50% 56  $%*
 (/ )&! 0      &'

'=/ '
3. %- ' '# 
56  $% '*(  "# 56  $%    "# ()
 / /

/ 56     *($%' '( / 


/ Miliary () Disseminated
56  $%' ,(/
4 '*( -'(/
0  *  
0  * ! /
0  * '
2   '6) ),- ()  &&
' >
/ 
 4% ,(/*(/ -'(/ / ,
)0
0  * '
'  '6 (

 '6)) () 5 
4. %- ' ; 7
)
   756  /
4$%()  1  / 56  
+$% /0- /

   + 5)/' && WHO (&/


# 
&56  
4 6 

'/-
1.  ': (New)
 56- /
+$% /
 56  
 -'$% - /
  1
'0 () - /
# 
&!(5$% (/
 /

32



 
   


2. < =- (Relapse)
 56
+$%() -'&  7/() 0&+&() (/)&

4$%%' 5) &
0 $%'  Direct smear () /0 Culture
3. ;=- %
'  (Treatment after failure)
 56    +' Category 1 (/5)
 
0
'0 5
4& 0) 
4
& Remained positive) 0)&
4& (Become positive)
 56$%
  )&
0
  +
0-'&+(/5)
 
0 *'
'0 2
)&
4&
 56
  +' &&+1, ))
)/ &&+ /
4. ;=- %7  (Treatment after default)
 56   )& + )'+- / 2
'0 '/
5.  (Transfer in)
 561#&%" &)0%'#
&() -'&+()  #
6. + , ? (Other)
56  $%- / "')/ *
!)/ * 56  ')/ /56  )/ * 
/ : Bacteriologically negative relapse (M-C-)
 56  - '& +$%)  0/
 / 1
'0 %'  - /
#

&!(5$%(/ /
 Chronic case -'(/ 56  
 0   *'+1,()
  
4&
5.2 
;5
6  
!>*& 
!+$%       6  1#  "+56  !-'
0& 100 %
56& &,'  ,
.!+56$%! /  "T)
)
() 
 '$%'0 () 56  - / *= % +56  ! ,#"#  /-
1. !"6  '() , & '  _ /
0 !$ &  '   *' 
 8

 &%
0 1#  '!' '#  - / " +$%-' !
4 && '
! &&
" 6  ()  - / +56  $%'

' +$%'
  &
0  2   !
 
  Initial phase 0 Intensive phase 1#   _
/
0 $%
0&  '/'
. ,!56  
  ( /
0 ) !  /
0  (Continuation phase)  !/ 2  1#   _ /
0 $%
 )
)0/6
0 T)&
41,
%' -56  $%'
  &
0 -'&    () 2 '= (!
%')
,
0 $%!
   )')   "' 
0 5/'-' (/"
4
0 $%'0 )

0 $%!
   )')/   ,&56  $%- /  8
> '0 ) (56  
)+() 2 '= .
  
 8
> 0 ?
      

33



 
   


2. !"6 ' + -'5)' !"6 ' "',


 -
0
$% - /()  /!
 '>8'0  !$
''6
 - 56   -'& 
   

3. !  
   &&    
)(/ (/ 6
'0 () 8
'0 
56   -'& ,'#
4 ,8
4/  7 ()
0$% - / '()
56
4$%
4.  /
0 + 56  +- //
0 
0 $% - / ,!56   - /
'& /
0+56#
4 ,8 ! 6() '6()56/ ,
 

4 ,
4/ '6()/
)0!56+/
   # ,%'3 
) ' &&
  + $ %'   &&    (&&  
)   (DOT) # 
4        , J &  % '
.   * ' # 
( ,!56  ! 0!5 R'  6 $ -, 
4   ,%'
7  !/  &
0
!
 
5.3   'L
, "
 ;
 ,8 '* !+$%!>*& 0
 -%1-  ' (Isoniazid : H)
 -(L R1 (Rifampicin : R)
 1 - '= (Pyrazinamide : Z)
 
.% 1  (Streptomycin : S)
 ( &6) (Ethambutol : E)
- /!
)/ %'
7  R () S !+%0 %
  '
0 %(&

 )5 !
.'# ? (Fixed dose combination)
/ -%1- 1 ' + -(L R1
(HR) 0 -%1- 1 ' + -(L R1 + 1 - '= (HRZ) 0 -%1- 1 '+-(L R1 + 1 - '=+
( &6) (HRZE)
 FDC *%"
 5    :"7 / 7 &* =S, - DOT
':7
7  
 'L
! &&+$%!(5$%(/ (NTP)
! NTP   &&) ? /6 4  && '

34



 
   


 'L $- 5


6  0: ?
Category

 

-   


-   

      
!"#

$  !%#
- &'(#)#
-   * #) !% #+ #
-     (&,    
 . /#
 & .0%1
   &,0%1
&2"# 2 #!*)#* &
   &,0%1
&2
 04 /  MDR-TB
-   

 / 
-   &'(#)#/  
-    !% &   #!% 
"

II

III
IV

 
2HRZE(S)/4HR

2HRZES/1HRZE/5HRE

2HRZ/4HR
 #   7

1. Category 1 (2HRZE(S)/4HR)
 ! 2
'0( ! 4  H, R, Z, E (0! S ( E) *
/ 
  Initial
phase 0 Intensive phase  ,8 
 ('"#     && ()  && /'
( /
0 -'' (To cut off chain of transmission)
 ,&!  ) 4
'0
/  /
0  (Continuation phase 0 Maintenance phase)
!
 2  0 H, R
*/-.' 56
  8( ,! HR 
4 7 - 10
'0 !$
 4$% '*(
/
dissiminated TB, $%
0 *   , $%    '
0 HIV / ', $% '6,&$%  

&/ '&, $%  ( 5)% '!8/&, $%/ ,


)0  +() 6
'0 / 
- /&* 56
  8
!
)+
4 9
'0  !   $
4?
 !$5 )
 
0   *'
'0 2
4& *' 2-3 
.&
  /

0 ()
'& -()+! 
  0  4  H, R , Z, E  1
'0 
 
0
  *'
'0 3 ()!/ '  /
0 
)
 !$5 )
 
0   *'
'0 5 
4& !/56  
4 Failure ((/
- /,/
4 Failure) 5) DST /
0 *'
'0 2 (!$/) 0/ DST
0 

'0 5 ($5 )


  
4&
0  
'0 5) ,&$ / DST
0  
'0 2 ! HR
/-/ -'5) DST 1# %' -5) -'& &! 3 - 4
'0 )/ 1# "5) DST
('/  resist / H () R ('/
4 MDR-TB ! HR ! Continuation Phase / - /-'5) $
/
!,/56  
4 Failure () !+(&& MDR-TB (CAT4) /- (/" 5) DST - /('/
4 MDR-TB
!,/
4 Failure () ! CAT2 -' !$5 )
 
'0 5
4& () )2/ 6)( '
/56  /
4 Failure
/ ) 
)),  (/), > 
 0 ? ( '/ 
      

35



 
   


8
> '0 
/
+ ()) ((56  R' 6))    56/ / &56   MDR-TB,
 - / ,
  (, DOT - /') !,/
4 Failure () ! CAT4 (/

 !0 (
'6()+56  $%'0 )  &* %  $*) "/-.' (=
 %)( ,!! CAT2 &56,)+' CAT1 () 5)
 
0 
'0 5

4& 1#  ! CAT4 (1) 0 CAT2 !  $
4?"  ,8 /
 
0

0 () '&
 - (DST) () !+ 5) DST /-
  $! && Intermittent !/+  /
0  0! H () R '=) 3 
(2 HRZE/(S)/4 H3R3) 
0 )'  " &)() 56  !   ! && 
 ) 
%'' H

4 10 ./. () R
4 10 ./
 !$
456  Meningitis, Disseminated 0 Spinal Disease with neurological
complication,
   /
0  4
'0
4 7 - 10
'0 (
 7    
)+  ' 9 - 12

'0)
 
.'  (Fixed dose combination
/ Fixed2, Fixed3, Fixed4  $!!(5
$%(/
 )2
  += (evidence base) / ,! Compliance '# 56   # ! /
 
 . '   #  FDC  $
*  '
0 "0-' (
/  Bioavalability, Bioequivalent ' )
2. Category 2 (2HRZES/1HRZE/5HRE)
  
  3
'0 %' 2
'0( ! 5  0 H, R, Z, E, S /' 4  0 H,
R, Z, E  1
'0
   /
0 ! 3  0 H, R, E  5
'0
 !$5 )
 
0   *'
'0 3 
4& !*' 2 N 3 
.&
  /

0
() '& - ()+! 
  1
'0 %'! 4  H, R, Z, E 
 

0   *'
'0 4 "
4& /'& -()! HRE /&
 "5)
4&
0 *'+
'0 5 0) !/56
4 failure
((/ - / ,/
4 failure) 5) DST  / 
0  
'0 2 (3) 0/ DST
0  
'0 5 $
'
! HRE /-/5) DST 1# %' -5)-'& ! 3-4
'0 )/ "5)
DST ('/  resist / H () R ('/
4 MDR-TB ! HRE ! Continuation phase / - /-'5)
$
/! ,/
4 Failure ()# 
&
4 Other (chronic) () !+(&& MDR-TB (CAT4) (/"
5)
 
'0 5
4& () )2/ 6) ( '/56  /
4 Failure
/ ) 

)),  (/), > 


 0 ? ( '// 8
> '0 
/  - / ,
  (, DOT - /
') + ()) ,    56/ / &&56   MDR-TB !,/
4 Failure () ! CAT4
/

 !0(+56  $%'0 )  &* %  $*

36



 
   


3. Category 3 (2HRZ/4HR)
  
  2
'0(! 3  0 H, R
   /
0 ! 2  0 H () R
4
) 4
'0
  $! 2HRZE/4HR
4! Category3 -'
/ 
56!$/-
- /   E
/
. 56$%',
  - / &
0, (5)- /  - / (5)% !' () 5)
0

-
4)&
.
456- / "0
0 6)
&
.
. 5)'& -
0 / ('/
0 -/ H, R, Z
4. Category 4 (Second line drugs)

4! ,& Failure case 
 4 MDR-TB () Chronic case )0 ! Second line
- /
! / (/ 4 # -) () # ! 4  
47'  
)7'
4
) 6
'0
() +- // 18
'0 (/

 !06/ 0((/ ,&+$%'0
)  &* %)
 "- / "! Second line -'
0 
! /()- /-'5) 0 

*' !+(&& & 
 7  : ?
 7 $- 5
6 Y: ( #': 14 [)
'
,/+
< 40 .
40-50 .
> 50 .

H ( .)

R ( .)

Z ( .)

E ( .)

S ( .)

300
300
300

300
450
600

1,000
1,250
1,500

800
1,000
1,200

500
750
1,000

 !J & - / 


 '  /+56     ,
 # (/" 
 '
 ,.- /
4>8/!' %'!,$,  ! ./
 !
.'  (Fixed Dose Combination - FDC)
/ HR, HRZ, HRZE  /
 
 '!' -   () )
) 
)0 &-'
 - /! E !
'. - / "! 6)
 &&'/ 
.
 )
) ! S !8  ,) =
 $! S !56  6* (> 60 W) - /!'
  750 mg/d ( ' ,

  750 mg/d .

      

37



 
   


5.4 5 06' -; (DOT)



1. (&# ! 2


 <) . %
2.
   && &
3.
 2-3 & 1
&& &
#



1.
   1 )*+ &#*2 ! 
#
2.
 2
 ?'" .  %   DOT
3.    % &#
+ 1 (&% &#   *2 #! 1 (&%



1.
   1 )*+&#*2 ! 
#
2.
 1   .  %  1 DOT
3.    % &#
+ 1 (&% &#  *2 #! 1 (&%

   <  <)/# &


 2
?'"  
 
(
!/ ( 2
 .
!! @)


 1    ! <!
 < .
  %  1 DOT


$*)"    ! <!  <
.   %  1 DOT



38

1.
$*) .  %  1 DOT
2.    % &#
+ 1 (&% &#  *2 #! 1 (&%

- 
   DOT    
-  ! "#$%  %



 
   


5.5 7'' 5;

* & &'
 ('
 &
%)+
 !"# $ ) %,
#. / 
%% '
 %

+
 #0   ( &"1 
#2    +3 

      

39



 
   


* %4'
5
& DOT '
 !"# $ 6)#  %
* & &'
 ('
 &
%)+
('
  !"# $ ,7 (retreatment) #. &   3 

 , !"# $  )   !"# $ #. 7 (relapse) !"# $ ,  (failure) !"# $ + > 2 '
,

 (TAD.SS positive)

40



 
   


'@,  7%5


6 
,&56    +' CAT 1 () CAT 3 /
  +&56  -!% &) 2-3 
" 
 !/5 6  % &)
 " ! (6 ) (J &   /
  
, DOT -'!% &) ) &! 
)!, DOT  =) 1  ,& 
/
0  '56    1  /
'0   , DOT /
4--'
,&56    +' CAT 2 !/
 J &
/
'& CAT 1 () CAT 3 (/
 ) !,
DOT 
4
 $*
/ (!%56   &7' S) ,&  /
0 ' 1  /
'0
  , DOT )'+%  &)
/
$,, \'+,5
6 ' 
 &# 6),8)!&&#+() &56
 " 56  
/ '# - 8
>  -& )
 /56  
/  , '6
)0 1' )
 
  (
0   *' 
  5
'0 ()
'0*'+)
 /!
 ,&' /-
 && 
/ " 
 )  1 && DOT () '6 >  )
 !  !&%'
7 
'.  '
0 $%  (Q ()!+
0
!)*)
4$%
      

41



 
   


 , %$' $- 5


6 , 

 
4 ,
4 !+$%
 
4&/"#" 56


  56  */
  + ( !56  $%' 
  / 4
/+560 /+
0-'& 2
'0 (0 3 0 4
'0) !
'0 5 +
()
0   *'+ 56   
 
4&!
'0 5 +0) !',
 
/- (!
( 

0 (&/
& ( = !( = J &   , (Standing order) !
 $*
05!6  DOT
.&
   ,'')//6-'
) %'- / ( = (/) 
%- : 5
6   7$'   7':7 
S %;
 2 7+

     && / ,
 '0- / 5)
  
4)&
( = ,56  %')
'   
  7
   7/
4$%
 5 ' )'(/5)
 
4& ,(56  
4 Failure () # 
&
4 Failure ()
  +'
 && CAT2 /-
\$- 5
6 ,7 

0 56  '


  2  ! 
  0 1  =!  /
0 
 & !

& 6'*&56  () 1" "#
*5 6  - / & (
/ (  
' - /-' >8& ))

0 &
*()  % !56  )& +/ %'  ,  '!(/56   #

/ / " ! )& 0!


 ) -&( /'6()( /!)' ) () 56  
+' CAT 2 0 CAT 4
,!56  
!!-'/ 
 4%*'+()  ,/-
56')& &
&   + (56   5 ,& CAT 1 (56   6 ,& CAT 2 () (56   7 ,&
CAT 3 %' '"#
'.)
)/
 56   
/-()#'
 56  '(/-
 ' !/
  -
 ' !/# 
&! /-
 ' !/
) &&-
56  '
  2
'0 ,/
4 Default !
&$%

42



 
   


7-  %7'+, 5
6  7 
5 06' , 5 765
6  CAT 1 , 7 



    

 



!"  #



< 2 &#
+

/ *2


 CAT 1 * 

2-8 &#
+

/ *2

)  CAT 1



Treatment after
default
Treatment after
default
-

)  CAT 1

< 1 #!
> 8 &#
+

*2


< 2 &#
+

/ *2

2-8 &#
+

*2





1-2 #!
> 8 &#
+

*2



 CAT 1 * 

 CAT 1 * 


 " " )  
1 #!
)  CAT 1

Treatment after
)  CAT 2
default
Treatment after

 CAT 1 * 
default

 CAT 1 * 
-

> 2 #!

/ *2

2-8 &#
+

*2




*
-

)  CAT 2

 CAT 1 * 



Treatment after
default
Treatment after
default

)  CAT 2

> 2 #!
> 8 &#
+

*2



 CAT 1 * 

* )   +  5 '


1 #. Treatment after failure

      

43



 
   


5 06' , 6 765
6  CAT 2 , 7 



    

 



!"  #



< 2 &#
+

/ *2


 CAT 2 * 

2-8 &#
+

/ *2

)  CAT 2



Treatment after
default
Treatment after
default
-

)  CAT 2

< 1 #!
> 8 &#
+

*2


< 2 &#
+

/ *2



2-8 &#
+

*2



1-2 #!
> 8 &#
+

*2



 CAT 2 * 

 CAT 2 * 


 " " )  
1 #!
)  CAT 2

Treatment after )  CAT 2

default
Treatment after

 CAT 2 * 
default

 CAT 2 * 
-

> 2 #!

/ *2

2-8 &#
+

*2




*
-

)  CAT 2


 CAT 2 * 



Treatment after
default
Treatment after
default

)  CAT 4

> 2 #!
> 8 &#
+

*2


* )   +  5 '


1 #. Treatment after failure

44


 CAT 2 * 



 
   


5 06' , 7 765
6  CAT 3 , 7 



    

 



!"  #



< 2 &#
+

/ *2


 CAT 3 * 

2-8 &#
+

/ *2

)  CAT 3



Treatment after
default
Treatment after
default
-

)  CAT 1

< 1 #!
> 8 &#
+

*2


< 2 &#
+

/ *2



2-8 &#
+

*2



1-2 #!
> 8 &#
+

*2


> 2 #!

/ *2

2-8 &#
+

*2



> 2 #!



> 8 &#
+

*2


Treatment after
default
Treatment after
default
Treatment after
default
Treatment after
default
Treatment after
default
Treatment after
default


 CAT 3 * 

 CAT 3 * 
)  CAT 2
)  CAT 3

)  CAT 2

 CAT 3 * 

 CAT 3 * 
)  CAT 2

 CAT 3 * 
)  CAT 2

 CAT 3 * 

%- 5;

 ",(5)+-' '


1. ;  7 (Cure)
 56   
   &
0   7 1#
0   ,
 &,' 5)
 
4)&/
2  %'5 )
 
0   *'+
4)&'
2. ;  (Treatment completed)
 56 
  &
0  7 () 5)
 
4)&
0+&!/
 (/- / 5)

 
0 *'+
      

45



 
   


3. 
'  (Treatment failure)
 56  
  &
0   7/
  + () 5)
  0)&
4&!
'0 5 
+0)
 56  
  )&!((/)& 5)
 
4&)+-' 2
'0
4. $6Y  (Default)
 56   '
  2
'0 '/
5.  (Died)
 56   $   +$% (- /,#"#
*)
6.   (Transfer out)
 56%-+0%'- /&5)+
 $::5
6  (Refer)
!%0//56   !(&&L= //56  $% (TB 09) %'(/!&/' :
!56"0!& TB09 LT-  &56, /,
!& TB09 -"&%-+$=
()
.&,
 TB09 () - "% 
S  5;$- 5
6  , 
 +$:: \ 7  
"
4%!,

' (. "#  .) - / # 
&! /0,/
(//
(&&L= +-!"&%
/
"
4%/,
/ !- /#
&56 ,&,
%(/!#

&56 ,&,
&%%'!,(56/
456! / 5)+ "6%',

&%
"
4%/,
)
  !-() 5)+,
% 56  
4 Transfer
out () ,
&% #
&56
4 Transfer in
0 *'+5)+ "6/,

 & %-,
%  1# ,
% 
) 5)+ Transfer out -  5)
+- '& (
)/%'*0 5)+ ',
 %',
 # 
&56   (
/
'
0
4)
) /*! ' 5)+#%56-+/,
 !$
,
4  ?
/
5.6  76;  :'# ^Y &*
5.6.1 765
6  ,  08

 !+$%  & %' &&- /  Aminoglycoside, Quinolone (Ofloxacin,
Norfloxacin)
 ! Pyridoxine (   & 6) ) 10 . 
0&,*=

46



 
   


5.6.2 ;  5
6  
"56,))- (Haemodialysis) /6  "!*-'  "- /-')-
(Haemodialysis)  "! INH, Rifampicin () Pyrazinamide -'%'- /)'') ,&
Streptomycin () Ethambutol   )'') Creatinine clearance ()  ' 5)( 
0 (0')  
)! (Increase the dosing interval)
 )'' 5)/
 '&!
)0' ,!,
 --' (Too low peak serum concentration) !56)/* 1#3 6)
Creatinine clearance  &!'

