2556

2551

..

2556

.. 2556


(Abbreviation)
1

1.1

1.2

1.3
2

2.1

2.2 The Stop TB Strategy

2.3
3

3.1

3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
4 (DOT)

4.1

4.2

4.3

4.4

4.5

4.6

4.7 (refer & transfer)

4.8

4.9

4.10

4.11 (DOT)

.. 2556

9
13
13
14
15
20
21
21
22
27
27
29
29
31
31
34
35
38
38
41
43
48
50
52
57
57
58
59
61

 5

5.1

5.2

5.3

5.4

5.5
5.5.1 BCG

5.5.2


6

6.1

6.2

6.3
6.3.1


6.3.2
6.3.3
7

7.1

7.2

7.3

7.4 MDR-TB

7.5

7.6

7.7

7.8 MDR-TB

7.9 XDR-TB
8

8.1
8.1.1
8.1.2
8.1.3

8.1.4

66
66
67
69
70
72
72
73
81
81
81
82
83
83
88
96
96
97
97
106
107
111
112
113
113
118
118
118
120
120
121

.. 2556


8.1.5
122

8.1.6
122

8.2
123

8.2.1
125

8.2.2
125

8.2.3
125
9
128

9.1
128

9.2
129

9.2.1
130

9.2.2
132

9.2.3
134

9.3 134

9.4
136
10
140


10.1
141

10.2
142

10.3 / 144
11
148

11.1
148

11.2
149

11.3
150

11.4
153


1
162

2 / 177

3 /
181

1

4 /
183

2

5 (ISTC)
185

188

.. 2556


1
2
3
4
5
6
7
8
9
10


11
12
13
14
15




16
17
18
19

ZN staining
Fluorescence acid-fast staining
AFB



4FDC
2FDC H 75 R 150
2FDC (Isoniazid Rifampicin)







CD4

29
30
30
41
46
46
47
47
48
50
52
56
59
71
91

107
109
150
158

.. 2556


1
2
3


4




5




6




7




8

(Contact investigation and management)

MDR-TB Direct smear
Xpert MTB/RIF

MDR-TB Direct smear
Xpert MTB/RIF

MDR-TB Direct smear
Xpert MTB/RIF LPA LPA

MDR-TB Xpert MTB/RIF

5

.. 2556

14
58
75
100

101

102

103

157

 (Abbreviation)
AFB
AFRIMS

AIDS

ALT
ART
AST
BCG
BMI
BSC
CBC
CD4
CDC-US

CPT

Cr.Cl
Cs
CSF
CXR
CYP 450
DOT
DOTS

DST
DTC
E
EFV
ELISA

acid- fast bacilli

Armed Forces Research Institute
of Medical Sciences
acquired immunodeficiency
syndrome
alanine transaminase
anti-retro viral therapy
aspartate transaminase
Bacille Calmette-Guerin
body mass index
biological safety cabinet
complete blood count
cluster of differentiate 4
Centers for Disease Control and
Prevention (USA)
co-trimoxazole preventive
therapy
creatinine clearance
Cycloserine
cerebrospinal fluid
chest x-ray
cytochrome p 450
directly observed treatment
the internationally agreed
strategy for TB control
drug susceptibility testing
district TB coordinator
Ethambutol
Efavirenz
enzyme-linked immunosorbent
assay

EPI

EPTB
Eto
FDC
FLD
FLDST

H,INH
HAART

HEPA

HIV
IC
IC Nurse
ICF
IFN-
IGRA
IOM

IPT
IRIS

ISTC

IUATLD

K, Km
LED
Lfx

expanded program on
immunization
extrapulmonary tuberculosis
Ethionamide
fixed dose combination
first line drugs
first-line drug susceptibility
testing
Isoniazid
highly active anti retroviral
therapy
high-efficiency particulate
air filter
human immunodeficiency virus
infection control
infectious control nurse
intensify case finding
interferon grammar
interferon gramma release assay
International Organization for
Migration
isoniazid preventive therapy
immune reconstitution
inflammatory syndrome
international standards for
tuberculosis care
International Union Against
Tuberculosis and Lung Disease
Kanamycin
light-emitting diode
Levofloxacin