INH
R
Z
E
SM
K
PAS
Cycloserine
Ethionamide

 
5-10 ././& #/ ) 300 ./&
10-20 ././&
20-30 ././&
15-25 ././&
0.75-1 & /&
! 20-40 ././& #/ ) 1 & /&
0.5-1 & /&
! 20-40 ././& #/ ) 1 & /&
8-10 & /& (200 ././&)
250-750 ./& (15-20 ././&) #/ ) 1 & /&
500-750 ./& (15-20 ././&) #/ ) 1 & /&

5.6.3 
  5
6   
. "56     '%&(/5)
)0' &/  ,&  
"!* '-'
. "56   %&() 5)
)0'5 ' )/0
 "/ SGOT/SGPT 6 (/ / 3
// ! 2HRE(S)/7HR 56
  8&(
,/ "
456  6* ( ?) 0 8
> &0  $! 2SHE/10-16HE
)
 "/ SGOT/SGPT 6 / 3
// ! 2SHE/16HE
. 56   6!/  Acute hepatitis ()  Jaundice ! SM () EMB -/ Jaundice  
-  ! INH () RMP   !$5 6    active TB () *( !)* / Quinolone
(
/ OFX) %'
  )! SM () EMB -() 2-3 '= 0! OFX, SM () EMB -  ?
5.7 =
 
+$%  ,!(1/ ? '# /-. 56   

 +
7  '
5.7.1 %/

 '6/ ,!
0  * ' (Plural effusion) 0)  !/
0  * ' (Pneumothorax) 0- /
 - /   ! Paracetamal  ,
  )  !/
0  * ' /( =
0 +
  ,!
0  * ' /( =
0
  &,0! Steroids
      

47



 
   


5.7.2  %7
 /56
0
*
 "56   ,!
0  * ' 0) !/
0  * ' /( = 
 "56  6&&* 
4)') 
&
0 !*'&* "56  !'/
0  
() 
' (Wheezing,  $!+&0')
5.7.3 '+7
 "56  - 
)0'  +!% &)  $!)'- (
/
Codeine 30 . ) 3  ) () J     &/( ) "56   (-   !
*'(-   "
)0'- / +  ( ,!56     ?  (
& '//
4
* -
4
)0'
5.7.4  '+, ', ;
 +!% &)() $! Steroids !/ ?   &/
5.7.5 7"+ 7=

 !J  
  
5.8 ':*S $ 8%"
 (&/-'
4 2 
 -'(/
5.8.1 ':*S $ 8, 7%"

1. Isoniazid - / #  =  & -'(/
 Peripheral neuritis /!8/
 '!56      * % 0 (% 

 '
& /)/(6 )
/ !56  
&  =0
4%
-
4 )-
 ' 
  ',! Pyridoxine (Vitamin B6) !/
)')
 ' / pyridoxine 56    ) 0 )
  
/()
0 / '- / #  =  "T-''  ! Pyridoxine / -& Isoniazid
 +/& &-' $) 2 56   
 '! 4-8 '=)
   () 

4
 
 #  '&
-1 = transaminases &!
)0'0*( "#
 &
& (Hepatitis) .-'
 - / #  =0 ?
4  & -'(/
450
4- '&  ,
Frozen shoulder, Eosinophilia, Thrombocytopenia
4
+/ && ) ,!
 ' # & 1# )
0  *0
4
  - / #  = T () (--''  Pyridoxine
/
'&
 ' Peripheral neuritis
2. Rifampicin - / #  =  &-'(/
  &&
'  ,!
 ')0 -() 
-'(/ &- /&/ 
()  - /*(

48



 
   


 +/& /!8/
4
,! '&
-1 = Tranminases & 0 '&
Bilirubin !
)0'6#
/ 
 '&
& !56 >

 ,!
 '  5 '
/ 56 %&/6/() !566*56
Alcoholic  ' 
4
3+
 FluNlike syndrome 
 '!!'6() !(&&
  (Intermittent
schedule) 0-'& - / ,
  /!8/
 ')-'&  '/ 3 - 6

'0-() () 
  (')  1-2  %   J-'(/ - 
'
0 )
0  '6()  )0-/ ' 
)/ 
--'
 ! 12  % 
 J   6 -
  (Hyersensitivity reactions) ,!
 '
4- 50#
Eosinophyllia thrombocytopenia, Hemolytic anemia ()
 ' .
4
 - / #  =0 ? & -'(/ - /
) '  50 # 

  ' 
0/
'  '3+ # &  ) 0)


4
3. Pyrazinamide - / #  =  &-'(/
 +/& /!8/
4
,! '&
-1 = Transaminases &!
)0'6
# 
&
  '&
& /-. '6, &

4   ()  ' 


4
3+!56     > 
 
 Hyperuricemia
 '&56  - '& ( &* (// !8/- /-',!
 '

= )-
 '- / #  =
  '-'&"/'6
-
 ' (Arthralgia)
 '-'&  '!8/ ()
). (/ - /* (
() -'

 - / #  =0 ?   &-'(/ (' (' (flushing) ( (
&0 
)0 - 

4- /
) 
4
5.8.2 Major Adverse Reactions
- / #  = ,///*( /!
 ' 0
 
*'

      

49



 
   


Major Adverse Reactions

 $ # %$

)  #) 0 *&)#*) (Dizziness)

!% / /#)  (Deafness)


)#( )#*) 
U (Visual impairment)
Jaundice
)
&     Stevens Johnson Syndrome,
Exfoliative dermatitis
Shock and purpure (U("#0) 2)

Streptomycin
Streptomycin
Ethambutol
 !*&
 !*&
Rifampicin

5.8.3 Minor Adverse Reactions


- / #  =- /* (,!/   5 ' & - /   "+ 
0&(5+

). - / *'$%
1. $
 '- / #  =

). 56   "-' %'- /&  ,

/ 
). - / 5 0 )0 -
). > ()
0
4('
4  "!+ (5
' -'
%'- / *'0!+  %' &!56  
!() !,)!
2. $
 '- / # =
)."#) () &  ,56&
&
) 0!+ 
5.8.4 %7':*S $ 8%"

 

50



 
   


5.8.4 %7':*S $ 8%"



  (:)

* +
&
+
!" ( (=25%())
1. 2
&   Challenge  HZR   R #. &+


& '
'

 Z
2. 2 !'  !   Challenge  E R H Z 
      

51



 
   


$

1. &88  8=, 
 * 6 ()   =
 8 (&$ ), 0&$% 7&& =
  4 (7&&&*)   &$%(/
3- % =* )$=  ) .3.2542.
2. &88  88=, '' 3, &*8/ * () 
 * 6. (!$%
() % 2534, 2: 57-59.
3. 8.*  3 . !+$%() '
+$%.
 &&
',
 &* $%'  DOTS. ,&
 )  $%,  1-2 () 4-5
+
2545. %(
16 =
4.   3 '
 ' ( , 2542). J 6 &* $%(! /&  
 )  ,
,&56  $%
% &)!3+ 21 $
3=  )
! /,
 ) 3 )() ,&* % '/
 10
 &&
 J &  

0  &* $%,&


  3./ ./ . %( * =
! /.
5. American Journal of Respiratory and Critical Care Medicine. American Thoracic Society 1905, Vol.167,
No.4, February 15, 2003.
6. Crofton J, Horne N, Miller F. Clinical Tuberculosis. The Macmillan press, Hong Kong, 1992
7. Porter J.D.H., Mc Adam K.P.W. Tuberculosis Back to the Future John Wiley + Sons, England, 1994.
8. Toman K. Tuberculosis Case-finding and Chemotherapy (Questions and answers). WHO, Geneva, 1979
9. Treatment of Tuberculosis Guidelines for National Programmes. WHO, Geneva, 2003.

52



 
   


6.1 DOT  DOTS 


 Directly observed treatment
 DOT 




 


   ! "$#  %&
 "'("# ((!()*) + 
 (
,("!
-(( -("!
 . 
 ( /#0
1 
   1, 2
(

$((34
 . 15 2507 ( .<.1964) 
1 Fully supervised treatment (
((3(  , #  B*((
 14,C (National Tuberculosis Programme : NTP)
 DOTS  !"E<21"# ((3  2
(
. 15 2537 "H# , 0) (2 1
3,"E,H
"# ! (
  !
3-  (I00!(  5  23

/# 1( # 0

3"<1 (
3IJ3! (
'(,((3-((
,0
  !  0$
 .
!(1 (3
4 #!-H-
 <K
,0- H #1)1  (!(1 ((.
1 "!(1 (
H # !  " (Stop TB Partnership) /# $-
( (Expanded DOTS Framework)  # 5 2545 V(
 23

- 6  23
- !"E<2!  (Stop TB Strategy) /# $
1  (""# 2 3
""# 3 1 H # ,'(,(
-31,!"E<2 DOTS   !H 1$(. :1.     *),3)"#03H,#
' (31,( H #"'

'(,((  !  **(V(1 (' J 1)(3,


E!--4,
- 
" # 3"<
2. ! "#$   $%
&!$ !' ()*  %'+  H # (+ (*") #  

 H
 
 
-  ("# ' J"# !  $V(33 (() 0'V("0# 3
H1 V(H,<(*") # , 4 . HIV 3(
1! 34
"#  # )41( *)  * (("# * ) + 33H1
4 .  3
1! "#  1) 
(((1 Z
3.  , &!$   %      *-$$/0 ' + 4!%+ $ 

& *-$" 5 ! $ DOT 3
((!(*) + "4#  
,43,
"# ((!(


(( 
  
 
     

   
 
  !"# $
$%&

'  

( )*+

53



 
   


4.   , $/0 *  '/+  0& & 3


03
01"#
4 #  $
5.      %9
 * :  , :!5*-$% * % "
: 0&%$ $ V(H (. K(-
,*((1V(3 H #

$-IJ"#  0H
 
':$ 9*; ! 9'( % ) DOTS  4<!$ 0 $ * (
 333(
. K("# 4(I00!( $
H[(0
"$#  ( H Rifampicin "# 
H !) 
<
"4 

1
3 - 4 -(( (3"<"
# 'H[(3"<". (4
],
3! 0

<
"
4. 1( 0(333(.
V("# 30
2 1
 
!
'


,(-*) + 1 "# (  DOT) ((. V( ,E  "# *V("# (10( #'  (
-

 333.(K((.0$H[(H
 ,E
3!
2 4 DOT (*((
 !  ^3((.
"0# 3('333(. ($. 4  ,E" 0# 1 *) + $
,("#  (103$1* 
"1"

4 DOT "# *

$
3 100



01*)+ $
,("#((.( ( #0
333.(K((.

H 1*) + 
-

 $
1

,($1 -((  
!
,(-(( H3
- $1H
3 2  # 
"!

 !
1(
'( V(1 (
0$ 3 40 - 50

-


1 (
0
"'*

  
1
,
 
. -4 .
 ""# 'V( 3""# !    . -(( (Multidrug-Resistant Tuberculosis : MDR-TB)
/# 
 . 1$$(3, 3$]_/(, 1 
 (#  $1
$  

 MDR-TB (
0

03401  1' ( "# 2 H-(. 


$1#'
1 40 - 50 "1
,($
H30H$
4
  18 - 24  (3


$1
3$1
 '(,(!"E<2 DOTS  (
0
03 . 
V( MDR-TB 

,IJ .1( "# 2 H,#-.($
V( XDR-TB /#,#

-.( 
)  ^H3
,4 . 4$  1  
6.2 &   , :!*5 $- $/0  (Organization of tuberculosis treatment service)
0'V( *)+ V(<)(2
H #(10(

  ( 3
 

1$(. :6.2.1 (1 ( *)*,4(1((
6.2.2
-(. "3(
 03 0!"<(2 3 ,E ( # Z 41(
H3. 4 . 3-)
 (# Z "#
# -(!"3(4()4 .  3
-(. "3(*) +   ( !"3(*) +  
H #,33,(*
6.2.3



1*) + 3   -0 0'V((

#'
3  (3H #-03

H#.  *)((!(
6.2.4 H*) +   "!

 !:5*! $-  $%
 < $/0 
&!$ ' () :5*! $- 4
 :5*! $-  &!   ,  !$ &!   ,  DOT

54



 
   


6.2.5
(/
,

13 . (41 "# 3 
("
3"# )1
-*) +   ""# '( (*) + ,() H # ,1""<H"2 0  *1("(1 (  -1"#
"# )1
*) + 4 1 ,
  3

1*) + (
,1 ".   3("# ^H3(
 DOT

0 (*)+ 1 (
1( (( 03$*
1
,0

*,(
/# 
034
4
 ,
3"0
 1 
 V(
(  1  3
,
"#
'0 41(
41 
IJ! -*)+ (



0* 
 ((


 {{
6.2.6
*) + 
,($1 3
( 41(  -(($ (/"# _ $ -(

,(  .  1 ( 


4 "#  2   3   4 -(( (Fixed-Dose Combinations: FDCs) "$# 
K((
*,3
<
 Bioavailability "# 4 #  $
6.2.7 311*) + "#  3,"E,H 41(
11$(,
"# 1)
 (*) +  V((
6.2.8 03
H3
 3 10("# *((  14, (1 (,

E!-",(# 34!4(H # H,0"
 )
*) +   4!4( H # 1,
 0
*) +   3


 DOT *() '4!4( /# 003 ".
) *) + 4$ /24!4( 
6.3 $  &9 DOT
1. :!*5 $- 4
!  ,  DOT ' ' J (. :1.1 *)+   "# 03 
0!"<(2 H Acid-fast bacilli   AFB (Smearpositive TB) 3"#  0 Smear~negative 1- (- (
"#   4$ (!    (

"# (!  $
1
:!*5 $- 4
 "$# 1 $

  $   $1
,( 1  ( 3
:!*5 $-  &!   , $/0  !$ $
1 

V(/.' (Relapse) 

/.' 0
-((
,( 2  ( (Treatment after default) 3

/.' (Treatment failure)
1.2 *) +   "#  03 
0!"<(2$1H AFB (Smear~negative PTB) 
0 *H34 . V(
 V(
2. '
 ! %  %'  , $/0  (Tuberculosis treatment supporter)
/#1, 
1 H#. 
'
)*)+ 
,() 03$
%&
 

2H,0
!, ' ' J(. (14 #  $ (Accountability) V( ' J(
3

(
-,
 (Accessibility) 3
-*) +  (Acceptance) V( :5%!  %'  , $/0 

! %9A%$4
A!&54
!:5!*-$   , $/0  %9%  9
&&
$   , !  CE*EA
4
! 94:5*! $- *;%$ % %'&!$
  
 
     

   
 
  !"# $
$%&

'  

( )*+

55



 
   


 ' 9


!  *;:5%!  %'  , $/0  H0,  3 0

2*) + 3J, 3$


,(-*) + 13 $ 4
!:*5! $- :5%!  %'  , $/0 

2.1 0("# ! 
30'H (,
"
H"2 E!- 41(
(("# 1)
 (*) + 
"# ! "*# ) + 03$ DOT ("!
(  (33) $3
 0I 0H
0("
#  0('$*) + 
,("#  (
$
- *) + "0# 'V($ 
 (H
V(
("0# 3 DOT 0(
(3('
(
"' DOT 10'(1
- *) + "0# 'V(^(
V(
"0# 3
(, $ H
(
2.2 *) + $1 DOT "# H  ((   (.)  *)( '4!4( (#
$
1 ) H32 !  #( Z {{ "#)1()1(
*)+  (1033"#! H3)1
(*)+ 
/# ,# (3)1  ((4(" 
! 
, 2*) +   "0# 3 DOT ^# H 1 (15 3)1  (
0$1* ) +   (
0
(
.  * ) ) !-H- (((( /# $ 1  0
*) 3


0-( *)+   "#$

 ( ,E DOT) 
 1(3"< #( Z "#

%&
 "'("# ((!(

*) +   
 DOT $"  "
0("$# 
2.3 < 1  
*(( #( "#00("#"# 41 "'("#


 DOT 41( 0
*((  . ( *(( "(# ' {{
2.4 "# $$1 4,
 J,   *)+ "'("# DOT H3030("#
*)  *,4""# Z *) + )1 # ,1(,(# Z ^H3(33--(-

 "!
1-2 2 ( 2
 (
H # "'("# DOT 
)  1 -
# 
1 *
03$1
 1*) + $
,("#
( /# 03
-


H Z
(
3.
! :5!&!  
 4
!*;:5!% %'  , $/0 
3.1 
'0 3((!()*) + 
 (
,("!
-(("!
 .   ( " # $
  1  . / (
3.2   

-*) +  1
H $1 
$1
41(  (# $  #
  " 0  ,
(3('
(, H
  I  3V(
4 1  

  1 


1(. 41( ( * (# -(.     0($1! )(



!
"("  1HH"2
3.3 0
*) + 
3 H # 1 0 1( ("# 2  ("# 5 3 # ,(. !


H #1*
 0H"2"3"" (*

"!
.
3.4 ("

 DOT (("


 (
0("# V(*) )   DOT card (V(
  *)( '4!4(V(*) )
3.5 
'0 30* 
 ((

*) + 34,
  $"H # 41 
1,*)

$1-

56



 
   


3.6 '(,(
,  # (*) + *,(
3.7 )30
,
$ H)1 
3.8 *) ((!(

  *) + 03$1)1 V(
4 #  0
$4 #  $1
,( 1 
2  003
11$)0
(,
"#K("#3
4. &9 % %' &&!  F
4.1 ,
("# 011 Z 41(!(# - ,(
, (DOT corner) "# 
<1"
$3
0,3
<4 # -*) + 3 ("0# 3 DOT H".  package  /1-
*) + 13 ( 13 ('*) + 
,( .   0   (FDCs) H # 0(""# 0# 3 DOT
'*)+ "#)1
(H$3

4.2  #H"2 ,(,0^ 3


'(3 (*)+ 3   


(Counseling) E, 0'V(H # 

 DOT
4.3 "#)1I00!(40("#03,$("#
  -"<H"2 ),'(,
)41 #  )(1 (  #'H 4H $
$ 41  (

 3 
, 

  (#   
4H,
"( (0' {{
,("


"'( H # H,0
103!  "0# 3 DOT  $1
4.4 H,0 
*)"#03"'("#((!(

{  3 3 ,(-
*) + 13 
H,003)1 (H (. K(-
/#
(3
( (1*) + V(*)  
*) ((!(


) *) + )1
H  (,
!-H 33
(
,("
0 DOT
"# (,
((. Z  )$1

H0, (*) + $,1- DOT 0
(,
(  -1 
(
-"# (,
*,4"#
 , , (K(
( 3)1
 (*) + 
"# ! 1 '(
("


"#

-)*
 0 $ 
4.5 $1 1 *) + 03$

'($ DOT *)   ,E   0V(*) + "#  $1
)1(3 ' J"#03 DOT 41(*)+ "# Smear-negative  003$13
"#03 DOT
1("#
*) + 03
(0
$
 ,(0, ^ 3

V("# -03 003, , (



 
('"*# ) + $ $
,(*) + ,# , , 

,( . 
1(0("# (3V(

() DOT 0("# ) 3$1 011 ($


*) + "0# 3 DOT H303"'*) + 
$, $1
 
'
)
4.6
 DOT ( # H! 
 3"H
0'
 (33
1(^H3*) + 
"# ' J((#
1( *3 Smear-positive 
1  13(331( # 
$]_/(,
  DOT $0(  6  (  #  H(I001 Z
0- DOT $*) + "#
Smear-negative $
4.7 (*) + "# 0("# V(*)  DOT 043 (33 23 3 ( H # 3
". -*) +  30("#
  
 
     

   
 
  !"# $
$%&

'  

( )*+

57



 
   


4.8 *) ((!(



  V(  *)( '4!4(  *) )  (( 0("# E!03
$# *) , ,  # (*) + 1(23 . (33--( 31( (3 .
(331( #
4.9 H,00,# 0)0 (Incentives) 3I00 (# Z "4# 1 *) + , $,  (Enablers)

1*) + "# 

 DOT 41( 0
*4 ( H #  _
30)
 $ 30 -4 1 (
,( 130'" , {{
4.10 *)"'("#((!(

  0
 3
1*)+  H #
31
,
,   0
'( . 3 2  1  # $*
 0
0**) + $HH"2 H # "" (


 ^H3 #,.(!

33--(3 # 


5. & * : DOT
5.1  0" 3 1 "3(
 03 *1(("


 "3(*) + 
 3 DOT card ,"#   )1 )   (I 3
5.2  0)
3(3-)"#' J(*1(("


 41(3 ,

(
3 *
 03 {{   ( 3"(1!
2H # "" (*

H"2
5.3 "' Cohort Analysis -*) + V(!(1 "-# (. "3(( 3 3  ( H # 3,(*
 0

*) + ".  3*"E,- 
  ! 
5.4 
 H3
 
*)" "# '("# ((!(

  (DOT Meeting)
observer H # "IJ ! 3-((3(
, ,

58



 
   


 % ! 
1.    13"<$"(H34)2 1 

  ! ,1
3" E!3 ! 44213"<$" : ( "
 ,(0, ^3
  (3"<$" (H,H2 . "#
2 ^!) H.<.2543
2. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of
America : Treatment of Tuberculosis AM J Respir Crit Care Med 2003; 67:603 ~ 662.
3. Fox W Ellard G A Mitchison D A : Studies on the treatment of tuberculosis undertaken by the British
Medical Research Council Tuberculosis Units, 1946 ~ 1986, with relevant subsequent publications,
Int J Tuberc Lung Dis 1999; 3(10) : S231 ~ S279 (supplement)
4. WHO : A Guide for Tuberculosis Treatment Supporters Document WHO/CDS/TB/ 2002.300 WHO Geneva
2002
5. WHO : An expanded DOTS framework for effective tuberculosis control Int J Tuberc Lung Dis 2002 ; 6 (5) :
378 ~ 388
6. WHO : Eight Report of WHO Expert Committee on Tuberculosis, 1964 Tech Rep Ser No. 290, WHO
Geneva 1964
7. WHO : Guideline for Establishing DOTS~Plus Project for the Management of Multidrug~Resistant Tuberculosis,
Document WHO/CDS/TB/2000.279 WHO Geneva 2000
8. WHO : Ninth Report of WHO Expert Committee on Tuberculosis, 1974 Tech Rep Ser No. 552, WHO
Geneva 1974
9. WHO : Treatment of Tuberculosis : Guidelines for National Programmes Document WHO/CDS/TB2002.313
WHO Geneva 2003

  
 
     

   
 
  !"# $
$%&

'  

( )*+

59



 
   


7.1 $ %) 
$ $/0 0 &%)

,4 . 4 $  "'J


I   !(-(. 3
  (1)
,4 . 4 $  "'

+ V(  (TB disease) !
-(. ". (*)" # H,# $ 4 .  (Recently acquired
M tuberculosis
infection) 3*)" $#  4 .  41 33 (# (Latent M tuberculosis infection) !"
# ,4 . 
!
0("' + V(  ( # 0
3) , !
(1( ". (. 
"*# ) , 4 . 4 $  "# , 4 . 
03+ V(  )3 10 15 (2)
,4 . 4 $  H,#
+ V(  /.' (Recurrent tuberculosis) 0
!
!
-4 .  , (Endogenous reactivation or true relapse)  
4 . 
1-$(1
 (Exogenous re-infection)
"# 0 '( (*) +   H,# -(. (*) , 4 . 4 $ /*) + 
2"'

H1
304 .  (4!4(H,# -(. $
:   &< <$/0 &%) : $ '$/0 
< 

) H,# 
(
,4 . 1Z  ". 4 .  $1  (Susceptibility)  # *) , 4 .  

"'
+ V(  H,# -(. 0'( (*) + "# H,# -(. 03H1
304 .  $
-(.  ".
H1
304 .
((,
E!-) H,# 0'( (*) +  
) H,# 
(

,,
, , 3 1
 23  "'
- -


 )-(.
) 
-)-.(
0) 0'( (*) +   4 , 0

,4 . 4$ ) -(.


^) H,#,((
,


 
4)
-3,
!-H14(*)" #  
 1+ V(  ( # 0
)
 )

0
"#
# -
 2
:  $/0 : $ '0 &%)
< 

) 01

) , !
(-*) , 4 . 4$ /*) +  2
-)
 ,(0, ^  (*) , 4 . 4$ /*) +  2
-(.

60



 
   


) H,# 0'( (*) , 4 . 4$ /*) +  2/# + V( 


) *) , 4 . 4$ /*) +  2 
4 , )-(. ( # 0

+ V( 


0) H,# ,((
)!-H-*) , 4 . 4$ /*) +  2
7.2 :%:%  $ '$/0 0 &%)
*I
  
+ 3
4 , "#
,0

,4 .  23  1 


(
$"'* %)
1 H # IJ  (
!1 *) , 4 . 4$ /*) +  2
2 H # IJ0

,4 .  $ / 2(*) +  


&9 
3"<$"  4!
-
,4 . 2(
!1 34
" # $

13 1   

,4 . 4$  (*) +   

13 5 '(,(
,0
(.
1.
.
$
3( 1  3 1*((  32
1.1 0. 2
3( 1  3 1*((  32"!
3
1.2
%3  4!
-
,4 . 4$  (*) +  
1.3 )
*(
'(,((  !  32
1.4 '(,(
  !
'
 , 3,(*
,0

'(,((  !  32
2. IJ-  (
!1 *) , 4 . 4$ / *) + 2
2.1 , -- (
 (*) +   (
!1 *) , 4 . 2
2.2 
(
+ V(  (*) , 4 .  %
 $$(3/,
2.3 
(
H1
304 .  ((,

3.

,4 . 4$ (*) +  
3.1 ,
03 3

H # ,(0, ^
,4 . 4$ 
3.2
 )  #  2 3

(
,4 . 3H14 . 4$ 
3.3  $
/( (Co-trimoxazole)
(3

,4 . ^ 

3.4 
-($ 2
3.5
)
3((!("0,0 3 
1.   * % $  $ 
$ : $/0 &%)

 2
3
$
3( 1  (( 23  (.( )1(H .(K(-
3 33
'(,(((E!-(I00!( !3 2

$
1  (

'(,((**( 23  


)

 ,E
'(,((( 23 
H #('$)1

$-IJ"(E!-"#3,"E,H
 ,  -.%$%$
 !"# .$/

61



 
   


2 &*EA
$/0 4 ' :5! & < <$/ :5*! $- &%)
2.1 &    &!
:5!*-$$/0  (Establish intensified tuberculosis casesfinding)

1 (  (*) , 4 . /*) + 2H". 



  . 133
03"'

4 , -*) , 4 . /*) + 2 !(  -(. H,# !H4 , 3
H14 .  ((
""# *# ) + <)1 3(4!4($  
$  &9  :
. $    &!
$/0  0 3
1 (  (
!1 *) , 4 . / *) + 
2 *(
1Z 41( ,(
,  '
H #  04 . 4$  ,(
, )*) , 4 . 4$  ,(
, ($ 
,(, J,. 23  (,
 0*)+ (
*)+ (<)(2
)*),4 . 2 ".(
H3(4!4(  ". (("#
 )*) , 4 . (4!4(334

!1 #  (# Z 41(
!1
*) 4H,((


(
. :5!  9
! 4   $& !
$/0 
 0 
 (  (*) , 4 . 4$ 
$1 V(3(- ,(
,  )1 ()-0("# (2 0V(*)  '
 (Counselor) 0("#"#*,4(2  0("#"#*),4 .4$ )1( ) 0("#((
 ".
(('*),4 . *)"#03"'("#(
 0 
 (  $
H #$" 
H(E23 123  
  ( "(
 ,(,0^3
  (*),4 .4$ 
 ". ,E
 (
 0 
3("
*
. !
$/0 4 ' :5! & < 
+ V(  
,-(. $"
! 33-2
". "#  3 CD4 

1 200 //)
<
2, , #'
1 1
+ V(  H,# 
-(. 
CD4 

,4 . 4$  0"'


-   

-(. )
1  3) , !
(-*) + H
H
) , !
( 1(- *) + 

 
 
*) + "$# 1, 4 . 4$  
 , 
3$1
H1
30$  31Z 1
), !
(-*)+  #$
^H3"##'
1 50 //
)
<
2, ,

"$# 10'H3 
H  (
3  H1
30$1  3
 ,(0, ^
,# 
43
 ,(0, ^0*,H$1  4
 0 ,(0, ^H,03

.  $!
$/0 4 ' :5! & < *) , 4 . 4$ 1 $
23
 0 
  "!
( 30

 0 . 

 0 
,  "!
6  (/# 03V(
33 

 0 CD4 "#
  0"!
6  (41(
( 4 

1 
3 , # 
( 1 
( *(
) 

   
"!
. ""# '
23 
3

3,(*0'( (*),4 .4$ 1"."#$
 0 
30'( ("# 0H 1+ 
V(   ".
,
(H # 0 
( .1$
"#
 103V( 
Suspected tuberculosis 1$1 
K(HH(

 ,(0, ^ %3 3 0/.'(33 1-2  (

-)
1*),4 ."!
(
"#  H # 0"("#"#
 (
0
(."!
.
"# *) , 4 . H  (( 
/

-   

62



 
   


. 9   ! :5!&<*-$*;$/0 


"#
 0H*)+  

0311-3,
^H3 41( ,(
,  H #
,3
1$
2.2 *I  *-$*;$/0 4:5! & < $/0 K&!$ Isoniazid

 Isoniazid 
1*),4 .  %H #
(
!
+ V( 
1("#03
Isoniazid (10 1*) , 4 . 4$ "# , 4 .  1  ((. $1$
'+ V(  /#
 0 ,(0, ^V(
 # ' J
( # 0
 Isoniazid "# 4 
(
V(-(((# (-(("# 4 
+ V( 
41(
(

 Isoniazid 03"


! ( (3 300 mg. ,1
(V(  9  (  1
 Isoniazid
0334(2
1*) , 4 . 13 1( # 0
-(. (1 Z /# !1 
'
(1, , . 1
 0 ,(0, ^
(14 1$1$
'+ V( 
"*, ( (Tuberculosis skin test) *
3
10

*) , 4 .  "$# 1$, 4 . 4$ "#  <! 


"#  ) 33
2
)*) , 4 .
3"( Isoniazid ,1
(V( (( 9  (

(
+ V(  $4 1  (# (3
2 5) 0
((. $ 4 . /.'

 
+ V(  $  ". *)" # $ 3"( Isoniazid 1
(, 
$1#' + V(  (( 
 

 . 1 Isoniazid ) "'


+ !1 
-(.
(.(

(
+ V(    Isoniazid 0$141

"#03'(,(
*),4 .
4$ "
!  1H0, V( Z   0-*)  ,
 3 H3<
H-(
,
E!-131
2.3 &4
!   *I $ '    < $/0 4%"  

%" &


H1
304 .  
1*) , 4 . /*) + 2  
!1 "#  # 1
,4 . 2
0341 
+ V(  $

 ,(,0^3
*)+   33H14 . V(

"# ' J
"#! ((H0!3(("# Z "# V()11 41( ( (0'
/# 0*) +   3*) , 4 . /*) +  2 1 
()1 
-
H1
304 .  $ (
4,  

!1 # 03V($$1  ((. 0 


(
  !
(
H1
30 4 .  *((

  !
,4 . (TB infection control plan) "4#  0( ". (( (1)
,0
/# V(1 ("# ' J"# !
H # 
*14 .  (2)
  ! 3 H #  --(- Droplet nuclei "#  4 . 
3 (3)
4  #  (

((1331( # 
3. & &< <$4:5*! $- $/0  (Decrease burden of HIV/AIDS among TB)
3.1
,

 # 23,
03  H # ,(,0^
,4 .4$  /#
' J
( # 0

,4 . 4$ V( (4 . H, "/# .',IJ  (3"<


,4 . 4$ 
(*) +   V( Marker -
H1
304 . 4$ (34
 (#  V( ,4 . ^ 
"# ' J
3V(!' J-
4 ,(*)+  2 (.(-)-
,4 .4$ (*)+   0
 ,  -.%$%$
 !"# .$/

63



 
   


' J1
)*) +   
! H 41(
($ 2(41  "# 3
,


 # 23,
03 
,4 .4$ 0V(41"*)+ $
)3-

($ 2 ^H3(33
-

  /# 41 
4 , $
33 "# 3 "*# ) +   $
 04$  ( "
'(,(
(.
1. . 1*) + $
 ,(0, ^ 1+ V(  -  "'"
2, 4 . 4$ 
-*) +  3

"# 3$  - H,0  *) + 003$1H"0# 3]I*

+ V(  3
,4 . 4$  (-3
( (
0
(. 0("*# ) 

 )0
 " (,
(

(
( (
"*# ) +  0H4 .  (3
2.  # 

   2 2   # ( . 1$ -   # 
(
H14 .  $0("# -H,0  
-3
,"# * ) + 003$1$
 

,4 . 4$  


K(4,30
2 1 (*) +   "#
 ,4 . 4$ 03 
! H"# - (. 303
$
 # $-($ 2 *
 0
,4 . 4$ V(,# "# 1 ($ (Sensitive) 3
# -

,"E,-*) + 

 0 ' J H3
_**) + 0)

00
 $
3.2
 )  #  2 ,E
 
(
,4 . 3
*H1
304 . 4$  3
(
0
(.*)+   $
 0 
 ,1"H<H(E2 3

) ,E

(

,4 . 4$ 1  Z 41(


4! (
4- 1 
( V((
3.3  Co-trimoxazole H # 
(3
 ,4 . ^ 

 Co-trimoxazole H # 
(
 ,4 . ^ 
"# 0
,"
/(
1*) + ,4 . 4$ "# + V(  03
4 ,
$
 Co-trimoxazole '(,(
$1  00(" # ,(
,  $ ( # 0
V("# 1  1(-
$1 1H
-  (.( (   Co-trimoxazole 
1*),4 ."#V(  "!

^H31,#*)"#$1$ $1$($  ()3( )1 ( ,,
'(,((**(
 32)
3.4
($ 
($ 
1*) , 4 . 4$ 03!
, 
+ V( 
$

1 80% 3
($ 
1*)+   "#,4 .4$ 
03
$ "'
!H4 .  -(.
(.( (0((3($ 
1*)+   "#,4 .4$  "# CD4 #'  "#!
"1"0# 3'(,(
$ 3*) , 4 . 4$ "# + V(  (-3"
# '$ ($ 
$1 !
($  
  $H Z
($  ()3("")
3.5
0,

)1  (31( #  1V( 2 
3"# ' J 
,
"#
 !HIJ1 Z (Comprehensive care) 3
,
"#  1( #  (Continous care)
1.
)1  ( (Comprehensive care)
1.1 "
H"2/
H
1.2 "( 0, ,"
1.3 "(<K
,0/
'4 , /,
" /
 ! ,"E,

64



 
   


2.
)11( #  (Continous care)
2.1
)
11*)+ 3 1(H 3  -1,
!-H3 
(34!4(
2.2
"'
, 1( #-
,0
1 Z (1341  -
'(,(-

,0

)1  ( 31( # (41  "#
 ($ 2
( 1H1 *) , 4 . /*) + 
 2"#
 ,4 .  -$
-(. ((3"#  . 1(,
!-H(133
^H3(1 ,
3K), (Primary care unit : PCU) H3V((,
E!-"#
4, ". 
*) + 34!4("*# ) + <)1 3( ,( , ", # ('
,0

)1  ( 31( # 
$4$V(1"0# 3 H-   4!4( 33((
 2
",(# H # 
*) , 4 . /*) +  2 3  $13,"E,H
7.3 4
!  * # ,  $<$%9
 :5*! $- $/0  (Provide HIV testing and counseling)
 4
!9* # , 4:5*! $- $/0  & < <$

 '
*) +   "#  $1  0
,4 . 4$ 
1(
1. *) '
33 
4 .  0
*)+ ^H31,#("#H14 .$
($

  (
1 2 2) ^3(.( "#3(


0V(


 -(.  2 2 30H ,#   *) +   (

N 95  "#
 1 H # 

H14 . ("# !
2.  '
 ' J-  
1*) + 
- )
-4(, -(^H3("(# .'(
 ( "#
 "'(3$

H1 3 ,E
 (,  (( ' J-

,("# 1 ( # 
- -"
/(- 
-

,(1#'H # $1
,
 . 


11( # 
3.  '
H # 
(
H14 . $)*1 ) ( #
$0

,(
)1 1 
(
4. '
 ( ' J-
 0
,4 . 4$ (*) + "# V(  -3*34(2
"#$0

 03" 3
,4 . -"#$1$
 03 ,(,0^
,4 .4$ "#0"'


  $1"1"#  31
#1
, ^ 
 #( 
H14 .4$ 
1*) #(

 '
*) +   "#  0H 1
,4 . 4$  1  
1. H #

'03 -0 1".  34$  )
  
! H4 , 41(
(
,$ 3-
$1" # (I00!(
2.  )
1*) + 
'(,( 3

 ,4 . 4$  
3,(H3
33- 2
3,(" ,(,
3
 03), !
(*)+ "!
($
 0 CD4
H # "33- 3 *(

"#
)  ("#  ) , !
((
1 200 /2/)
<
2, ,
$ 
( PCP 3,# 

 ($ 
 ,  -.%$%$
 !"# .$/

65



 
   


3.  '

#

4($  -(- ,E
 (, "#
)  -"
/(-

 0,11( #H #
(

 3
,4 . .  ".-)
- 

($ ,"E,
3
(!-H33
(  H #*)+  )
,"E, 3) 1

H #


4.  '
 # 
)!-((1)
"( 

'

 (,  1


,(3
 0,0
H"2 (( 1V(

4 , 3*-
-


"' 
14  , $
 '

 *(   3
! ( "# 330
(
0
 
,(

. 2
 *(  
!  V(,# ""# '$

 
320(4 . $ 2(1
(
1 50 5/ )
<
2.
5.
 '
 # 
1 H<1
1! ("!
. "#
 1 H<H #

(
4 . 0
*) ( #
H1
30-4 . $)*1 ) ( #
,0     3
4- ^1 
*) ( #

. 2$1$ *(


4-4  1 
*) ( # 41(
$
  
(
 )
 
,( Post
exposure prophylaxis
! 
 4'!-3H<H(E2  !  , ! * # 0
*) , 4 .
6.  )  -03-, -, 4,
(   "#
4,
*) , 4 . 2
7.4 $  &5$/0 4:5! & < <$
:5*! $- &%)
43  - CD4 (
1
" ,(
, -  (*) , 4 . 4$ V( 2
 
1. *) , 4 . 4$ "#  3) , !
() ^H31,# 3  - CD4 

1 300350 cells/L 
" ,(,
-  
$1
10
 (*)$1,4 .4$ 
1 
HH"2  
-      # !   01

$1H1(.' 
 1  
2. *) , 4 . 4$ "#  3) , !
(
H1 ^H31,# 3  - CD4 (
1
200 cells/L 03H  (
   H1
30$

13 50 ("

*) + "# 3  - CD4 

1 300 cells/L HH3 28) ((.  (*) + 


2 0HH"2  
Z
$ $1 
^H3030 -(.
 1  ((. 
,"#  3
(1
 1*) + 
". 
$-  #  3(.'(
 1  



1. )"#4
  (*),4 .4$ $1
10


  "# $ (3('4
)K(33(. 6  ( (1$
 *) 4# 4J"1((3('V( 9  ()
2.
H,0($ (*) +   "# , 4 . 4$  
, ,  (.
2.1 H,0,# ($  # 3  - CD4 (
1 250 cells/L (TB treatment before
start ART)

66



 
   


 CD4 < 250


 CD 4 > 250

start TB treatment after 2 wks - 2 mo later, start HAART


start TB treatment F/U CD4 every 3-6 months
start ART if CD4 250
2.2  
4($ 
!1"#$1,
,, ,
,,("#!1 RMP ((
"#4
)K(33(. )  (
!1 nucleoside reverse transcriptase inhibitors (NRTIs) 3 nonnucleoside
reverse transcriptase inhibitors (NNRTs) I00!( $1(3('(
!1 Protease Inhibitors (PIs) )"# (3('

2NRTIs + efavirenz (EFV) V(4!
(First-line regimen)
2NRTIs + nevirapine (NVP) V(4!"# (Second-line regimen)
3. ( "

  -*)+   "#,4 .4$ "#-

 $1
<

^H3 ((. (3(' ( ", , " # $ 1H"2"#
  

11( # 

 ,  -.%$%$
 !"# .$/

67



 
   


 % ! 
1. Self-study modules on tuberculosis, US-Center for Disease Control and Prevention, p 19, March 1995
2. Interim Policy on Collaborative TB/HIV Activities, World Health Organization 2004
3. Mohammed, R. Ehrlich, R. Wood, F. Cilliers, G. Maartens, Screening for tuberculosis in adults with
advanced HIV infection prior to preventive therapy, INT J TUBERC LUNG DIS 8(6):792-795
4. Kimerling M. E.1; Schuchter J.2; Chanthol E.3; Kunthy T.4; Stuer F.3; Glaziou P.5; Ee O.6 Prevalence
of pulmonary tuberculosis among HIV-infected persons in a home care program in Phnom Penh,
Cambodia INT J TUBERC LUNG DIS 6(11): 988-994 November 2002 IUATLD
5. ( "34,: !"E<2
**(
'(,((  32 H #
  !3
(

(*) , 4 . 2(3"<$"
3" E!- 2544 ISBN: 974-294-006-1
6. ( "

(  ((,
E!- 3"# -  0'
""H
,  2
(

2003
  !
3" E!7. WHO. 2004. Guidelines for HIV Surveillance among Tuberculosis Patients, second edition.
8.
!1  '(
 2  3 ,1"H<H(E2.2550. )1 


(
 0
  H # ,(0, ^
,4 . 4$  ( ,(
,  . '(
H,H2
 
]]_ (2$ /(2.
9. 
*H1
!1  '(
 2  3 ,1"H<H(E2. 2550
)
 
K(
 The Tuberculosis Coalition for Technical Assistance.
10. WHO Geneva. 2004. A guide to monitoring and evaluation for collaborative TBHIV activities
11. )(,E , 0,   3 2. 2549.  04$  H # 4 , H # *) +   "!
(.Orane group 086 924
3434.
12. World Health Organization. Strategic framework to decrease the burden of TB/HIV.
13. WHO/CDS/TB/2002.296. Geneva, Switzerland: WHO, 2002.
14. World Health Organization. Management of TB: Training for health facility (A: Introduction). WHO/CDS/
TB/2003.314a. Geneva, Switzerland: WHO, 2003.
15. World Health Organization. Guidelines for HIV surveillance among tuberculosis patients, Second edition.
WHO/HTM/TB/2004.339. Geneva, Switzerland: WHO, 2004.
16. World Health Organization. WHO report 2007: Global tuberculosis control surveillance, planning, financing. WHO/HTM/TB/2007.376. Geneva, Switzerland: WHO, 2007.
17.
,
"
H"2
4"2. (*

*) +   ( (0'/"( 8 1(-

!"H(  30'53 2548. 