.. 2556

L-J
LPA
LTBI
MAC
MDGs
MDR-TB
MOTT

MTBC

NNRTIs

NRTI

NTM
NVP
O, Ofx
P, PAS
PCP
PITC

PMDT

PPD
PPE
PPM

lowenstein-Jensen
line probe assay
latent tuberculosis infection
mycobacterium avium complex
millennium development goals
multidrug resistant tuberculosis
mycobacterium other than
tuberculosis
mycobacterium tuberculosis
complex
non-nucleoside reverse
transcriptase inhibitors
nucleoside reverse transcriptase
inhibitor
nontuberculous mycobacterium
Nevirapine
Ofloxacin
para-aminosalicylic acid
pneumocystis carinii pneumonia
provider-initiated HIV testing and
counseling
programmatic management of
drug resistant TB
purified protein derivative
prutitic papular eruption
public-public or
public-private mix

PTB
PTC
R
RTC
S, Sm
SGOT

SGPT

SLD
SLDST

TAD
TAF
TB/HIV
TLTI

TST
UNAIDS

UVGI
WHO
XDR-TB

Z, PZA
ZN

.. 2556

pulmonary tuberculosis
provincial TB coordinator
Rifampicin
regional TB coordinator
Streptomycin
serum glutamic- oxaloacetic
transaminase
serum glutamic- pyruvate
transaminase
second line drugs
second-line drug susceptibility
testing
treatment after default
treatment after failure
HIV-related TB
treatment of latent
tuberculosis infection
tuberculin skin test
Joint United Nations Programme
on HIV/AIDS
ultraviolet germicidal irradiation
World Health Organization
extensively drug resistant
tuberculosis
Pyrazinamide
Ziehl Neelsen

(Tuberculosis TB) Mycobacterium
Mycobacterium Mycobacterium
tuberculosis ( 80)




Mycobacterium tuberculosis complex (MTBC)
Mycobacterium africanum Mycobacterium bovis


Mycobacterium Mycobacterium
Atypical Mycobacterium Mycobacterium other than tuberculosis (MOTT)
Nontuberculous Mycobacteria (NTM) 50


Mycobacterium avium
complex (MAC)
Mycobacterium
1.1


(droplets)
droplets

.. 2556

1.2 (TB infection and TB disease)

droplets


(TB infection)

90
10 (TB disease) (5%)
2 5 %

50 2
1

70%

(Exposure to TB)

30%
(TB infection)

10% (Active TB)

2 5%
2 5%

* 90%
(Latent Infection)

50

Source: State Government of Victoria, Department of Health Services

.. 2556


(primary tuberculosis)

primary
focus Ghons focus (mid-zone)

(lymphatic vessels)
(hilar lymphnode) primary focus
primary complex
(pleural effusion) (atelectasis)
(bronchiectasis)
(broncho-pneumonia)


(secondary or post-primary tuberculosis)




10

30-40 1 50-70 5-7
1.3







.. 2536 (.. 1993)
(global emergency)

.. 2556

1 3
(prevalence) 14
(infectious) (incidence) 8.8
1.7

22
.. 2541
(.. 1998) 80

1 .. 2555 (.. 2012)
86,000 124
30




65,000 50

.. 2537 (.. 1994) 9
.. 2543 (.. 2000) 15-40
6 2-7

.. 2542 (.. 1999)

2.4 .. 2544-2553
(.. 2001-2010) 1-2



112
2550-2552 (.. 2007-2009) 855, 826 862
93
3.4

.. 2556



20-37

.. 2554 (.. 2011) .. 2552 (.. 2009) 9.4
1.2 13 1.7
400,000 ( 24)