'(, 255
18. '(
3 ,". 0'( (*) , 4 . 4 $  3*) +  2(3"<$".

68



 
   


  . (3"<$"V(IJ"H# V(33 (( . 1,#  


  !   #

 50 5"#  ( # 0

  !  (3"<$"3,"E,H"$# 1 "'*) + -1 . 3



,
 .   
,-(. (
1(5 2528 /# ,# 
4333(. 6  ( (

*) +  
( 
  !  34, IJ-   .$1)1(3"#!(3
 .03HH

 . 1 Isoniazid 3 Streptomycin V(


"1((. *) + "#  . 1".  
0

  )"#  Rifampicin $13,"E,H (41 3 10 5"*# 1 (0



43
33(. (
 . -(( (Multidrug Resistance Tuberculosis, MDR-TB) ( Z ("#
IJ0

*) +  MDR-TB "'


 4'
-(. /#  //(
1

 333(.
1

4'$13("#303"'IJ  ,#  !$

-.(
((. ! 
"# ) *) +    ) -0( # -   . 1
8.1 9 
 Primary drug resistance 
 . (*) + "$# 1 

1( /#  
(

 Drug resistance in new cases


 Acquired drug resistance 
 . (*) + "# 


1(  
'

/#  
(
 Drug resistance in previously treated cases
 MDR-TB 
 .   1( 2 -(("# ' J  INH 3 RMP 0 
 . 
4(, (# Z 1   $1
$ 
 DOTS-Plus for MDR~TB 
)
*)+   H #
$-3IJ MDR~TB
 
4 Second line 3 DOTS "#  1) ,V(

4*
" $ -H (. "(# (. Z
 -*)+ 1343

H,0 
)

 0 
 
 1
( "2

69



 
   


8.2  &*EA
$ %9A & 
  4* (
0
WHO/IUATLD Global Project on Drug Resistance Surveillance /# ' 0
 . (
3
Population-based ( 58 3"<3 1 1996 3 1999 H
 . MDR-TB (*)+ 1 (primary)
1) 3 1 0%  14.1% 3H 1(
' 0 . "# 2 ((. 0'( (-H (. ""# #   
 . 4(, MDR-TB
) (Hot spots) H,# 
-(.
1
' 0 . "# 1
(
2 
   . (3"<$" 0
-)
' 0
 .   (41 5 H.<.2540-2541
3 H.<.2544-2545 H 1 
 . MDR-TB (*)+  1 "1
 2.02% 3 0.93% '
'*)+ "# 

1( H
 .-((V( 20.3% 3(
' 01! ."# 3  #
H.<.2548-2549 
 .  MDR (*) + 1"1
 1.65% -3"#  
 .   -(((*) + "#
 

1("1
 34.54%
(H (. "# 13(34

1! 03H
 .   4(, primary ". # Z (and drug
resistant) 3 MDR-TB )
1(
1! 34
" # $ 41( ( (0'H MDR-TB (*) +   "$# 1 


1() 5.9% (
1! *) , 4 . 4$ "#
 + V( 
H MDR-TB ) 41( (( " 
5
2539 H 8.8% 30 4 18% -38% 3((H (hospital-based) 1 41( H
<( ,("2 -(
1( 3HE, H 1 MDR-TB (*) +   "$# 1 $


1(
". "# , 4 . 4$ 3$1, 4 . ) 5.7% 3 5.1% '  4!
-
 .  MDR-TB (*) + 
1(H (. "# 

1 3% 03  1V(IJ' J(E!  *EA


&  *EA
MDR-TB  &  , :!*5 $- $/0  4
   & 
W#  4
! &:  4
  F &!  &!  ) %  /%' ( ,  &! % 
 & *I 4
! Drug resistant tuberculosis  MDR-TB  &# 0& 4
!  ,
4
!:*!5 $- $/0  4
 %
 $ 4
!
 &&!$ ' DOTS #*;  % 9A% &'

'(,(
 DOTS-Plus '(,(
(H (. "# Z 
  !  1)  ( # 0
 0'V(
"0# 34"H
 3 1  (,
"
H"23E!-1
(Z 3H # 
 4 # (# "' DOT -3"#
 4 second line 11( # V(33 (( (
0
(.   0'V("#
03H[(  -13
H34 . 33-)"#H #
   , 323('$H[(3

)
 ,# -(.
8.3
 !
:!*5 $- % %$  &  $/0 
  

H,0,( 1*) +  


   . -(( $1  ' J1,# H3
*) + "$# 1
IJ   . 1$
 ,(,0^ 1   .-((03$

 3( 
( "# 2 V(33 18 ~ 24  ( "'(,.   1401 (

3 
! H4 , "$# 1 ("

(*) + 
"#  
   .-(( 1$1$

 3"#303"'*)+  !

-.(3

70



 
   


0 "
/("'4 ,$ 3
H14 .   .( $ (.(
1 13
 0",
, ( "# 3 0341 
 ,(0, ^  . $ 3

"# 3
$"(  
8.3.1 *)+ "#
 .  -((
*) +   "#  
)"0# 3 3
 . -(( $
1
1. *) + "#  
 .   -((
1(

 *) +   "# , 4 . 4$ 
 *) + "#  3 
, *
*) +  MDR-TB ( ". ! 
"
H"2"# + V( 
33 
, *
*) +  MDR-TB)

1! #  (# Z 41( : *) + ( 4( *) + ( (0'  (, *H-(J1
2. *)+ "#
 .  -((3 1


 *) + 
'
 ) CAT1   CAT2  
$1- (. 1 
3$1# (
V(  # ,(. !

33--( 30
4 4 4(, 1
1  (3
1)
 *) + 
'
 ) CAT 1   CAT 2  *

 3H"2*)
 
(# 0 1*) + 3"(#' ^H3$

 ,E DOT
1! (.  
# "# ) 03V( MDR-TB
 *) + "-# 
,( 2  ( ,1
(
 0/.' 3*3V(

 *)+ "#3 , $




1( . 33"($1#'
3. *) + "#  
 .   

  
 ^H3 # 


V(/.' # !0
 $1
,( 6  (
8.3.2
 ,(,0^
 .33 (' J(4()
(
H,0 1*)+    . $10'V(1,#"#03*
 03 
,# 1 0"# 1 1
 H #  ((((!(
 ,0 *) + "#  0$1H4 .  0

 0  ,E Direct


smear 1 (J1$141 
   .  (
"#  1
 . 0

3" ,(
, "*#  DST $1((!(

 ,(0, ^  *H34 . $1-(. 11


1H"2*) 4# 4J H # 
 ,(0, ^3
"# 31$
 #  1
 . 0

3" ,(
, !  2 - 3 (
1(1 Specimen H #

H34 .  3


" $ 1(  (Drug Susceptibility Test : DST) (1 ("#
<
 H
8.3.3 
)
*) + "#  1
 .   -((
*) + "#  
 .   -(( 003$10'V(,# (4 # (3V(
second line "!
 *) +   "*# 
" $ 1H 1
 .  H"2*) ) 03 '(*


"# V(1) (-3""# *
"
 . 1   *) + "#
 (1

"#  03

 3"# 41) 1 $ 

" ,(
,  3*

  
 . -((
,-(.
003H,0#(31

 0 
 
 1
( "2

71



 
   


 # H*) + "#  
"0# 3
 .   -(( , ,  (.
1. 13H # "' DST
H (. K( 4 - 5 4(,  H R S E 3 Z
2. 3 1* DST 
)
    . (1$ ( "(.
2.1 H,0# (3V(3( "# 2 $ (*) + "#   1 CAT 1  
CAT 2 

 3 Empiric CAT 4 (1)   Empiric CAT 4 (2) '
2.2 3,/#
'$ 1-) 3((. $
1(3* DST (,# " #  '( :
*) + 04 . 4(, Nontuberculous mycobacteria (NTM)
$)
/ $  !
$  , &!$   CAT 1 4$ :5*! $-   *  
%9%&!$  DOT   /
' + $ *  4<!   CAT 2   :  ,
 &9
" ! * $   <&   *;*&! & & 
  !$ (Acquired MDR)
*;
Sensitive bacilli 5  \ &! 4
! : DST " !  :5*! $- & +  % $ $ *A
E
&< HIV
&!$ 4
!* # , ):5! < $< A*; / F *   \&   $ )  0
94
!4<! CAT2  :5*! $-   9  , &!$ CAT1 : $%
 % & 5 *;
$ W# 4<! CAT4(1)
4
! HR * : DST
4
! CAT2 4
! / *; F

$ 4  /  $ *X   ! 2.1


 2.2 %  "4<! /Y) 5 !
  / 0 % & &  $/0 
   & 
1.  %   (  ! * *9
 $)
2.  ,/ * *%
 
$   , (Fall and rise)
3. * $  &!  DOT 4  ,   
4. +  %*& / $$   [$  !
$  , &!$   &
5. * $* E %  & 
     ,
< /   %   & * *%
&!$$ Direct
smear &      % %'&& 2
 3 % %'&& 5 *; ,/ rise (grading
*; $  # ) +  %*& / & 5 ( / &!   $ )  $  '   #
 ,    &! DOT    & 0 % *; &  $/0 
  %5 \$ 4
!
   , &!$ Empiric CAT 4 *
3.  # $ * DST
 ( "
('* DST 3

# (3(.
3.1  43,1) # (3* DST
3.2 
,# 3 Empiric CAT 4(1)   Empiric CAT 4(2) $ H0, # (
3* DST <
(" ,(
, 3*
(-33 1

 
(  ( "# 2 3
 /# ( . 

 3,  Empiric CAT 4(1)  
Empiric CAT 4(2) 1$$

72



 
   


3.3 * DST V( MDR -TB 



 - 8.6 /# 4( "# 2 3((


  DOT 0("# E!-V(H# .   "*# 1 (
 "1((.  011
1H"2
*) 4# 4J H # 
 ,(0, ^3
"# 31$
* DST "
# 3
(" ,(
, $1 
( 43  , 
#'-
3"( 3


(" ,(
, 3*
 03  ,E Direct smsar
V(

(
H,03"#034
8.4 #    , :5*! $-  MDR-TB
-(. "3(*) +  MDR-TB $V( 7
!1 
0
3"3(
, (TB 03) (.
1. New Category4 patients : $
1 *) + "$# 1     
  (
1 (less than)
1  ( (
"#  1 3 0" $ -4 . 1 (DST)  # ,# (
 3
CAT 1 31* DST  1V( MDR (  ,E Solid media method 03"* 3 - 4  (
1)
0 *) + V( New Category 4 patients  1 03$ CAT 1 
,(
1 1  (

2. Relapse Category4 patients : $
1 *) +   "# 
3 1
V(/.'*
DST (-3"# 1  0
1(

/.')  1V( MDR
3. After Default Category4 patients : $
1 *) +   "#
  - > 2  (,1
1(



. * DST (-3"# 1  0
1(

 . ().  1V( MDR
4. After failure of first treatment : $
1 *) +   "#
  . 
(1 (J1  3 CAT 1)
  (*3 #  ("# 5 
) * DST (-3"# 1  0 # ,(.  ("# 2   5)
 1V( MDR
5. After failure of retreatment : $
1 *) +   "#
  3 CAT 2   (*3
 #  ("# 5 
) * DST (-3"# 1  0 # ,(.  ("# 3   5)  1V( MDR
6. Transfer in : *) +  CAT4 "#
) 11 (Transfer) 0
(1 ,
(# (/# $-(. "3(*) + 
CAT 4  ) $
(1 ,
(# H # 
1 (*. ) + 0V(*) + -(1 ,


(1 ,
V(*))1( #  #
  031*

$(1 ,


 
7. Other : *) +  (# Z "$# 10-(
!1 1-6 3 *) + 
 CAT4 "$# 


0
(1 ((
3 NTP   ($1-(. "3(*) + 3 NTP)
0  
%"      , :5*! $- $/0 &  $ !)*  
&  $
%  "* %   
$  F   $!  4
!  , * %:%5
% &' : *5! $- #&!  4 / &)*   &  $* $ %  "  , :5*! $- $/0 
&   $ &!& $ %:5*! $- *  , 4%"    $  !
  4  ,
:5!*-$& *
 0 
 
 1
( "2

73



 
   


8.5  $/0 $ 1  2 4 <!4  , :!*5 $- $/0 % %
 & 
  
 & $
  1   ( "# 1 3 2 "#  4(

*) +   "# / 
 . -((3
-(1 (
:!5*-$9
 $ :!5*-$9
 $ :!5*-$9
 $
! $ 40 40-49 0  4<!   50 0 

$ , 
0  4<!  &  & ( ) / # *4<!  &
( ) /$
$
( ) /$
750
1000
Kanamycin (15 mg/kg/day)
K
500
^-
 (3 1 .
1,200
E
800
1,000
Ethambutol (15 - 25 mg/kg/day)
2,000
1,000
1,500
Z
Pyrazinamide (20-30 mg/kg/
(27)
day)  ( 3 1 . ( 
3 500 ,,
)
600
800
400
Ofloxacin (7.5-15mg/k/day)(18)
O
 3 100, 200, 300 ,,

 ( 3 1 . *
500
500
750
Ethionamide (10-20 mg/kg/
Et
day)(18)  3 250 ,,

1 ( 3 2-3 . **
500
750
500
Cycloserine (10-20 mg/kg/
Cs
(18)
day)  3 250 ,,

1 ( 3 2-3 .
8000
10000
12000
Para-Amino Salicylic acid
P
(200 mg/kg/day) 1 ( 3 2
(8 gm.)
(10 gm.)
(12 gm.)
. ( 3 1000 ,,
)
500
750
1000
Streptomycin (15mg/kg/day)
S
^-
 (31 .
750
1000
Amikacin (15 mg/kg/day) ^
A
500
-
 (3 1 .

 
': *  ( 3 . 0(
103*- 
0 11 ( 3 2 .
**
 
 3 1ZH,# -( 41( ,# "# 500 / (
1( 1-2 2
 # 3,( 1"($0 H,# V(-(
,

74



 
   


8.6   4 <!4  , :!*5 $-  0  %%5  & &  <& MDR-TB
*) + "#  
)"0# 3V( MDR-TB 1 (J1 $1  0'V(# (3"(" *
DST  ((
1( 1
  V($$) "0# 3V( MDR-TB 3
*) +  1(-(
(seriously ill)
# ($43 Empiric CAT 4
1((3 1"# * DST 

4
*) +  MDR  
Suspect MDR 034" #  14 . $1 . 4 -(( V(^ 1 -(( 3^  6  (
3 Empiric CAT 4  2 3$
1
1. 3 Empiric CAT 4(1)  6 K5 O. P.E.Z / 12-18.O.P.E.Z
4'*) + "
# '
 3 CAT 1 3*

V( Failure 3 1* DST
1 4 . 1 

,
 .   -(() (# 0 1*) + $1 $ S 
1(  * DST "#  1
-3"# ,#  CAT 4(1) 4 . $ 1 S  S "( K
(# 
3,( 1*) +  Failure 0
CAT1 3
"# 4 . 03 . 1". E, Z  
0H,0-$4)  CAT4(2) 
2. 3 Empiric CAT 4(2)  K5**. O. (P*). Et, Cs.(Z) /12-18 O. (P*). Et. Cs (Z)
* 0 
PAS(P)  Ethionamide(Et)1  0'V(0H,04". 2 -((
** (
-^ ^"!
( ( 1(23 5 ( ) V(  6  ( 1 *

 03  ,E  4 . V( 0H,0^V(23 3 ( ( ( ( () V( 
3  (
(
0
(.  H,0
,("
# '4 1 3,"E,HH 3*) + "("E,-   -^$$
1 * 03H4 .  # ,(. ! ("# 3
4^(( 6  (
  0'V( 


4
^ (("# ! 1( 6  ( *) + "($3$1
,"E,-   "# (! 0

(
"*#  03V(. 1 ("# 2   3  3*) + "(^$1 1 $ 0H,0
^0
23 5 -  V(23 3 -  ( ( ( ()
 , &!$   $ 2  Empiric CAT 4(1)  Empiric CAT 4(2) 9*;!4
!
 , &!$  DOT '/+  0&!4
!!
! %  /%'
 % % %  /%'
:   
* % /)*;  
 , $/0  *& *; MDR-TB



 (
H
 ( ,# "#   '( 
"# V(  (
 )"1 # 3
3"1 (
 (Central Nervous System) "#  
4  
! , *1( # ! , $-($
 RMP, INH, PZA, Pt, Et 3 Cs /*1($- 3"# Kanamycin, Amikacin, Capreomycin 
/*1($ (-3"#  # ! 

  1 ( PAS 3 EMB /*1($( 

8.7 & * :  , (  ')

 03  ,E Direct smear V( ,E


 ,*

"# 4 #  $

1H
34(2( $10'V(
 01 Z
 0 
 
 1
( "2

75



 
   


,*

1( 
 0",
,  (.
7.7.1 & :  , ()"# 2 3
)

,*

1( 
 0",
,  (.

 03 Direct smear 3
H34 .   # ,(. ! ("# 2, 3, 4, 5, 6 
0
((. "!
3  ( 0(
  ".
 0  # ,(. !


 0
" $ 1( 
 0'V((

1H  0( ("# 3  ("# 6 0
((. "!
6  ( 3 # ,(. !



  2
 0",
, "0# 'V( H # ,*

  (-


End of Month
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Direct smear


Culture














Sensitivity

CXR




 :  


      ! "  # $% %&"  $% 
%"

76



 
   


1 (J1-*)+ "#(1

3*

 
03
#(-3
0

V( ( 6  (
-



3,(* sputum conversion 0) 


* direct smear 3 culture "#  01
(1( 30 (
3
 0H4 . 

H"2*) 4# 4J
8.8 9 :  , (Treatment outcome)
1. Cured :  *)+ 3 CAT4 "#
,( ( "*((  14, 3
* 03  ,E H34 . V(1( 5 . ,1
((41  12  (!"-

 "# 3

1
($1( 
1 30 (
2. Treatment completed :  *) + 3 CAT4 "
# (,  ( "*((  14,
1$1/ $1 * 03 ((  ,E H34 . 1V((41  12  (!"-


3. Died : *) + 3 CAT4 "# 3 1

$1 1  !
4. Failed :  *) + 3 CAT4 "# * H34 . V(
$1( 
1 2 . ( 5 . (,1
()
(41  12  (!"-


  *H34 . V(
1 . ( 3 . !"-
 0
  *) + "# H"2 ! CAT4 H3$1(1

  "E,-   0


0(*) + "($1$
5. Defaulted :  *) + 3 CAT4 "-#  > 2  (,1
(
6. Transferred Out :  *) + 3 CAT4 "#
) (
$
1"# ( # 3$1"*


8.9 & 
  , 
H #
, Relapse rate   Direct smear/Culture V(  24  (
 ( 0
"!
3  ( ( 6  (
30
((.  0/.'"!
6  ( 0(  2 5 '
1HH0, 
 0 # - 14.
8.10 
&  :5! %  :%  :5*! $-  MDR-TB
*)  *
4, (Close contact)  *)" # <)1 ((
*) + MDR,  4 1 
*) + 
(34 # (, (""# "# '(( Z (Indoor living space)
'*) J1"#  *3
 $
3,( 1
'+ V(   $1 V( 
H,013 0 DST "(" -3"# * DST 

 Empirical regimen $1V( 


 ,4  (3"# 3 ($1 4
!1 Quinolone) 0H,0"' CT scan   Bronchoscope 0'V(

"#  * 3

+ V( MDR-TB *
4,
 MDR-TB  *
4,

*) +   "# 3 1


 
$
 ,(0, ^ 
"' TST (Tuberculin Skin Test)
1H

 03". Direct smear H34 . 3
"' DST
 0 
 
 1
( "2

77



 
   


(
"#
K( 1 
,4 . 03 '( 1
,4 .(.(Z0$141
,0

MDR-TB " # $ *)  *


4, 03$
,3,(*1( 2 5 + V(  $

  ( "# 2 (CAT4) "(" (1$
 WHO $1(3('4( "# 2 H #

( MDR.TB
(*)* )
8.11 $  &9  9  &  
$  ' 4 &  F  % %'
(Programme Monitoring Evaluation and Support )
1.  
$  '  $!
)  %9 $/0  $ '0 
1. ((!(( ,4
1 
*) 4# 4J
1(1 ((3- 
1.1 0"'3*H1( "
)*) +   "#  . "# V(K(-3"< 3

!/3,(* (( " {)
1.2 ,0 ((!(
 ,0" ,4
 H #H[(
 ,(,0^ (4())
)

  .  3H[(3 3,"E,H
-(. 3
 ,0 ( !H-
1.3 H[(<
H! 
"#
# -
1.4 H[(( "

(3  !
H1
304 .  ((H
1.5 ( : '(,(
/3(/((!(  (  ( "# 2 "#  
! H( 
"# 33HH 3  ! !H  "# 0 '(1(3"<$"
1.6 (4() : ((!(
 '(,(
" $ 1(3- 3
  !
!H
" $ 1
2. (,"<((3-
3. 0"'3((!( ]2(
("


*) +    . 
4.   -)33,(*3
'(,(( 3*

(33"<
5.   -)
%3    .33"<
)  %9  *I $ '0  $ '0 
1.
1"" ( 1"( "
)
*) +   "#  . "# V(K(
-3"< 3( "

(3  !
H1
304 .  ((H
2. H[(<
H! 

1(1 ("#
# -(H (. "#  *,4
3. ((!(3 '
 H # 
 0.   -130  3
'(,(((
3
  -1"#  3,"E,H (  
((!(
 H34 .  (H."#  H (H (. ""# #  J
I 
  . )
4. 1 
*) 4# 4J (
 '

#

 ,(0, ^ ) 
*) +   "#  J
I 
 .
1H(H .("#*,4
5. (,"<(H1-1(H .("#*,4
6.   -)33,(*3
'(,(( 3*

(H .("#*,4

78



 
   


7.   -)
%3    .(H .("#*,4
8. ((!((H(H (. "# (
0. V(1-1 
 ,(0, ^ )
*) +    . 
(Specialized MDR-TB Center)
 /Y)4  & Specialized MDR-TB Center
 /Y)4  & Specialized MDR-TB Center # 40  
%"   
 &9 &5  , :5*! $- $/0 &  &!$   $/0 $%  %"  
0  
$ $  ! & :
1. &!     :5 ! 
"#$ %9A*EA

2.  '   )%  /%' 4 4
! &5:5*! $-   
3.   &!  <%5  %:5*! $- & 
4.   DOT 4  , :5*! $- $/0 &!$ $/0 $ 1 & 
5.   #   :$/0 & 
6.  Second line   /
' + 

)  %"   *;   &5  , :5*! $- $/0 & 


   (Specialized MDR-TB Center ) 0&)   +%<
1. 
 ,(0, ^3
*) + "# 3 ( "14,'

   . 
-((
2. 
-(. "3(*) +  (Registration)   . -(( -0 ((. Z
3. H,011*) + $
)1 ((

,(H# . "# H4!4( "# V(
), '(-*) + 
4.  03,*

 33,(*

*)+ "#
-.("3(

5. %3  ,(0, ^ 3


- 0


3 "
/("# V(!(

1*) + (H (. "-# 0 ((. Z  H (. "-#   -1((. Z (
"$# 
1 


6. , 42  ( "#  ( "- 4.
)  
$ 4
!  , :5*! $- $/0 &  4%"   (MDR-TB clinic)
41( (H4!4("# V(), '(-*) + 
1. 
 (*) +   "# 
 .  1 0H #
 ((
 ,(0, ^   . 
2. 

*) + "# 1 10
.H. 1-1  (Specialized MDR-TB Center) 3
"$# 
'(   ,E
 
 (Directly Observed Treatment) ! 
"
H"23E! ".
,*

 ( "14,'

   .-((

 0 
 
 1
( "2

79



 
   


3. 

*) +  Ambulatory   ,E Directly Observed Treatment ((! 

"
H"23E!4. 
%3  )
 *- 0
  "#$1!( 311*)+ H #



1H1-1 (
"#V(!(<
H-(H
5. 3,(*

-*)+ (H .("#"#*,4 1 
H1-1
6.  #( Z 41( (*)*  !3
(
H1
304 .   .((
H
)  !
!    $/0  (H1-1  3(H4!4( 

""(
)*) +   "$# 1 .  
1. 03 ,(
, *) +    . 
2. 3((
 !H"2(H1-1  H"2 (H4!4( (



   ( "# 2
3. 0"'3
-(. "3(*) +    .  (Registration)
4. %3 3
)

-  31 03H #
,*


31 3,(*


5. 1 3,(*


*) 3((  30  (PTC) 3H"2 H *) 


 (
"# ,(,  (.()1((H1-1 3(*
1'(
(E!-0 
H #   3(1$  .
6. 3((
*) 3((  3'330  (
0"'(
7. 1 (
03  !3
(
H1
304 .   .((H
[)  :5*! %  $/0  & 9+

""(
)*) +   "$# 1 .  41( 1 (
0"'"3(*) +    . 
(Registration) 3,(*

*) + (- *,4 3
0"'(
<)  :5*! %  $/0  & 
$&

""(
)*) +   "$# 1 .  41( 1 (
0"'"3(*) +    . 
(Registration) 1   *
 (*
 (*) +  . 1 3,(*

 H #   3(
1$'(
(E!-0 
W)  :5*! %  $/0  & 

""(
)*)+   "#$1 .    "'"3(*)+    .
(Registration) *
 ( *

0
*) 3((  30 H #
3,(*
'(,((
(H --1$
x)  !
! 4%"  
1. 1 (


*) +  Directly Observed Treatment
2. 

H  3 '(3('  ".
11H # 

((H"#
3

80



 
   


2 % !  Laboratory network    $  < $/0   &% $ 


$ ! $/0  (Drug Susceptibility Test)
2.1%9 $/0  0& '
!*X   ! <%5 $/0  $ '0 
1. V(<)(2
(
"' Drugs susceptibility test-  ( "# 1 3( "# 2
 " ("# 3 3*
1 H1-1  H # H"243

03(


1"( 
2. ((!((
H[(<
H33
( !H ( (
"'
H34 . 
3
" $ 1 
1(1 ((3-
2.2%9  *I $ '0  ( ' <%5 ) 0  (5)/$ *
1. V(<)(2
(
"'
H34 .  (H (. ""# #  *,4(("H# 
2. V(<)(2
(

" $ 1 'H (. ""# #  *,4(("H# 
3 &
 $/0 $ 2   /
' +  
$<+/Y)
  ( "# 2 03, 2
4
 1  - 4. ((K(3 Financial
Agency) 3'(

  ! ((K(3 Technical Agency) H #    ( "# 2 "#  
! H
3$1- (

 0 
 
 1
( "2

81



 
   


 % ! 
1. Siriarayapon P, Yanai H, Glynn J R, Yanpaisarn S, Uthaivoravit W. The evolving epidemiology of HIV
infection and tuberculosis in Northern Thailand. J AIDS 2002; 3: 80-89.
2.
!1(,,
4(),
!1  (2547). 
('((
34!!*(30'5
!1
 5 2547 
3


3. Yoshiyama, Takashi. Supawitkul, Somsak. Kunyanone, Naowarat et al. Prevalence of drug-resistant
tuberculosis in an HIV endemic area in northern Thailand Int J Tuberc & Lung Disease 2001; 5:
32-39.
4. Annelies Van Rie, Robin Warren, Madalene Richardson et al. Classification of drug-resistant tuberculosis
in an epidemic area. Lancet 2000; 356: 22-25.
5. Iseman MD. Management of multidrug-resistant tuberculosis. Chemotherapy 1999; 45(suppl 2): 3-11.
6. GUIDELINES FOR ESTABLISHING DOTS-PLUS PILOT PROJECTS FOR THE MANAGMENT OF
MULTIDRUG RESISTANT TUBERCULOSIS (MDR-TB). Geneva, WHO, 2000. WHO/CDS/TB/
2000.279
7. Payanandana V, et al. Surveillance for antituberculosis drug resistance in Thailand: Results from a nation
survey. Thai J Tuberc Chest Dis 2000; 21:1-8.
8. Pablos-Mendez A, et al. Global surveillance for antituberculosis drug resistance. N Engl J Med 1998; 338:
1641-1649.
9. ANTI - TUBERCULOSIS DRUG RESISTANCE IN THE WORLD Third Global Report The WHO/IUATLD
Global Project on Anti -Tuberculosis Drug Resistance Surveillance 1999-2002. Geneva
10. National Surveys-cluster sampling proportional to size, TB Cluster, Bureau of AIDS, TB & STIs 

3


11. Amatayakul N. MDR-TB in hospital-based. Thai J Tuberc Chest Dis 1998; 19:73-80
12. TB/HIV Research Project, RIT-JATA 
3


13. Reechaipichitkul W. Multidrug-resistant tuberculosis at Srinagarind Hospital, Khon Kaen, Thailand. Southeast Asian J Trop Med Public Health. 2002 Sep; 33(3): 570-4.
14.  ![, ) ![, 3 3
 .(  (*)+ ,4 .4$ 1 
  -H
E, 5 H.<. 2543-2544    " 
3 4' ,
, , 2546; 24: 221-228
15. Suarez PG, Floyd K, Portocarrero J, Alarcon E, et al. Feasibility and cost-effectiveness of standardised
second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru.
Lancet. 2002 Jun 8; 359(9322): 1980-9.
16. Pleumpanupat W, Jittimanee S, Akarasewi P, et al. Resistance to anti-tuberculosis drugs among smearpositive cases in Thai prisons 2 years after the implementation of the DOTS strategy. Int J Tuberc
Lung Dis 2003; 7: 472-477.
17. Crofton J, Chaulet P, Maher D. Guidelines for the management of drug-resistant tubercusis. Geneva,
World Health Organization, 1997

82



 
   


18. World Health Organization. TREATMENT OF TUBERCULOSIS: GUIDELINES FOR NATIONAL


PROGRAMMES THIRD EDITION. Geneva, World Health Organization, 2003
19. Mukherjee Js, Rich ML, Socci AR, Joseph JK, et al. Programmes and principles in treatment of multidurgresistant tuberculosis. Lancet. 2004 Feb 7; 363(9407): 474-81.
20. Treatment of Tuberculosis. Guideline for National Program. Geneva, WHO 1993.
21. Cohn ML., Kovitz C, Oda U, Middlebrook G. Studies on isoniazid and tubercle bacilli, II: the growth
requirements, catalase activities, and pathogenic properties of isoniazid- resistant mutants. Am
Rev Ruberc 1954; 54: 641-664.
22. Snider DE, Kelly GD, Cauthen GM, Thompson NJ, Kilburn JO. Infection and disease among contacts of
tuberculosis cases with drug-resistant and drug-susceptible bacilli. Am Rev Respir Dis 1985; 132:
125-132.
23. Cole ST, Telenti A. Drug resistance in Mycobacterium tuberculosis. Eur Respir J 1995; 8: Suppl. 20,
701s-713s.
24. 
2
,(H<2 3,"E,*-
  ) 2HRZES/1HRZEW/5HRE   3
 " 
2545; 23: 107-114
25. (,EH, [
 (2 0
!   . 4(,    " 
3 4' ,
, , 2546; 24: 95-100.
26. Wing Wai Yew, Chi Kuen Chan, Chi Hung Chau, et al. Outcomes of Patients with Multidrug-Resistant
Pulmonary Tuberculosis Treated with Ofloxacin/Levofloxacin-Containing Regimens. CHEST 2000;
117: 744-751.
27. Sir John CROFTON, Pierre CHAULET and Dermot MAHER. GUIDELINES FOR THE MANAGEMENT OF
DRUG-RESISTANT TUBERCULOSIS. Geneva, WHO 1997.
28. Guideline for the Programmatic management of drug-resistant tuberculosis WHO/HTM/TB/2006.361
29.
%3 
 .   "# 3. 2549-2550 '(

  !
3" E!30. 0! !"
.

   . -((.  ^H,H2 . "# 4 (^!)  
 13"<$"(H34)2 H,H2"# H,H210!
2 ,"
31. 2007-2008 XDR & MDR Tuberculosis Global Response Plan
32. Jose'A Caminero Luna. A Tuberculosis Guide for Specialist Physicians. 2003 IUATLD
33. Anti-Tuberculosis Drug Resistance in the World. Report No.4 WHO/HTM/TB/2008.394

 0 
 
 1
( "2

83



 
   



(Tuberculosis in Children)

     
 
!"# $%   &  #    
&! '&(  )(*  $  '*%+ , 
*-   $(  .  &! )(
 ) &
*-
"+ &&!%#
'
$"+  
!"# $% 
*- !  )  $ /&& 
 .' '%#&) 
"#& '%+$%*'01& )( * $ $ $ #2
("&
'%+3# * 
$ $ )(!  $%&)( (cavity)

"+ & 


 2 
!"# '%'+ 2
 
$%2  /&'2
 

$
*- *6 )
!"#   "+ )($$% ( ' '3& 1$ )
$"+ $%
 

 3/ # 
*- ' 
 3  3&7  83&* ! 
$$
!"# 3&  !7$!


 
!"#   
$ 9/&+ ) &:/&*'013& 7$'%+  &**7&
 .
 # !) '&
%   
 ! ethambutol &&3  
$
 20 $(( $/ ( $/
>'03?  &
%&'%$+ % (  #   

  
1)   '&( 
 * , 
'%$+ %  )( ) &
3    $ 3" + % &  2 3 ) 
1.1 1&%'& ( .$ * '
%+ 3    $%* ) &# ) $ #2
("
'%+3# * &
% "$%)(
"# * $  "$% #2 !&
"+ 7$ * "
*- !  miliary B(B 
:1&%'& '#&   )(  3&
"+  '%+)$ 2$ 3/#
1.2 *C   '7
8(7  10 $$. $ 
% 9% %9% $% )("$  $ &!%:# &/ 

!"# M.tuberculosis 9/+&$%$2 *
$  )(  . ('%+$%1$7$   &"
 
!"#
!% !3    5 $$. :*C   3  '7
8(7  15 $$.   7 $ :/&)$$$%
*6
%+ & $)

84



 
   


1.3 * $  * , *  


! 
$$
!"#
 '%+ $$%   ( Contact Investigation) ! 1.1 + 1.2 + 1.3
2)   "  '&&*C  
:$% )( ) &
3  $ 
!"# $%"

!"#
:"
*- definite diagnosis
!"#   $"

!"#  &+ &
!
$ #2
"+ 7$ *
#23 (& #2 
 B(B
$"+

!"# )( &' $3&
!"#  

$+  .
"+ *
$$*
! #
"# '& (&7('H 8! '% +   $! 

! '%+  $ #2
("&&
'%+   & 
"+ 7$ * & * & B(B
 '%
+ *-   * '%$+ 1% :&%'& *  
&+ & #2(& 
"

$
"+ 
!"#  $%$  $
!"# $)  2'2
0% $J '&&*C  
! ) 
 ")  %#  0'% &9%(%+
 ' !  &J $% $)($2
 (
%& 0%  $%'  (AFB stain) /&&$  $
!'+* *67   0% !%''%+ $!  $ "0% PCR
"+& $%$
   (

( 1-2  $)($2


&$ ( 90 3/#   primer '%+! !   

 3/# $:  . ' '% 3'%+( 



!"# )( '%+

!"#$3/# ) '&( 
3
    ( 0% PCR !     .
"# & 0
% ( %# $$:'2  &*C 
 '+ * /&&
*- J *&"$

("
"+ *$ IFN-Y (ELISPOT, QuantiFERON-TB Gold : QFT-G) !!  
  )]&)('%+ active disease   $ 3$( '&(  $%3 %" 
(" 
 3
%&&#
%'2'(  )$% )&)(&! &*C  
 &$$:'2 '+ * 3$(

&$%$$  /&&$)  2!

 $% #2
"+ 7$ * &
 9$8 adenosine deaminase (ADA)  #2'% +   $
!    $ $%$*$( 92  '%+ 2) &" + J
!  !&
"+ 7$ 
 $& $)  2'2  ADA
 )( ) &'%+ 3&!  &J 

1)  (Pulmonary Tuberculosis) $ $  '+ *
! 3+2 J
"# &
"+ 
#2  (   
'%+
! 
"# &
     *$( 50
2)    (Extrapulmonary Tuberculosis)  $%
 * $   )  

"+ 7$ $& $% ) &3&$   $&& (increased intracranial pressure
! * H%.$ 
%

 & ! B(B) $ 3 '%


+ *- $ $% 9/$ $   #23 (&( .2

$ #2
("&  '%+ $%   $
 
*-
"#&)  $%
 &(
*- J J
'&
  $  '+ *
! 3 #2  (  
'%+ $%7 
&
"# & * '& $%(2 7  $%   '& $% #2 !&'& B(B
  

   
 
!