.. 2554 ( 27 2555) 91
15
90
68 15




Thai Working Group A2* (The Asian Epidemic Model (AEM) Projection
for HIV/AIDS in Thailand: 2005-2025)
.. 2553 (.. 2010) 1,138,020
641,633
499,324 10,853

3
1 ..
2540-2541 (.. 1997-.. 1998)
25.4 (multidrug resistant tuberculosis:
MDR-TB) 2.01 2 ..25442545 (.. 20001.. 2002) 14.8
(MDR-TB) 0.93 3 .. 2548-2549
(.. 2005-.. 2006)
15.7 1.65

.. 2556




/
5-7


.. 2554 (.. 2011) .. 2553
(.. 2010) (MDR-TB) 2,190
( 890 1,300 )



.. 2553 (.. 2010) 400 300
100
2 (second line drugs)

1.


2.
3.
4.
5.
6.
7.

8.

. :
. 2
: .
. .
. .
2553 . .
2550-2552 .
2550-2552 .

2548-2552 - .. 2554.

2550-2552 (Situation of childhood tuberculosis in Thailand: Fiscal year 2007-2009).

.. 2556

9. Akksilp S, Wattanaamornkiat W, Kittikraisak W, Nateniyom S, et al. Multi-drug

resistant TB and HIV in Thailand: overlapping, but not independently associated
risk factors. The Southeast Asian Journal of Tropical Medicine and Public Health 2009:
40(5):1264-78.
10. Hemhongsa P, Tasaneeyapan T, Swaddiwudhipong W, et al. TB, HIV-associated TB
and multi-drug resistant TB on Thailands border with Myanmar, 2006-2007. Journal
of Tropical Medicine and International Health: volume 13 No10, 2008, 1288-1296.
11. Tuberculosis: Epidemiology and Control. World Health Organization, 2002.
12. WHO report 2011. Global tuberculosis control: Geneva, World Health organization
(WHO/HTM/TB/2011.16).

.. 2556

(The internationally
agreed strategy for TB control: DOTS strategy) .. 2539 (.. 1996)
The Stop TB Strategy .. 2549 (.. 2006)



(Millennium Development Goals: MDG)
8
6 2 .. 2554 (.. 2011)
(The Global Plan to Stop TB 2011-2015)
.. 2554-2558 4
(1) DOTS (2)
(3) (4)

.. 2015 8
6
(combat HIV/AIDS, Malaria and other diseases)
23
24 (case detection)
(The Stop
TB Strategy)

.. 2556

2.1

1. 70
(success rate) 90

2. 50 .. 2558 (.. 2015)
.. 2533 (..1990)
2.2 The Stop TB Strategy 6

1
(DOTS)


(DOT)

2

/

.. 2556


4


(International standards for tuberculosis care: ISTC)

5





6


6

2.3
1)



(National tuberculosis control
programme: NTP)
NTP


2) (.)


NTP

10

.. 2556

3) (.)




NTP
4) (.)



5) //


1. (Intensify case finding: ICF)

2.


1. (ISTC)

2. .


BCG (Bacille Calmette-Guerin)
(Expanded Program on Immunization: EPI)

/


(.)




.

.. 2556

11

 .

1. First line drugs Second line drugs



2. /



3. electronic

4.

1. .
2549. 2549.
2. .
2558. 2 2554.
. 2554.
3. .
.. 2550. . 1 .. 2550.
4. . .
http://www.undp.or.th/thai/focusareas/mdgprogramme.html.
5. An expanded DOTS framework for effective tuberculosis control. WHO/CDS/TB/2002.27.
6. Framework for effective tuberculosis control. WHO/TB/94.179.
7. http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm.
8. The global plan to STOP TB 2006-2015. Actions for life towards a world free of tuberculosis.
WHO/HTM/STB/2006.35.
9. The global plan to STOP TB 2011-2015. Transforming the fight towards elimination of
tuberculosis.
10. The STOP TB strategy. Building on and enhancing DOTS to meet the TB-related
Millennium Development Goals. WHO/HTM/TB/2006.368.
11. United Nations Development Programme. The Millennium Development Goals. Fast
facts. http://content.undp.org/go/cms-service/download/asset?asset_id=2883030.