85



 
   


   $ $%$ '%3+    


  &$% sterile abscess
 $% hematuria, sterile pyuria
 miliary $% 7 )& 3& 9/$ $% B(B
 

 .
& &# )   '&( 
"# & $  $! intermittent
regimen
&!3  & 9/&+
%+ &.3&
%&3& $  $! ethambutol 

( :2
*- &!
&&$3 
 20 $ ./ ./  .
*-  Directly observed therapy, short course (DOTS)

!
%     
*- )$ "
 (%# & 
9/&+ &: &)($+2
$ * & 

 '%+ J  !2*/ .'%


+ $$ 
$+  .  
"+ *'0('% + %   % )(
$
  "# 3&
!"# 

'%+ !$% 3 Categories 
! 2 Categories " Category I )( III
Category I 2HRZE/4HR "  Isoniazid $  Rifampicin, Pyrazinamide )(Ethambutol
 2
" ) $  Isoniazid )( Rifampicin % 4
"  %# !
- * , * ! 
$$
!"# 
- * , * ! 
$$$
!"# )$% extensive lesion
 * , '%
+ *-   * !  7 )&
! !  )     )(3 
 * , 
!"#
!%  *'  9 - 12
"
 '%+
*- 
"+7$$&! Streptomycin % )' Ethambutol  2
" ) $ 
Isoniazid )( Rifampicin % 7-10
" $
*- 
( 9-12
"
Category II 2HRZES/1HRZE/5HRE "  Isoniazid $  Rifampicin, Pyrazinamide, Ethambutol )( Streptomycin  2
" ) $  Isoniazid $  Rifampicin, Pyrazinamide )( Ethambutol
% 1
" )($  Isoniazid $  Rifampicin )( Ethambutol % 5
"  %# ! 
*- PTB
! 
$
!"# 9/&+
  .$)( )
- Default 3      2
"
!"#   "# (3 
- Treatment failure  .)( 5
"
$&
!"# (   Relapse  .)(7 
 (
*- $)(
$
!"#  /& ! 
)
Category III 2HRZ( E)/4HR "  Isoniazid $  Rifampicin )( Pyrazinamide  2
" )
('%+ &
!"# !  "# 
$+ Ethambutol  !& 2
" ) ) $  Isonazid $  Rifampicin
% 4
" !
- * , * ! 
$$
!"# " !  $$% cavity  *
-   * '%+ $ 7 )&
! $ #2
("&  & (3   &'%+ 1   6)

86



 
   


  
 &J %3 /# 
( 1-2 * 8 ( 80   %! 
  3
" )(( 90 %3 /# $ 
4
" 1&%* '%$+ % 
"# * !
( 10 - 12
" /& &  #
$"+  . 6
" )(
:&
  1&%* $2
*- &    # 2$ #2
("&'%3+ # * !
( 2 - 3 *{
/&7
*- *  &  # /&$2
*- &:1&%* J
 3&
%&3&  $ $%(" +  
%   $(  
*-
!+ )( J * :$% 7 )&
!
*- 3 * 3 %9 &7 )( 
 9$8
3&   .$$
$$ "*/ .
 !%+ !
$"+  ) &J * /&
$+ 
 . 3  J
 .* 
 ( %$ ( 95  Relapse  ( 1
  

*|&  '% + '% %+ 7 "  * , *  
! 
$$%
!"# )(  .
&: &
"+ $)
!"# * 
$% 1$  $7   % 9% %9% %  
"+ *|&  
$ * ,   # $%*! 8
 $ '%
+ %+ & 
 
*-  J *
1.    
% 9% %9%% ( *|&  
)*'01&$
*- '%+ 
 

8 & '+ (  1,200 & 7*9% %9% % $:*|&   1$
%&(
50 *|&  
"+ 7$ $&  ( 64 )(*|&  !  )   ( 78 /&'2$% $$
 (9% *|&  !  $'$%+ *% '01&3/ # $:*|&   '&# primary, reactivation )(
exogenous TB $%
' (%$J
! (9%  cell wall antigen  ! recombinant technology 9/&+ 
 & H/ .'&#  #
*
'H'  % 9% %9% % ) 
)
  *67  %# (7$
) (
" ( 100
% 7  $$*% ! 8
$$:*|&     
)
 '%)+ $ 
!"#
!% "

'%+ 
!"#
!%)$$%  $:% 9% %9% % 
*C   3&
%&(& % 9% $ ) & 

* ! 

  9% %9% % #    %# !  
!"# 
7 10-14 *{
*-  2
*67  )  2 % 9%  *
'H'%$+ % high prevalence 3& (&  40/100,000  *{) *
'H'
.H. 2535 $%$!7
'  83/100,000  *{ )( .H. 2549 $%$!7
'  62/100,000
2.  !    "# (Treatment of Latent Tuberculosis)

'%+ 
!"#  $  '
%+ *- * ( 
&&+ ! 
$$
!"# )
)(
&$*, 
*- 3/ # $ :"
 )]& (LTBI) &*' *|& 
"+ $
!"#


( %# 2
 * *,
*- 3/# $ :"$%$2)(
*-   /+&3& (7'08
 (& (TB Elimination)

  

   
 
!

87



 
   


7    1 *{
$"+ 
!"# *,
*- 3/ # $( 40 - 50  !& 2 *{) '%+ 
!"#
)($% *,
*- !  7 )&
$% ( 10 - 15 3'%+   
!"# $% 
*- 
( 5-10  !&( !%


!"#      ' *C   '7
8(7  '%+ 
 H 8 (& 15 $$.  

$$%   1:&%'& *   H/ .3& & 2 &#
$"+ .H. 2538-2540 )( 2542-2543

7    5 *{ '%
+ % 9% %9% $% )(&# ))
   $  * &'%*+ , 
*- *
! 
$
!"#
*,
*-  ( 9.1 )( 8.2 $(2  *~ '7
8(7  15 $$. (
22.6 )( 18.7 $(2 
"+ & H/ .'&# 2 &#
*- H/ .) (& (retrospective) /&  H/ .
) prospective
$"+ .H. 2547-2549 $%
*,
*- ( 1.64 
!"#( 61.4
H/ . &*
'H
*,
*- *$( 1 )(
!"# ( 20-30

( %#
   *' *|&  &# )
!"# (LTBI) )(*'   *|&  
  :&/
( 90 )($
*- !  ) * :/& 19 *{ *' *|&  $%*! 8$ 

 
!"# 

*- recent infection
$ )(
$ 7 )&
! 
"+ 7$ $&
!  ) 
" !$%
2.1)
$ * , * ! 
$$
!"# (Infectious Index) )'8'%+ * ,  
)  2
'7    $ $7 )'8 
$% :7*&8 
*- "
!"#
"$ (3   %
# % Contact Investigation)  9 *  
 *, &  :1&%*
)('2 ' *C '7
87( ) 
'%+$$
 :)(

*- '2  . $  
 :)(
$
*-  
*- 1
!"#  *' *|&  & %#
- 7 < 5 *{ '7  *' 9 9 5 - 10 $ ./  6 - 9
" ($
*C   '7
8(7  $%3 
' )
- 7 5 *{ '%*+ C   '7
8(7  15 $$.  *' 9 9 3  5-10 $ ./
./  6 - 9
" :*C   '7
8(7  10 - 14 $$.    . LTBI
*-  J * :*C   
'7
8(7  < 10 $$. 
]|& 
 *,'%
+ 3    :$%$ : '%+ $: $

 ' *C '7


8(7  9#2% &#  8 - 10 * 8 $ :3     &# (& 10 $$. )(
$%3 
$+ 3/ # $ 
$&  6 $$. :"
*- 
!"# $ (recent converter) &9 9
*' *|&   6 - 9
"
 :  073'%+$$% #2'7
87( &
*:   &3/#
(): $$ % #2'7
8(7  
]|& 
 *,'%
+ 3   :$%$)
-

!"#
!%' 7 
$"+ $%* $  * , *  *' 9 9
9
"

88



 
   


 $
*' $+2
$   '%+
!"#!  "# isoniazid
$  rifampicin  3
" " rifampicin  6
" " */ .
 !%+ ! "  $
:$%
 *,$
 *' $ (

 
    5        ! " #$%!& ' & $ & $( )* )+ & , #! " %!& '
$  (-." "  2.1 * -#+   0

2.2 *|&  
(7$
%+ &" + 9/&+ $$*%  $ * , 
*- 3'%+ 3 3& (7'08 
(& (TB Elimination)  )  *' 9 9 6 - 9
" 

< 5 *{ '%*+ C   '7
8(7  15 $$. (
'%'+
%+ % 9% %9% )%

'%+1$7$  +2
!
*- 1'71!  ,
*- '%+ 2(&*' Steroid, 
!"#

!% '%*+ C   '7


8(7  5 $$. ('%'+   *' Steroid !*C    10 $$.)

'%$+ % old fibrotic lesion * 9/&+ $
 .$  $%*C   '7
8(7  10 $$.
 Recent converter :'*C   '7
8(7 
*(%+  (
*-   2 *{'%+  $
&
%7 (7'08 TB *  
1)  * , *  
! 
$
!"#   . 0% DOTS
2) '2 Contact investigation )(  .)( 
!"# (LTBI)
3) '  
!"# 3& (7$
%+ & )(*|& 
  

   
 
!

89



 
   


 '
1.
%  7& '8, 2
   ', 7! $H 
'%+     )
!"# )(
'& 2526;4:7-14.
2. Srinavin S, Chotipitayasumondh T, Suwanjutha S. et al. BCG Efficacy, Pediatric Infect Dis J 1991;10:359-65.
3. 718 73
 8, H%*1
 $. (
$. )('& 2542;2:
10-8
4. Guidelines for the Investigation of Contacts of Persons with Infections Tuberculosis : Recommendation
from the National Tuberculosis Controller Association and CDC MHMR 2005
5. International Standard for Tuberculosis Care (ISTC), stop TB strategy and Global Plan to stop TB http://
www.int/tb/publications/2006/istc.report.pdf
6. American Academy of Pediatrics / Committee on Infectious Diseases. Tuberculosis. In : Pickering LK, ed
2000 red book : report of the Committee on Infectious Diseases. 25th ed. Elk grove Village, Il :
American Academy of Pediatrics 2000:595-611.

90



 
   


: 87   8


  *
'H'
$+ 3/ #  !& 10 *{'%+  $'2 *,&3/ #
 
$%*6
%+&'%+2 ( '3& ) 3&
!"#
 8 $'#&*6
%+&&( (7$
*! 
%+ & 
!"# )(*,
*- ( J (7$  )   
!"#
 8  $      '&&$

! !7$! )   &3&


" 2  &  
*-    %# 7 ( '&073
*- % (7$
 /&+ '%$+ % $
%+ & 
!"# 
"+ &$  ) 
!"#  :  073
 $ % H/ .
%+  $
%+ &3& ) 
!"#   :  073  *
'H
'%+ 2(& (*
'H 7( '%+ )(*,$%$
%+& 
!"#)(*,
*-  :
 &  $$% "$%$  7$ 
!"# '%+ $$*% '01 &
$$ % )
!"#  :  
073'7     %# & *6(&$:) 3 0 % & J $
%!$ 
%&)
'
%+ %+ 3&$2 )( 2
 
*- *0$ $:*|&  7( *( 1 
!"#
 :  073 
* 
 "+, " 
-/0 

$"+ * ,  $  ")$) &


(& $:'2
!"# (  $(&(  H
 
   (&
$
*- particle " droplet nuclei 9/&+ droplet nuclei '%$+ 3%  *$ 1 - 5 $
(&
$'%$+ 3%   (& "#  )(&
$'%$+ 3% 
( (&( '2
!"# $:
  H
*-  J  
$"+ $% 

!"# 
3* & 
!"# 
3*: &7 ($
( J  *
(alveoli) )(:   alveolar macrophages )() *'+ & 
 
!"#
!"# &
& (dormant bacilli)    (*{
% 
!"# )]& (latent TB infection)  $$%  )($$:
)
!"#   
!"#   (5 - 10%  *! '+ J *) $% *,
*- 
($ 
3!&4  %, "+, 
-/0 
 *63&* ,  "
*- * , '%
+ *- 3&'&
  $%  $
" " + J '%'+ 2
 )& J  $* * )($ $%
!"# 
$ )(
 "# 


$%&!!  '

91



 
   


* , $%)(& * 9/&+ $%


!"# 2  $   %# &
    073
'%+  .(!  .$: &"  7 
 *63&&+ ) ($ )  : '%'+ '%+ / )() :
' H'%+ $
$$
3!&4  %, %
-/0 
 $
3$3 3&*$
!"# '%(+   H
 
()($ (!  $
3
'4 *!5 %4 
-/0 
'4 %, 6
7   ) 
 
!"# $ (Recent infection)
 
!"#
!% 
%+ & 
*- &  '+ *&  10
'
 % "+ J
! '
%+ 
*- )(
&  % $%)(
*-
(" * , 
 
*,3  * ,  Silicosis
*- 
8!9: 8& "+, 
-/0  '; +
   )( .*, $ *   3&:  073
'+ * 9/&+ $*:/&  )( . 
!"#
 8 )(* , " + J '%$+ % ( '1$  '
3&& * ,  &  # * , )
!"# $:) 
!"# *& "+ '&# * , " + J '%+
$%1$   ' +2)(7( 3&:    # J   $  ( $
%+ & ) )( 

!"#  $% 3  
1.  
2. 7$1) ($
3. 7$*|&   7(
1   (Administrative control)
 :"
*-  ) 3&$ 7$ )
!"# )(
*- $ '%+ 2'%+ 7
7 *&83&$  % #
"+ *|&  $
  expose 7( )(* , " + J )(( )
!"#  
 '%+$% &)(  .*, 
 '%+7
 '% + % *  
1.1 *
$ $
%+ & ) 
!"#   :/&&+ * %#
 2  * ,   )(*{3&:   )(3& & 
! ) 7 $
3&/ * ,  
 2  #&3&  *, )()
 
'%$+ % $
%+ && ) 
!"#
! '%
+ 
$
1.2 &)  &#  $ 
"+  !  2
 & )(&) $ 

92



 
   


7$  :/&: '%(+  .3&* ,  ($7


%+ &&J
! $!7 3&* , 
!"# HIV
*- 

&"+ 3
()(&*$$'#& *
$  7( 
1.3 $7( 073'%*+ C & 
"+ 
3:/&  7$ ) 

!"#  :   $7( '7  


"+ ':/&''3&)(   2
 &

"# 3& $* * 32 7 3 &* %#


1. $ "#  3& ) 
!"# )(0 2
 3&
2. $
%+ &3& )
!"# *&7( )(
 '%3+ &:  
3.  )( ) &3&
4. $$ 083&)(
 8  
!"#
 8
%+ & *,
*- 
5. $23& 7$ ) 
!"#  :  
6. $ '%+ 2
 *C & 
"+ ( ) 
!"#
7. $ '%+ $:*|&  
& 
!"#
1.4  * , 
"+   .&# )
$+ )
"+ ( 
('%+ * , )
!"#
) * , " + J )(7(  &  # * , '%+ &
*-  (TB suspect )   
$ 
  $%

 '%+ :$ 3'2 :* ,  $% 


"# &
 2 * 8 $%! &'&  "
!&'&
H.   '%)+  & $ &+ $ * , " + J )(&*C   '2 
)((' '%
"+ )'8$:    &)$ 2)(  .* , 
 '%+ 7 9/&+ '2
(
( ) 
!"#
1.5 37 H/ .) * , '%$+ %  
"# & *|&  )
!"#  
&&+
$2
"+&73  * * )($ '7 #&'%+ $ $  )     $"  .'!!
* , '%+    
*-   &  $ *C    )(
& 
 *' 
'# & 2  '%+  :  3  '%+
$$ )(
('%+
%  &"+  
$*H
!"#   
  '%+ 7
9/+&$:( ) 
!"# 
1.6  : '%'+ %+  ) * ,  

'%
+ %+ & )
!"# $%(  . & %#
 
'%+ * ,  &+  
*- '%+ (&$% :
' H'%
+ $$
 $%(%  )   * , " + J )($%' %+ &+ ) & 
 $* , " + J '%
+ %+ & 
!"# )(*,
*- 
!  
!"#
!% * , 

 
'%+ 
%$2* ,   
&&+ * , 
$
 '%+ / * ,   :$%* , '%+ 
"# &
 2 - 3 * 8 9/&+ &
*-  :$
$:)  *,"+      &
"+( $
%+& '%+7( )(*,"+ J
 $
1.7 ( $
!"#  &!  :/&&+ * %#
 2 
7('%
+ %+ 3&
'  # '%+ 
3* &! 
 
'%+ * , 

$ $ &! 
 $%!& & &&
$'%+
$$

 "# 


$%&!!  '

93



 
   


1.8  .)* ,   $%  &) * , 


$  
&&+ 
*, MDR-TB :$$: &) &    ) 
  & * , " + J )(
$"+ * , &
  & )
"+ *   1  & $ Surgical mask ) & '&+  
 . '%
+ $$&  2 * 8 "
$"+ $%  %3 /#
! $$%  
*- 
1.9 $) *!!  !7$! $:/& (7$  
!"#
!% 9/&+ $%  $$   !7$!
: &/ $
%+ &3& *,
*-   & *|&  
!"#   "+ )(:$% 
* '%+
"+ * , 
3:/& 073
2 8&'<+" &

*- 7$1) ($*H
!"#   H9/&+ $%0 % (&  ( 
&&$2
*- &!
' (%'%+ &7  99 )($2
*- &
%! $  )0 % &&
'%+  &!
' (%! # & 
$2&(3  '$%+ %   )( .* , 2  $ )(
&$%&*$
%& &  # /&
(" 0'% %+ 2
*- )(
$$ :  )()&
0 % &J $% & * %#
1. :
' H$0$!
*- 0%'%+&'%+7 )(
%! '%+7  H
( :
' H 
'%$+ % * ,  " 3&'&
 & J
! $% :
'
 H '& &1   : '%+ '%+$%$
%+& )
!"#
! TB Clinic " TB Ward
/&$% &'%+ H1 $::
' H1     )($$% 
"+&*
 H 9/+&
*- 7* :
' H1  :&$% & 
%$% )(
*(%+  H
*$
(   !& # J '%+  ( &
'  # &  # /&$% &"!&'%
+ *   (  3&&
(
*-  & 2  " & *)
2. !*7 8 H
! $%  ($ H'%+ & "!*7 8   H
 1 
"+ 
 $  H
*- ( (Negative pressure) *|&   H'%*+
*
!"# 
3$ 
"
J  2 'H'&3&($$%$2
"+  H'%$+
% !"# *
* :   &  " + J
 2 'H'& &2 /&:/& H'%+ 7'0?   7( '%+*C& *&*,)(
 1  
'%+
*- '&
33& H & 
'%+   H
"+(%
(%+& ( (3&
 H '%*+
*
!"# 
3. !7* 8'%+$%
' (%7& 99 )(&
%!$  )   & H

"+
 Particles '%$+
% !"#  *
%  High-Efficiency Particulate Air (HEPA) filter " 
!"# )&
7(
( (Ultraviolet Germicidal IrradiationUVGI)

/4   HEPA

*-
"+ & & H   2 H'%$+
% !"# *
*
3*
"+ & &  3 '2(

!"# )(*( H'%+   $!$


$2&
( J '%$+ % 
2  )('/'%+ $$:
 H$0$!   #&
"+& & H $$
$$)(&$% 
71&$+2
$

94



 
   


-"'8%=
%!>
-/0 (UVGI)
 H/ .
!"# 
$"+ : )&7(
('% + 
%& /& 2$! '2(

!"#  $%*! 82 Ward 3  "


* ,   '%$+ % * , 2  $ J )
*- 0'% %+  &
%
!& )(+&'%+&2 /&:/&" 
 (3&
%&3/#  
! 
"&)( &3&*,)(
7( '%+$$
 *  & # $ &  2$!$'#&  #& &2 /&:/&(* 
 
( .)(3  3&&"'%+  &# &H/ .(
% !*7 8)( 27& .

"+' 71&$+2
$ /&$%*'011
%& '2(
!"# :  
073
3 8&   8
*|&  
!"#
7(
*-
%&$ 
$ 7$    
)( 7$1) ($ &  # $2)(*'013& *|& 
7( 3&+2
$"+

*%
'% $ " + J )(
*- *|&  
!"#  7 ' 9/&+  *! 8
7(
'  # 
!*7 8&&/&)  2! : '%'+ $%+ % $
%+ & 
!"# &
!  &) 3&* ,   

&&+ * ,  MDR-TB & Bronchoscopy, & 7


 ) * , )
!"#
*- 
8 :!4 -   %
-/0
+8 = " ,
1. Surgical mark
*- *|&  ) 
!"#   $" * , * 7 (3&
 '2
$" #2('%$+
% !"#  ' %+ Mask "%,=&,'&;  
-/0 ; 8 /
@%5 6 '&', &  # /&  Surgical mask ) * , '%+ &") !  
*- 
2. 7* 8'%+!*|&  
!"#  H'%+
3*  7* 8$: &!# 

( J 3  1 $  
! HEPA mask, N.95 9/&+ )  2!  7(  & Bronchoscopy "& Lab
'%+  &  
!"# 

# %
-/0 "6
7   8 '9'8*
7( '& )'8
*- '%+$%$
%+& 
!"#  H& *C& 9/+&&$%
*|&  
& 
1. $%$
 %+   ( . )
!"# )() '& *|& 
2. 7( '% + 2(&
$+ '2& 
! & 
*- "$ :*  % &  

!"#   '  Tuberculin


2.1 :( Tuberculin
*-  ) &

!"# )(& $%1$  $7  )( 
]|
& *,
*- )(*|&  
!"# $ & '7 6
" 1 *{
2.2 : Tuberculin
*- ( 9#2(&  # 1 * 8 (Two step testing) :&# '%+ 2
*- 
) &
*- Boosted reaction 2
 $3 2.1 :#&'%+ 2
*- ( ) &&$

!"#)($$%
 "# 


$%&!!  '

95



 
   


1$ $7  


]|&)('  tuberculin 9#2% 6
" 1 *{ :(1(&
*-  (Tuberculin-conversion)
) &$% 
!"# $ !& 6
" 1 *{ :& )($ *,
*-  *|& 
$$
$$

 : 8*6 7  '%$+ % * , 
$+ $ 3/ # $'&# * , 
!"#
!%'$%+ % $
%+ && *,

*-  : 


!"#  * ,  $'&# 2  * ,  :  
$+ $ 3/ # )($%  &#
"+ &*
 H1 $ 3/# 9/+&'2 (
%  H
*- ( .* $$% :
' H1  '2
7( $% 
%+ && 
!"#   :   7$ ) 
!"# /&$%$2
*- &
2
 &
$$&&
"+* *|&7( '%+*C& *( 1 
!"#)(*,
*- 
  

 '
1. $  &H8
&%+$ )('%'&    (. ) '&*|&  
!"# 7( '& )'83&
&()(:  '& )'8'+ *. )('& .2539 ; 17 : 131-136.
2. World Health Organization. Guidelines for the Prevention of tuberculosis in Health Care Facilities in Re
source-Limited Settings, 1999.
3. Centers of Disease Control and Prevention (CDC). Tuberculois Infection Control in the Era of Expandin
HIV Care and Treatment, 2006.

96



 
   


11.1  
  
11.2  
 
11.3  
 
11.1  
  


!"#$%&'
"    !
 )* $ .+ ,
*-$%&  #"$
&$/ & % /
0
 %&
'0 $%&#/45+6 # %**7+& $
-$'0 
$
- 706+8#  9:& 60 ; 
' #"6 0  '6$!"#

& 60;
- $%&' 
6$*'< $ #
60 ; 
 %  '0:- = 

- !"#
  : %6$6
#+
#!"#
> >
> %'+$?+@* $ #-
$%&-#*> 
>     %'7+'? '$
- @
5 0   +$% & % 0 +

 %"
! #0    #+0
460 ;  % ## $
4> >  5%

%$
-
'$%&%# * *#'7+& A +
6
4' 7:
4   '
 /45+  $ 
   
460;
  %'  
> 
 9:&*

4#
 * #"& 85 #%-  
  :=$$6

#+
11.1.1 
  
   
 # '
" &'$
-@
5 #$%&%& )*
%@
5 &    *& ''
*
?@*
'7+'

$%& $0 
- 
*- $%&  
6+ $
- ++ )

4 + '"
! #' 

  


  !

97



 
   


*& #+>++ )
 $+/$%
  6 
#+ #' 


4 *- $%&    %  #  060 ; 
 
 + #
4 & 

4# $%'&  *-  *& 60 ; 
 # 
 9-
 

11.1.2  
  /  ! 
# $
%
&' #()  **
+ 
!'
* ,, -
 &
0
1. %'$
- @ @ */'7+
#$%& %& 
1.1 #@ > 660 ;  660 ;   #
'0 #/
@'
 #% E;
'
 E; '
 /'@+   & A $%& %&  
/
460 ; 
 '60 ;  :- $%
4
$%& ++ 
 * 
() 

 +*43 5 
( ) 
,, -
/
0 +*6*
7# &(
1.2 #@ + 60 ;   %60 ; #
4>  & 
' '60;>
$   
2. 

- ++ 
 One stop service > #
/ 
-  0 *- $%&
$%& /  7$>' %'/'''7: *&  '%& *- 
  
* !
*' #"+ 
- & 
/$
&  * $ #- * 
-
  *
3. # # % #$%& ++ 
 * (Hospital TB coordinator) ++
$
  %$ %& %  *%* ++ J #+$
 #:- 0 
*
- A #=' 
%+++ 
'
#< 1 
$
- %$- 
- 
-  %60 
6+#
  %#$%& 
%3.1 
- 
 #+60 ; 
$%&  
+ $ A 6 *
3.2  ' '$
- #@  @ *
$%& %&  & :- $% 
$ 3  (Cohort analysis) '+ 60 ; >
 =  7
3.3 *& $#$% & # 0 :4 '/:4  )*

+60 ; 
(DOT) $%'&
  +##$%&
4. 

- DOT corner #  % - *% %& %-  *& '
'+  %#$%& *%& %- 
60 ; 
 *& *+ & 

4#  85 
4.1 %'#
=
 60;
4.2 %- < '- 7
- & +- #-:- 0 
 
 * *& '60; 
$##$%&
4.3 % Treatment card *& ##$%& 
$:
$60 ;  


98



 
   


4.4 

60 ; 
 Daily dose % Drug packet *&
'#$%&60; 
$'
& 60;>


 9:&9 %'%-*&N
' 9:&
 Drug packets %-'
  
@'

4.5 '
660 ; $%& J #+$
 24 
&  >
#))+ # *& '60;
  +##$%& 
#
#  %$%&
11.1.3 &&(
1.   #  $%& 
 $$%  $%&  %&     *&  $'7 < 

* +6
460;
$%&:-$%
4  
6+ */
'7+
- (0% $& $%) >
1.1 6
'0
 
$$%
'0 (TB04) *& $6'0 '

$%&
>
++ )

 ' 7 +6'0 '

>
' # 3 
-  $
6
#+6
>
#$%'&    %
%7-  #$%'&  > >
++
 6' #*
  %6>
++
*& #
'
##
- + 60;
$ :-$%
4
 *
1.2 #$%& ++ 

$:$%
4
 (1.04)  OPD Card
$
#@  7 
 ,$%' (TB10) 
$ 3  > TB 07, 07/1  08
'#
# 60 * *&$'7 <
4
  * '

'
'? '
#
 *- $%& *&  +'7 < @* 
#

2. '
N
  '
'? '
#

'

 '
 '< 
  +$*/'
*
?< $% + 3
'7+@
5   
 (9:& + > @*
. ) &  %
4 $%& 
 *& $'7 <"
! # ' 7 #=$
"
! #>+& :11.1.4 !!

!!+*43 5 64
 ) (
(#
1. ?+$
4
 +?% DOTS #60;$$%&'60;


4$%&/0<+'? ' #$%&$
2. %''$%& %
 (TB09)
3. 6 * 60 ;   6' # WJ < 69<
4. 
+ 
4#7' OPD card (TB01) $%>& 

4  
#:& *&>

4>70 $%
 
$: $%' (TB10)
*&' + 6
460;
  


  !

99



 
   


11.1.5 4&
&! / 
% ' &' '
(Public Private MIX : PPM)
1. #
5> '
N
 '
'? '
#

 60'#
 #  '& '  #
*/'7+
5 $ #+$
 @  <+#'$7+& #
$%& %&    ''
*
?@*'
'+ 
 60 '
#$%&
$%& %& $
- @
5 +
 6 
#+
2. # *
X0+
   )*'#

'7*@
5  
 #'

4 $7+& 
3. * ' 7  
 *
5$/ '
60;>
4

  #+ 60;$%&
  %$%&60;

'
 
+
4$%&
*>
4. '
N
  '
'? '
#

 # %  
(TB Network meeting / DOTS meeting) *&  *
X+
 >+  +6
4
>!"#' 
  & '+- ' + 3 
5. @
5 # 
''+  #+ DOT *& ##& A >+
 #
5
11.2  
 ,

 +$%'& 
"$
&  &   %
4 *$
!
'%& 60   $4 '@* 
 :$ # *- #60  
& (1)   !"#

 =$% +& :- )* '7 <*+- '< $ # % 
60 ; 
 # *+ & :- '#
$/>$* 60 ; 
'0$
& > 8-20 $ (2, 3)
 $% & %  138 #  %60  
   2 ' (4)
 '= + 
 $/>$ 6'
 $%&%#   $'? '  $
,< $+? 9:&#
#=
 '
"!"#
  %# $%&
  %$+$%&
#$$#$%& +  '
# '


+$*$<  $
,< '
N
  '
'? '
#
 
 
 ,
11.2.1 , -

++)
 +?%#;+
-
 ' # ,< #$%& %
$/<' #$%& $%&>  %$/<'$%& * %
#/0<

 *$<'7*$%& ' #60 + + )


 '
& 
4 $6

100



 
   


 
#+ !
 %
  %
6$0 '%& '
;

9

+ =;
 
+ >  2 '
#< 
+ 
4

11.2.2 
0
 &*60;
#$%&$:-$%60;
$%&'7*
 9:& 60 ; 
 $%
$
& > 
4 *$<
# *60#'0 $6
#+ 60;
>

4
@ 
0 
$#$
- #$%'& 7*#60  $%>& 

$#$%&060;
  %
#'#
60;
' #*- *&N

*-'060
& 9:&6
40  ,<$%&*   %6' #/-'0


4#'0:- 7:  ' #"

4#> 7:  ,<$%& WHO 
- >  85 & 
*
'0 +- '<    %60 ; '#:& >

#>'0
& A
11.2.3 &&(&

#$%*& #
'
" + DOTS 
- A 
% $%
A #$%&*60
$
$ 3  
'' #
+$*$<  $
,< '
'? '
#
$%& 
- 0 $
- %'- 

'? '
#
 ++#<
  $
& >
#

- A
11.2.4 &!!
60 ; 
$%&  #* $4#
4 7 %$# #$%'& 7
* # 0 /0<+'? '@ # *$%6& 0 ; >

4
 * 
' ' #60 ;  1  #60 ; >+'% 1 ' #/0 <+$%6& 0 ; >
4
  & 60 ; >
4$/0<+$%& 
60 ; ' 
 
 9:& +$%6&   60 ; 
$% & %#
>

4 60;$%&
 &* $4>


/0< +@  > $60;>

4#>  9:& %*
X'
 60 ; 
$
- # #@ *& #60 ; >

4&  >=%
!"#  $'
 (Social Stigma) *\+ 
 $4=$$ '=
4
11.2.5  

+ 
  ' 7+$ *- $%&  A $%6&  
* %0+$%&
 *-$%& 9:&
'# 
   $
,< $
- %#- ' %+$/ +  +6  
# *- $%& >
'
N
  '? '
#
 *& #+ 
  %'+$?+@* 
 5%


  


  !

101



 
   


11.3  
 !*&'
!

 %**$/*&  $
- $%7& 0 8#  
 0  
& #%- *& '#> # '#+'? '$%& % +
#$ & (Migrant worker) $%&&
&
:& 7 (cross - border population) %'@* 0$ %& 

'@+ 
'+& 
% carrier 60 + - $%%>
'  %0  
'0 $ #+!"# +  
% 
   '< $    + A $%& *+ & '0:- $ #>$ %
'%& ; +$%&  *  #+- $%& E0 *+ & :- !"#'? '$%& +*+ &
'0:-0 

 &'
"$%&%&
##E; $
- $'? '
'& A %+*& N
 > '7 <>  # 6% $'
 

& $/+>
!"#
   
$% *+ & :- $
-     +
$%&   >
 #'
6
'& '@* 0$ %& 
  '%& +'<& *\+  ''%& *+ & :- 6'  + # *./.2539
 43 
#
 *60 ; 
 1,451  60 
  372,242  # 390 '
#  5 - 6  
 >$   60 ; 
$%& *%'-   #"0  * %& >  $% %& 0  #*

$%&  >' 7*- 


>
'0  & %-  #
4$%>& 70  '#$ #- 
- >  $ #

9
9:-  +*'0>$$
&>> 

-: % $%&
'$E; $
 
$ 
0!"#
0> 
!"# A $
- $
& A * 
  > 
 '+  6
6$$%& +:- # 
11.3.1 
 4 &>&  

1. *& EN
'7 <

    ' +


$% &  + 
&  
*-$%&
2. 
#60 ;    #/
  _*
/
 #'
'@*!"#
8% 


3. 

4' (Referral system)  0'
4. 6* 0 
*\+   $'
 8# $%& # '  *
- 

&  9
9 %& 
 %67:++?%  :
#+ - 
  *& ' $j+
+ 
1. :-$% (Registered migrant worker)  $%&j+
+70
:-  (@$ ) 8# 

102



 
   


2. $%&
> >:-$% $  $%&>
$
(@$ )
3. +'6+8#  (Illegal migrant worker)
4. Cross border population  7+& 
&   ' +

+  6+8# $%& 


  + - %- %
7'<*& 
EN
-+ !"#' 
6+ %& > '@*!"# 8%$%& %& @#
#$% & % 0 >
11.3.2 , ?@&


1. '
'? '
#
'
 
#
  *- $%#& 
 + + ' 0 
$5 0 $% #
'@* EN

 @$ () 
 # 6% 0 
6+  %  + !"#& 
2. #60 ; 
 '@*:- $% #
"$* $'7++* 
3. EN
 0;
 '7+'? '  $
- @
5

$% '7++ )*
4. '# (Active case finding) #$%*& 60 ; 
   /

   <'$7+&  # #$%&%&

$'7++*60;
5.    W< .506 '
+$ $%
 (TB03) )*
11.3.3 , ,
&
0
'
'? '
#

 # %++
$%& % 5 6
#+ (National
Tuberculosis Programme) $*- $%&  @$% & %  # 
@$
460; 6' # +60; :-$%
4
$ (
"%> )*)
10.3.4 
 &4& + (Monitoring and Evaluation)
j+
+ 
+  +6 + $j+
+%
+
 6
#+  +6
- %   $
& > (0@6)

  


  !

103



 
   


*
1. Drobniewski F. Tuberculosis in prison - the forgotten plaque. Lancet 1995 ; 346: 948-9.
2. Snider DE Jr, Hulton MD. Tuberculosis in Correctional Institutions. JAMA 1989; 261 : 436-7.
3. Braun MM, Truman BI, Maguire B, et al. Increasing incidence of tuberculosis in prison inmate population.
JAMA 1989 : 261 : 393-7.
4. +$*$<  $
,< $ #>$. '7++60
60;
 
$/>$  *./.2540-2547. (
')
5.  
 '
 '< 
  +$*/'
*
?<   . 0 +

 . $* : *+ *<$
,< ; 2546.
6. Pleumpanupat W, Jittimanee S, Akarasewi P, Rienthong S, Jittimanee S, Chiewlian Y, et al. Resistance
to antituberculosis drugs among smear-positive cases in Thai prisons 2 years after the implemen
tation of the DOTS strategy. Int J Tuberc Lung Dis 2003 ; 7(5): 472-7.
7.  *=" +<+ X

<, '* '$, ' + *


?<*\4<, *="'
< *++, * %%& . 
- 
#6
4'
-  #". 
 $ 2548; 26
(1) : 11-22.
8. 
 /%@
.$$ * + DOTS (Public-Private Partnership for TB
control).' +j+
+ : *
X  
  @
5
@  -*$

@

 
$%& 9-11 '+# 2547 # 

 '
 '< 
  +$*/'
*
?<
9. 
""
+ +"$<.  
   #". ' +j+
+ : *
X
   + 
$ . @
5 2546. 
$%&
2 - 4  4 2546 #   
 '
 '< 
  +$*/'
*
?<
10. *
?<

' .DOTS: $$@
5  
 . ' +
j+
+ : *
X  
  @
5@  -*$


@

 
$%& 9 - 11 '+# 2547 #  
 '
 '< 
 
+$*/'
*
?<
11. +
'?*% X
 + <.$$ 5@ 0
460 ; 
 
- j+
+  #+
60 ; 
   # *#
)%

 *./.2545. '
 +j+
+: *
X  
  @
5@ 
-*$

@

 
$%& 9 - 11 '+# 2547 #   
 '
 
'< 
  +$*/'
*
?<
12. * % $.'
#'7*@
5/0<' 1
'

 $ . ' +j+
+ : *
X  

  @
5@  -*$

@

 
$%& 9-11 '+# 2547
#   
 '
 '< 
  +$*/'
*
?<

104



 
   


13. +$/ 
   .% % #   /%?  *./. 2546
14. +$/ 
   .@0= 
 *./. 2547
15. EN
$+$, '
+$ 2545
16. '' 0+
 '
'? '
#
, 2544
17. 6'  +, $'? ', 2539

  


  !

105



 
   


$%&  #:& $%&  


 +  + 
 >
% 
$: 060;7:'@* # 
460;
- 9:& &
 0
 
$=' 77:'+$?+@*+ @* > #

- 
'+& $%$&  #% '+& '
'A >**% %'+$?+@*
12.1&(&
6 
* $%& 
 # %  W<  A # % $%'& 
9:& >
 # >  ' 
$W< $%  A %
%- (0

@6)
 
 DOT (DOT Card)
 
 DOT '#
60 ; $%*& %& %- "+#60   
 DOT 1  '#


4 1  ?+$ DOT 
$:& #   
$:  '#
 
$  
%*%& %- 
 

7
0
 (TB 01)


$:
4
 '+&$%&% # 
460;


$: %-  % '7+'? '$#$% & 6% 0 ; 

4
0  060 ; 
 

$:
4
$
$%$ %& % 
460 ; 
- =

$:
4
60 ; $
> '7$%& %
 *& #
$$'

$: #'7%
# '. %'  
060 ; #
  0$
& > 6' # 9:& $
- $% & % ' #
)*
4 '+-' $%&'$# % 0%
4
)*%$ DOT  0 #7 #60 ;  >
@& A =
 > 
 0% A '60 ; 
 (TB 09) '>
60 ; 

106



 
   


 &(
$ (TB 03)
$%
@'$%&
$: 06
460;
$$%& :-
$%
4$%& @ 60 
6+ 
$ DTC  0

$:
4
70
$:6

$%
$
-$%& %:-$% %&
4 %- DTC 
' 7 
$%
%>- 
$ 3 $
- 4 > #; (W< TB 07)
6' #%&  & '+- '
4  (W< TB 07/1) 6
4
(W< TB 08) +6' 6'
 '< (W< TB-HIV01) W<
 A  % 0'
"$%& $  

%1. 
$%& :- $%  
$%& DTC $%60 ;  $%
@ 

- 
$%& :- $%

$%& + & 
4 
%
#
=>
2. $%
   + & 
 1 #  %
>&  A  
$%
%-
$
- 

$:
4
 $%
@ $%
'0
$%
70# 60 '
@  $%& DTC $$%60 ; 
3. &60;$%&0 %&-' $%&0+$%&/
0 $%&
  
4 
 (>$ >  >$ 60  
 /$
,'7) >  
1. 60 ;  
# (#) #60 ; 
$
- 2 +
# 60 ; 

2. :- $%
4  :- $%@$   6 @$
3. '0$%& 
4
4. 6' #*& +  +6
4 & '+- '  $%& 5 '+- '

4
5. #  6
4>  & 
4
6. 
$: 
4 *%& %-  9:& % %& *

60 ; 
7. 
$: #:4 #+- HIV # CD4
8. 
$:>
>
'N
 ) '
 &('
3
 (TB 04)
$%
'0
$%$%& %' ##- 
 $
-  %
++ )
 + 6
4 60 
$ #$%& 
'0 *./*$/*/. DTC ' 7 $%

'0%- *& 
$#; 3  ' 7 ' 0
$%

@>% 
 F> , & (TB 05)
'#
'' #*&
#60;
 #  60 %''

 *&
+ 6
4 
CAT 1 :  & '+- ' $%& 2 (3) #$%& 5  & '+- '
4$%& 6

 "  # $%$ &  '

107



 
   


CAT 2 :  & '+- ' $%& 3 (4) #$%& 5  & '+- '
4$%& 8
CAT 3 :  & '+- ' $%& 2
 
 6 
#+ %
$0 4 + #;
(W< TB 07) 6' #%&  & '+- '
4  (W< TB 07/1)
6
4 (W< TB 08) +6' 6'
 '<  3 - 6
 (TB-HIV01)

$ A  3   %%
% *45 (F> TB07) DTC  
#$%& ++ 
60 
$
'6$%
@ $%
'0
 (3 ) $%& *+& >*&  +
6 #; 
- A  %+  #;
 $  !  TB/HIV+
& !  TB/HIV- Unknown 60 ; $%& :- $%
4
$@$ 9:&  60 ; 

  # ' # (  % - %  '
"$+$'? ' : # % */60 ; 
   7   ) 60 ; 
 # ' # 
9-60 ; 

49-@#

# 
49-@#
(' #) & A ' # (      < 15  > 15 )
 $
- 60 %''
$%&' #60;$%&* 60;$%&
 60;$%&

 + &4() ,4L ) # 
0&&* * (F> TB07/1)
DTC  
#$%&++
 60
$ '6' # &'+-'
4 60;$%&:-
$%' #*- 
$ ( # , 
9- ,
49- @#
 #
49-@#
)
&!  TB/HIV+ &!  TB/HIV- Unknown  '$%
@
(3 ) $%& :- $%>#%- 6 - 9  %- '+& $%& %-  '+$?+@* (
- ) 
4

@
- A
 +
0 (F> TB08) DTC  
#$%& ++ 
60 
$ 
'6
4 &60;
4# $%&  + 60;
 # ' # 60;

 # ' # 
9- 
49-@#
 # 
49-@#
 (' #) &
!  TB/HIV+ &!  TB/HIV- Unknown  '6$%
@ (3 )
$%& :- $%>#%- 12-15 
 + +
&>  4 - 8  ( TB-HIV01) 
+ + $?/'6' 6'
'<  3-6 $%6&    #$%& ++ 

 
#$%&++'<60
$ *& +6+'7 <
 '<
% 2 ' '$%& %& 
60 ; 
 '$%& %& 
60 + - /60 ; '<
$
- 4 + =  +6+ 
 $ +6
9:&  4  A  3 

108



 
   


 

-  1   > 4  (Quarterly report) 
% $%& 1 : 1  - 31 ?