12

.. 2556

12. United Nations site for the MDG Indicators. United Nations Statistic Division. Official
list of MDG indicators.
13. What is DOTS? A guide to understanding the WHO-recommended TB control strategy
known as DOTS. WHO/CDS/CPC/TB/99.270.
14. WHO launches new stop TB strategy to fight the global tuberculosis epidemic. http://
www.who.int/mediacentre/news/releases/2006/pr12/en/.

.. 2556

13

3.1

3.1.1 (patient-initiated pathway) passive case finding










/

14

.. 2556


3.1.2 (screening pathway)
(intensified case finding: ICF)
patient-initiated


1) (contacts of TB cases) (

5 )

2) (clinical risk groups)

(silicosis) (chronic

obstructive lung disease) (malnutrition)



3) (risk populations)





3
( 6
8 )


(Active case finding)



(TB prevalence survey)

2
( )
(hemoptysis)
2

(TB suspect)

(specimen)
(paraffin)

.. 2556

15

 smear (acidfast)

3 2
50

2
1 (spot sputum)

2 (collected
sputum)

EQA (external quality assurance) smear microscopy

3.2

3.2.1



(..)

1,100
(light microscopy) smear Ziehl Neelsen
(ZN) LED (fluorescent
light-emitting diode) microscopy

16

.. 2556

 1 ZN staining

Grading

()

Negative

200

0 AFB/100
1- 9 AFB /100

actual cell counts actual cell counts

( AFB ) ( AFB )

100

10 - 99 AFB /100

Positive

1+

100

1-10 AFB /

Positive

2+

50

>10 AFB /

Positive

3+

20

: acid-fast bacilli: AFB

2 fluorescence acid-fast staining

AFB

0 AFB/30

negative

1 - 29 AFB/30

AFB

>29 AFB/30

1+

1 - 10 AFB/

2+

>10 AFB/

3+

3 AFB
SCALE
(1,000 x
LIGHT MICROSCOPY (ZN)
field = HPF)
Stain

MICROSCOPY SYSTEM USED

FLUORESCENCE MICROSCOPY (Fluorescent Stain)

1,000 x magnification: 1
length=100 HPF

200-250 x magnification: 1
length=30 fields

400 x magnification: 1
length=40 fields

Negative 0 AFB/1 length or 100 HPF

0 AFB/1 length or 30 fields

0 AFB/1 length or 40 fields

Scanty

1-9 AFB/1 length or 100 HPF

1-29 AFB/1 length or 30 fields 1-19 AFB/1 length or 40 fields

1+

10-99 AFB/1 length or 100 HPF 30-229 AFB/1 length or 30 fields 20-199 AFB/1 length or 40 fields

2+

1-10 AFB/1 HPF on average

10-100 AFB/1 length on average 5-50 AFB/1 length on average

3+

>10 AFB/1 HPF on average

>100 AFB/1 field on average >50 AFB/1 field on average

: WHO IUATLD

.. 2556

17


24
AFB

AFB

AFB 10,000 /
1 smear

AFB

(laboratory register book)


treatment card primary default

(scanty actual number)

1
(sputum smear positive case)

3.2.2 (chest x- ray: CXR)






3.2.3 (culture)



77

1 (drugsusceptibility testing for first line drug) 33
2 (drug susceptibility testing for second line drug) 4

18

.. 2556




1. (sputum smear negative pulmonary tuberculosis )

2. MDR-TB 1 6 2



3.




culture
(decontamination)
2

1.

decontamination

2.

biological safety cabinet (BSC)

BSC class II

decontamination procedure
aseptic technique cerebrospinal fluid (CSF)
Lowenstein-Jensen (L-J) culture

L-J 2% Ogawa medium
BBL MGIT
Bactec MGIT 960
Oxygen consuming

.. 2556

19




2
8 (No growth)
Bactec MGIT 960
3-7 6 No growth

(drug susceptibility testing: DST)


1.