 $%& 2 : 1  - 31 %
 $%& 3 : 1  4 - 30 +7 
 $%& 4 : 1 8 - 30 

,
4& + !4L 4 ,
#
'+- ' 3   60 '
 $ +6j+
+   4 +

% 1/2550
1 . .-31
. . 48

 (TB08)

 2/2550
 3/2550
 4/2550
 1/2551
1-7 . . 51
1 . .-31 . . 49 1 . .-30 . . 49 1 . .-30 . . 49 1 . .-31
. . 49

 (TB07/1)

 (TB/HIV01)

 (TB 07)

1. , *45  3  Q7) 7# &(


0  ) 0-3 ! (Case finding
on New and Previously treated of Tuberculosis patients)
  3 

- *60 ; @$ A >%- $>60 ;  #  : 

' # 
' # 
 60 ; 
9- 
49-@#
 #

49-@#
 (' #)
  3 

- 60 ; 
' # # $%& * %'
'*/#"+
  >
2. ,  
+ &
,4L  3  Q7) 7# &(
0  )
6 - 9 ! (Negative Smear Z Sputum Conversion Rate)
  3 

- 60 ; @$ A >%- %
6' #
$> 60 ; 

' #  #  60 ; 
9- 
49-@#
 # 
49-@#

 (' #)
 :    !"# "$#
 

     
New M+
> 85%
Relapse
> 85%
Treatment after failure / Treatment
> 75%
after default

 "  # $%$ &  '

109



 
   


3. , 4& +


0  3  Q7)7#&(
0 ) 12-15 !
(Treatment outcome)
 3 
- 60 ; @$ A >% - 6% 
4> ?
60 ;  #  : 
' #, 
' #
60 ; 

49- : 
9-' #,
49-@#
 # 
49-@#

(' #)
4. , + +
& >  3  Q7)7#&(
0
 ) 3-6 ! (TB-HIV01)
 3 
- 60 ; 
 # 60 + & /60 ; '< >
 #+'@*$%& %& 


 '<> ?
+ $% & +
- %60 ; >

4$  ?
12.2 \ 
 &4& +
+$/  
+ $%'& 
" 6 
 
7'<+$/*+ &
'+$?+@*$#$%&  # ' "
! # 
 +$/
' &' & $%& %& $
 !
'
"$%'&  $%& $ #' 7$!"#$%& +:>!"#>$
$$% ' 7
 #+60; # %'+$?+@*'0'> 60+$/
'%#@$%$%
*& # + 
707
 j+
+  % # * $
- 
$
+  +6 3 
$
- 4 + ##@%$%& %&  +$/ 
 A > % $> 
% &
 !3&
,

 60+$/
 (Regional TB Coordinator-RTC) +$/


#
' &' &  *& +#<"
! #':4# #%& 
 3 

' #/- 6
460 '


#
 (Provincial TB Coordinator-PTC)
9:& $ # #== @ 

> 9:& ' 7$> +$/

# RTC 
 PTC
 &
,

 !3 &
$ & 
  PTC +$/ DTC 
'
#$%& ++ 
 *' &' &  %'% A 
$%
'0 $%60 ; 
@  #:4>!"# # DTC %'  

6+ 3  %& 
#60 ; 6
4
 &
$ !3&
 (
 &  . DTC 
6+ &0 
4
60 ; 
 >!"#$%& +:- 
- + & 
47:
4# 9:&  % A %
+70 j+
+  %'# *@
'7%

+ DTC '
 *60 ; *- $>
:- $%
4#>  
$:
 0+  #
460;$%&

4$%& * + 60;>
 >

110



 
   


'7%
70#>  '$%
'0 $%
60;
$%&'7%

 DTC '$ DOT 70 
-j+
+#>  ''
6
+
4$%&'7%
 
-''' # *&+ 6
4
$70 ##>  7 ' . %$$ $ DOT  DTC %& ' .  #
:4 7%& +$/:- 0 

+$/ 
%#%"&

 
.

 
 &
RTC
PTC + RTC
DTC/TB clinic

' (
 4 
 4 
 4 

 - 
   RTC    PTC (  )  ! "  . #
- 
  .   $#% 
&'* DTC + TB Clinic ,/ # +" & '0'%  1 DTC + 2" % 
   34" &'*## TB Clinic + "   5 "  . 

 "  # $%$ &  '

111



 
   


112



     

 
   



 

  

113



 
   


114



 
   



1
 







AFB

Acid Fast Bacilli

ART

Anti Retroviral Therapy

BCG

Bacillus Calmette-Guerin Vaccine

CAT

Category

CBC

Complete Blood Count

CD4

Cluster of Differentiate 4

DTC

District Tuberculosis Coordinator

CUP

Contracting Unit of Primary Health Care

CXR

Chest x-ray

DST

Drug Susceptibity test

EFV

Efavirenz

FDC

Fixed Dose Combination

IUATLD

International Union Against Tuberculosis and Lung


Diseases

HAART

Highly Active Anti Retrovial Therapy

HIV

Human Immuno-deficiency Virus

LTBI

Latent Tuberculosis Infection

MAC

Mycobacterium Avium Complex

DOT

Directly Observed Treatment

NAPHA

National Access to Antiretroviral Program for PHA

NGOs

Non-Government Organization

NVP

Nevirapine

PAS

Para-Aminosalicylic Acid

PCP

Pneumocystis Carinii Pneumonia

PCU

Primary Care Unit

PTB

Pulmonary Tuberculosis

  

115



 
   




116




TAD

Treatment after default

WHO

World Health Organization

.



.

 

.

  

.

 

.

 !  



     

 
   


 
 

  

117



 
   


118



 
   



    

//

 
(  )

//

 
(  )

#

$%&' 1.
2.
 (# ) +
 # 

 
   ........................................
*     


    

//

 
(  )

//

 
(  )

#

$%&' 1.
2.
 (# ) +
 # 

 
   ......................................... 

  !"   

   

119



 
   


120



 
   


   

121

122

%
 & ++

  

......./........ ...............

/
District
 
 TB No.

  

!(
' G:',
'.,  "+,+
K&
-
 "






!(
' G:',
'.,  "+,+
K&
-
 "

 "

 - 
 -1+- 
 !"

+ ........................................
',%.......................................

%
 & ++






 "

 - 
 -1+- 
 !"

',%.......................................

......./ ...............
+ ........................................
........

TB 03 (TB Register)
/
District
 
 TB No.


%


--
-
-

........../..........
'&
CAT................
.........................
.........................
.........................

/

  

%


--
-
-









6 (8)

 --
 - :;9
'&...............................
 - (%4 :;9
'&...............................

. ......./............../..........
 NAPHA No. .....................
%&!'(
0
2 (3)
5

- &-'

 
1  
....../........../........
...........................................
 
2   .
...../........../........
...........................................

 --
 - :;9
'&...............................
 - (%4 :;9
'&...............................
 
. ......./............../..........
NAPHA No. .....................

- &-'







Cu
Com
F
Die
Def
TO

....../....../......
....../....../......
....../....../......
....../....../......
....../....../......
....../....../......

%


........................

6 (8)
Cu
Com
F
Die
Def
TO

....../....../......
....../....../......
....../....../......
....../....../......
....../....../......
....../....../......






--
-  Co-trimoxazole
 ?
,....................................

=4;9&+ >;' ?








%

 --
 -  Co-trimoxazole
 ?
 ,....................................

=4;9&+ >;' ?

N
R
TAF
TI
TAD ...................... ...................... ...................... ......................
Lab. No. Lab. No. Lab. No. Lab. No.
O
Chronic

$   

  CD 4

 P
 EP
&"#(4.................
................................

%&!'(
2 (3)
5

N
R
TAF
TI
...................... ...................... ...................... ......................
TAD Lab. No. Lab. No. Lab. No. Lab. No.
O
Chronic

94
1 
. ...../........../........
%...........................................
94
2 
. ...../........../........
%...........................................

!"#
  

  
 
%%
+ '7%
.........................................

. ....../........../........








$   

!%&! CD 4

 P
 EP
&"#(4.................
................................

!"#
  

  
 
%%
+ '7%
.........................................

. ....../........../........

1(9" /%&!%


 

1(9"  

&!% 




%%


,
...........
M

 +
 (K4



........../..........
'&
CAT................
.........................
.........................
.........................
1(9" /%&!%


 

1(9"  

&!% 



%%


,
...........
M

 +
 (K4



/

  


 
   


" :

//

H.N.

Spot = Spot sputum


Lab.
(Lab.Serial
No.)

Col = Collect sputum


- 




!
"



"#
$!% 
1
$!% 
2
$!% 
3
Spot Col. Spot Col. Spot Col.

TB 04 (     Tuberculosis Laboratory Register)


"



 
   


   

123



 
   


124



 
   


   

125



 
   


108
126



 
   


   

109
127



 
   


128


X-ray

 - 

M Cul





 


!"
#" "
$
 % ""
& $'"%$

1 2 3 4 5 6

"$$'"
(outcome of
treatment)

Outcome of Treatment : 1 = Cure 2 = Complete treatment 3, Failure 4. Die 5. Defauit 6. Transfer (The outcome of treatment - not know)
: 
 (
 )  2-3    / /  !"
(Outcome of Treatment shoud be known (traced) within 2-3 months after the expected date of complete treatment)




 

#$%#  
& ' *+
" 

TB 10



 
   


   

129



 
   


130



 
   



    TB - HIV 01

 1 
 
!
1. 
 
!" # $"  %&

  [    New M+, New M-, Relapse, EP, TAF, TAD, Others (M+, M-)
!  
 "  !# $&% '!
 ' #*' !#'.'&/] 01
'2 30'4#'* 3 - 6 .'0 1  '
(
012'30'4*! 1 8.. 49 - 31 <.. 49 &'33=> TB/HIV 01 .1
!'01 31 0.. 50 $.1 # !
 #'8G%'#&3/ HIV Counseling and Testing)
2. 
 
!" # $"  %&  '  ( $& %) !%*
 !
#' 01 1 01 3# / 4#'8&*.2*0 (HIV counseling)
[# '3 &/''
 01 0 !8&.'' !*0 K'3&G'3%.'1  ]

+, 
 :

 2 01 '2 30'4! 3 # / 4.1 G>
X 100

 2 01 '2 30'4
3. 
 
!"  (/
%) %4)" %4'

 !
 #' 01 2 0G1 #&%'8&!.*.2 *0 (HIV testing) [# '3 &/''

 01 0 !8&.'' !*0 K'3&G'3%.'1  ]

+, 
 :

 2 0G1 #&8&!.*.2 *0
X 100

 2 01 '2 30'4
4. 
 
!"  %4'
%6

 !
 #' 01 3 01 0 !8&!.*.2 *0 K'3 [# '3 &/''
 01 0
!8&.'' !*0 K'3&G'3%.'1  ]

+, 
 :

 2 0 1 !*0 K'3
X 100

 2 0G1 #&8&!.*.2 *0
   

131



 
   


5. 
 
!" / + %4)" %4'
'   !'/ 8 !8

 #' 01 4 01  3 8QQ' 34 (#  8' S%38 % 
G G'!G> G/'G>  !8%8$UG$'<> 3)

+, 
 :

 2 081 % *.2 *001  3 8QQ'
X 100

 2 0 1 !*0 K'3
6. 
 
!" / + %4)" %4'
'   /
   CD4

 #' 01 4 01  3 8&3 CD4 
 01  3 8& CD4 #' 3 .'
'%14 .0 ! CD4 34 ( ''.&*!!# $%&
8& CD4 Q2/)

+, 
 :

 2 081 % *.2 *001  3 8&3 CD4
X 100

 2 0 1 !*0 K'3
7. 
 
!" / + %4)" %4'
  CD4 /
 250 cell/cu.mm

 #' 01 6 01 3 CD4 81/ 250 cell/cu.mm

+, 
 :

 2 081 % *.2 *001 3 CD4 81/ 250 cell/cu.mm
X 100

 2 081 % *.2 *001  3 8&3 CD4
8. 
 
!" / + %4)" %4'
   CD4 /
 250 cell/cu.mm '  / '
 (ARV)

 #' 01 7 01  3  ARV 34 (#  8' S%38 %  G G'
!G> G/'G>  !8%8$UG$'<> 3)

+, 
 :

 2 081 % *.2 *0!03 CD4 81/ 250 cell/cu.mm
 3 ARV
X 100

 2 0 1 !*0 K'3

132



 
   



 2 / + %4)" / 
 %*
1.   + /
%)  %4'
%6

# : 
 01 33% post-test counseling !3 ! HIV positive # 8
 3 %'&% Z  K' (   K'! # '3 #G#'G'01 1
 )
 : 
8 % *.2 /
 G> 01 3 !*0 K'3'! 
(
 01 3 ! HIV positive #* ! 1 8.. 49 - 31 <.. 49 &'33=> TB-HIV 01
.1 !'01 31 0.. 50 $.1 # !
 #'8G%'#&3/ TB screening)
2. / + %4)" /
 %*   + '  ( $& %) 
!  @ &*E % 
!

#'# 1 01 3$& .1! 3G4> \&&G01
5   '02
1. 08%8'%' 2 G > .
2. 0 8%  4' .
3. U#! *% 3
 ' .
4. 0 8#% * G%1 G$8%' .
5. 0 88%  ' .

+, 
 :

8 % *.2 /
 G> 01 33% 3 # / 4.1 
!G4> &\ &G01 

 33%8&!. ! !*0 K'3

X 100

3. / + %4)" /


 %* '    @ &* /

++ F
!  G+/ + 

 #' 01 2 0G1  8&%'&% Z  S%38 %  (*' direct smear !/. culture
for AFB, CXR)

+, 
 :

8 % *.2 /
 G> 01  3 G4>!G8&  S%38 % 
X 100

 33%8&!. ! !*0 K'3

   

133



 
   


4. / + %4)" /


 %*   /

++ F
!  G+/ +   J
 
%6
!

 #' 01 3 0$1 3  K'

+, 
 :

8 % *.2 /
 G>G01  8&  S%38 %  !$3  K'
X 100

 33%8&!. ! !*0 K'3

134



     

 
   


 
!" #$%&% ' ()* +

   

135



 
   


136



 
   


/
  +%K 
! (Tuberculosis Supervision Check List)
1. 
/+ & (TB 01)
S%38%
8  8  3 

8 3 '
3301$>G14
8 8 

 

 #G$3*.2 0 G. .''/
**' K'
G'3G''%'
& ' 0G1 '0'01 3 '
 #G
$3*.2G >#'*  '!.'#'
8'.1
0.!4  ' 1 .'
#' CAT 1 ! CAT 2 #'001 G$3*.2 .1
G%2'G  '
8&G$.18%8 !4
8 8
/'!
3' ' 8% 4
  5  081 &
G$3*.2 4 8&G3

8 33
"81/ 5 3 01 
# '3 '03
 
$*.2 38&  K'








   

137



 
   


2.  %
 
! (TB 03)
S%38%
8  8  3 

8 3 '
%1 !30'
 ! 1 .1 1 8!
!*.1 !01 
 
 *&'
 
 
! !4
3' !G$.18%8 !4#'
01
$3*.2 (/.1    !G$3*.2 )
3' !G$.1 8%8 !4#'
 01 
$3*.2
! !4
 01  4 5 .'!  8&G
$3*.2  K' "4! !" !'2 30'
4# 34  CAT 2
 0303330'*'G
8
 081 &$3*.2
 32'30'4
0 
01  '2 30' K' Primary defaulter (8&$3*.2
 8 3 4) .
 03033 ' 8%402'30'

 !*  G $'<>3  ' 8% 4.

138

















 
   


3.  @ &*
 
! (4   M %6'')
S%38%
8  8  3 


  K'

 3*'%!G0"01 '%  
8 

 3 
8 8 !3$30.1 

3!4 
8 

3G/_%'43
.2 ! '

3$ 01$33

3%<0 S%38%80$ 

3G/_0
G'3G''%'
'

3G/_8&G$.18%8
 ' 4

 3G/_'/
G  G01 81/
5 ` # 8&

 3
.1G$'<>!
8%*.2 *0





















   

139



 
   


4.  %N& 
!
S%38%
8  8  3 
(3................)
0"34  K'
.
0&/3_*0! !33%-&
8 3 '
.
"34#'G (*.'2 , GG, 
)%
01G.
0 %$0$0&1 G/ #* #'! 3-6 .'
.
0.G.1G$
#'!.
08&G3!4$0$1 G8
.
00#1 ! &  '' $.1 # G
'/ #*  ' Lot .'1 . (FEFO)

140




 ................
 ................

 ................

 ................




 ................
 ................

 ................



 
   


5.  4/
!  G+/ + 
1. # 
'
1.1 3! '*'G
8
 &/''2G%2' ..........................'
 3 ' ..................................'
 G'013 ..............................  3.1 ......................................................
1.2
 33%0G1 '3%G<G (Cohort jjj... 0 1  ')
  38&G! &!U'> ................................................ ' (..........%)
  38&G! &!U'>$.1%'%&Z ................................ ' (..........%)
 $3*.2AFB ........................................................................................ ' (..........%)

018&G$3*.2 AFB 2'30'4 jjj............................... ' (..........%)

018&G$.1%'%&Z 3 3 2 jjj......................................... ' (..........%)

 801 &G$.1 %'&% Z$3*.2 AFB 3 3 2 jjj..................... ' (..........%)

018&G$.18%843 2 2 ...................................... ' (..........%)
1.3 #3G8&G (Lab request: TB05)
 0 #* $ jjjjjjjjjjjjjjjjjjjjjj............................jjj.
 0#*
!!0
8 
!!0
8   ...........................................................................................
jjjjjjjjjjjjjjjjjjjjjj................................jjjjjjj..
2.
O O* "  %4)"
2.1  G
 %$0$
 3' 
!3'x G

 %$0$
 3' 
!3'*' '  G
 3' 
!3'x! '  G

2.2  '&G!>
 %$0$
 %$0$
 3' 
!#* '% G0'
 3' 
!#* G '.1 0'
 0! Serial Number
 0 ! Serial Number
 03' !8&G3'&G!>
 03' !8&G3'&G!>

   

141



 
   


2.3 ! &!U'>
 ! 80 (Monocular)
 ! G8 (Binocular)
 $0
 $0
2.4 '2/ G0*.2 AFB
 %$0$
 %$0$
 #* '2/ G0*.2 AFB 33 '%<0 Ziehl-Neelsen
 #* '2/ G0*.2 AFB 33"'%<0 Kinyoun
 '2/ G0*.2 AFB #'G8~0#* ''  6 .''382 8' 0 1 !%8
 '2/ G0*.2 AFB #'G8~0#* '''%' 6 .''388' 0 1 !%8
 '2/ G0*.2 AFB 
 '2/ G0*.2 AFB ! 
3.  % $ 4/% (TB 04)

8 3 ' 
!
%1 ! Lab Serial Number 3>.1 1 8!  `
!*.1 ! 
 *&'
3' !G
8 3 '
! !8&$3*.2 AFB 1+ 2+ 3+   G0
! !8&$3*.2 AFB   G0//'2/%'
!3''2 30'
 081 &$3*.2 

142

#*

#*



















 
   


4.  
O O@ J (Quality Control)  /
% 
OK*
1. $ G3' '&G!> K'!!"8'.1 
33 '
2. 0"3G!>01  G08&*.2 AFB !  ' $.1 
'$
3. 0#3'/GG!>$.1  '$ (QA1) #' `3 
\&&3'
4. 0#3'/83 ! " %'8&G3G!>" (QA3) #'
`3 01 '
5. #'8&$.1 %'&% Z  08&G3 3 2
#'081 &G$3*.2 AFB
6. #'8&$.1 %'&% Z  08&G' 
2 2 #'081 &$3*.2 AFB

#*

#*

   

143



 
   


144

You might also like