2.

3.

4.

5. 3

1

12-14

3.2.4 (Nucleic Acid Amplification) Rapid identification
Mycobacterium tuberculosis

AFB

Xpert MTB/RIF Real-time

Polymerase Chain Reaction (cartridge)



rifampicin

() ()

rifampicin 100

99 Xpert MTB/RIF





Xpert MTB/RIF 3

1. relapse, TAF

20

.. 2556


2.

3.

Genotype MTBDR (HAIN Test) Line Probe Assay (LPA)

isoniazid rifampicin

2

98 3

Xpert MTB/RIF
3.2.5

( tuberculin skin test: TST)

BCG BCG

TST

TST 5

BCG

BCG





Interferon Gramma Release Assay (IGRA)

(latent TB infection) Incubate Purified Protein

Derivative (PPD) Control antigen Interferon Grammar

(IFN-) lymphocyte sensitized

Enzyme-linked Immunosorbent Assay (ELISA)

(active

tuberculosis disease)

1.

2.


3.

,
, 2529.

,
, 2552.
,
4, 2547 ISBN: 974-297-224-9.

.. 2556

21

4. ,
5 2546
2546: ISBN 974-331-083-5.
5. Kawai M., and Fujiki A. Minimum essential of laboratory procedure for tuberculosis
control.
6. The Research Institute of Tuberculosis, JATA, 1988: p.53-54.
7. Kubica GP., Dye WE., Cohn ML., and Middlebrook G. Sputum digestion and decotamination
with N - acetyl - L - cystein - soduim hydroxide for culture of mycobacteria. Am Rev
Respir Dis 1963: 87: 775 - 779.
8. Kubica GP., Kaufman AJ., and Dye WE. Comments on the use of the new mucolic agent,
N-acetyl - L- cystein, as a sputum digestant for the isolation of mycobacteria. Am Rev
Respir Dis 1964: 89: 284-286.
9. 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.
10. The Research Institute of Tuberculosis, JATA, 1988: p.53-54.
11. Van Deun A. and F. Portaels. Limitation and requirement for quality control of sputum
smear microscopy for acid-fast bacilli. Int J Tuberc Lung Dis 1998: 2(9):756-76.
12. 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.
13. World Health Organization. Early detection of tuberculosis: An overview of approaches,
guidelines and tools. WHO/HTM/STB/PSI/2011.21. World Health Organization 2011.

22

.. 2556

(Directly observed treatment: DOT)

4.1

1) (TB suspect)

2

( ) /

( )

2) (TB Case) (definite case)





3) (Definite case) Mycobacterium

tuberculosis complex culture Molecular line probe

assay M. tuberculosis

AFB smear 1 definite case

1.

(Pulmonary Tuberculosis: PTB)
Miliary TB

.. 2556

23

 (Mediastinal and/or hilar lymph node) (Pleural

effusion)

(Extrapulmonary Tuberculosis: EPTB)




2.


M. tuberculosis
(PTB+)

smear 1
(PTB-)

smear 2





smear 2 culture

M. tuberculosis


65 50
/

3.



6

24

.. 2556

 1. (new)

1


2. (relapse) recurrent
(true relapse) (re-infection)


direct smear culture
3. (treatment after failure)
(new patient regimen)

5 (remained positive)

(became positive)
2


4. (treatment after default)
2

direct smear culture
5. (transfer in)

6. (other)


1





(bacteriologically

negative relapse) (bacteriologically negative extra
pulmonary TB)

.. 2556

25

+ +

+ -

+ -

4.2


100

1)



(initial phase intensive phase)



(continuation phase) 2

dormant form

2)





3)

(6 8 9 )





4)





(DOT)

26

.. 2556

(Daily package) (Fixed Dose Combination: FDC)

DOT

4.3

2

1. 1 (First line drugs: FLD)

(Isoniazid: H, INH)

(Rifampicin: R, RMP)

(Pyrazinamide: Z, PZA)

(Ethambutol: E, EMB)

(Streptomycin: S, Sm)

FDC HR HRZ HRZE FDC


30-70


2. 2 (Second line drugs: SLD)

(Kanamycin: K, Km)
(Levofloxacin: Lfx)
(Ethionamide: Eto)
(Para-aminosalicylic acid: P, PAS)
(Cycloserine: Cs)
(Ofloxacin: O, Ofx)

.. 2556

27



2010
3

1. (new patient regimen)
2HRZE/4HR

1

culture
(DST)

2 4 H, R, Z, E 4
2 H, R



1 (1HRZE)
( 2)
relapse failure
H (pre-treatment isoniazid resistance)

(delay response) 9-12

6-9
9-12

2. 1 (re-treatment regimen with first-line drugs)
2HRZES/1HRZE/5HRE

(treatment after default)

(relapse) culture DST

28

.. 2556


3 2 5 H, R, Z, E S
3 4 1 5
3 H, R, E
:

1 3



DST

3. (MDR regimen)
> 6Km5LfxEtoCs+PAS/>12 LfxEtoCs+PAS

treatment after failure
culture DST

( 5 ) 6
4
18

8
4 20
18



culture DST
DST (individualized regimen)

MDR regimen DOT

( 7 )
: K S

( 14 )
( 5) ( 6)

.. 2556

29

././

././

4-6
8-12
20-30
15-20
12-18

5
10
25
15
15

H
R
Z
E
S

(maximum dose)

300 ./
600 ./
2000 ./
1600 ./
1000 ./

S
> 60 S 500-750 ./
10 ././ 50 . S
500-750 ./

** (.)

***35-49
50-59
60-69
70

(.)*
H
4-6 ./

R
8-12 ./

300
300
300
300

450
600
600
600

Z
20-30 ./

1,000
1,500
1,500
2,000

E
15-20 ./

800
1,000
1,200
1,200

*

**

*** 35 ( 6)

30

.. 2556

 7 4FDC
4FDC (H75 R150 Z400 E275)

30-37 .
38-54 .
55-70 .

H
(.)

R
(.)

Z
(.)

E
(.)

2
3
4

150
225
300

300
450
600

800
1200
1600

550
825
1100

8 2FDC (H75R 150, H100 R150, H150 R300)

30-37 .

38-54 .


55-70

2FDC

H75 R150
H75 R150
H100 R150
H75 R150
H150 R300

2
3
3
4
2

H
(.)

150
225
300
300
300

R
(.)

300
450
450
600
600

4.4

(2 )

4.4.1 (2HRZE/4HR)

1) culture DST DST

MDR-TB treatment failure MDR-TB

DST

2)

( 2 )


2 HR
2 *

.. 2556

31


*

(drug-to-drug/drug-to-food

interaction)


(immuno-compromised host)

NTM


HR HRZE
1
3

3) 3

( 2 )
3 HR 4
3

Culture DST Liquid media Rapid test
HR

4) 5
HR


culture DST liquid media rapid test
treatment failure MDR-TB

empirical regimen

DST

5)

4.4.2 (2HRZES/1HRZE/5HRE)

culture DST DST
MDR-TB treatment failure MDR-TB
DST

32

.. 2556

1) ( 3
)
3 HRE
3 DST
culture DST
HRE
2) 5
5 HRE
5 culture DST
treatment failure MDR-TB
empirical regimen
DST
3)

4.5 (Drug to drug Interaction)

(Drug to food Interaction)
10

-

-

-


-

-

1


2
-

-


1

2
-

.. 2556

33

 10 ()

-

-

-



2

Ofx

Eto

Cs

34

.. 2556

20%

B12 folic
acid

-



4
-

2
-







-

 10 ()

PAS

4.6


2
1. major side effect
2. minor side effect

11

(vertigo nystagmus)
()

()
purpura

S
S
H, R, Z

E
R
S
-
Z, R, H

Z,E

H

H
Intermittent dosing R

Aspirin NSAIDS
Paracetamol
Pyridoxine 50-75

.. 2556

35

prednisolone
systemic steroid
prednisolone 40-60 .



H R E Z
1/3 1/2 2-3



/





H, R Z
bilirubin aspartate transaminase (AST)
serum glutamic- oxaloacetic transaminase (SGOT)/alanine transaminase (ALT)
serum glutamic- pyruvate transaminase (SGPT) R

36

.. 2556



> 60 , , ,
, ,

AST/ALT total bilirubin

AST/ALT total bilirubin 1-2
1


AST/ALT > 3 H, R Z
AST/ALT 3
3

total bilirubin > 3 ./ AST/ALT 3

R
AST/ALT < 5 1
AST/ALT > 5 H, R Z
re-challenge
fulminant hepatitis
AST/ALT < 2 total bilirubin < 1.5 /
H, R Z

AST/ALT total bilirubin 1

re-challenge AST/ALT total bilirubin

(optic neuritis, retrobulbar neuritis)
E H
(dyschromatopsia, - -)
(central scotoma)

.. 2556

37


50
E

(visual acuity)
E
E 15 ././ 20 ././




H H
12

H
R
Z
HR
HZ
HRZ

2RZE/10RE, 6RZE/6-9RZE
2SHE/10 HE, 2HZEQ/10-16HEQ, 2-3SHZEQ/9-10HEQ
2HRE/7HR, 2SHRE/6HR
2SEQ/16-22EQ
SREQCs 12-18
SEQ+oral SLD 18-24

: Quinolone (Q)

4.7 (refer & transfer)

(refer)

(transfer)

(TB09)
(refer)
(transfer) (transfer-out)
(transfer-in)

38

.. 2556

4.8
1 1

( AFB culture)
2



( )

2
*
(Treatment after interruption)

< 14

> 14

< 80%

> 80%

<3

-
- 9
()

>3

* ,

.. 2556

39

4.9

1. (cured):
2
2. (treatment completed):
3. (treatment failed):
3.1
5
3.2 2
3.3
MDR-TB
4. (died):
5. (default): 2
6. (transfer out):
(treatment success )
4.10
4.10.1

aminoglycoside, quinolone

(Ofx, norfloxacin)

pyridoxine ( 6) 10 .
4.10.2
(haemodialysis) haemodialysis
H, R Z S E
creatinine clearance (Cr.Cl) / ()
(increase the dosing interval)
(too low peak serum concentration) Cr.Cl

40

.. 2556

 13

H
R
Z
E
<10
S, Km






Ofx

PAS

Eto
Cs

Cr.Cl (ml/min)

-
-
< 50
10-50

>80
60-80
40-60
30-40
20-30
10-20
<10
20-50
<20
10-50
<10
<30
<10

12-20 mg/kg/day

24-36
48
15 ././
24
12 ././
24
7.5 ././
24
4 ././
24
7.5 ././
48
4 ././
48
3 ././
72

24
50%
24
50-70%

50%

250-500 ./

36-48

4.10.3

.



.

AST/ALT 3 2HRE(S)/7HR



2SHE/10-16HE
AST/ALT 3 2SHE/16HE

. Acute hepatitis Jaundice S E Jaundice

H R Active TB

Quinolone ( Ofx) S E

2-3 Ofx, S E
.. 2556

41

4.11 (DOT)
R
(M/XDR TB)

R


1. (acceptable)
2. (reliable)
3. (accountable)



1.
2. (.)
3.
DOT

1.


2.

42

: . 1
.. 2555.
, .(),
5 2546 ()
.. 2542.

.. 2556

3. . . .
DOTS. 1-2
4-5 2545. .
4.
:
( 3 2545).
5. American Journal of Respiratory and Critical Care Medicine. American Thoracic Society
1905, Vol. 167, No.4, February 15, 2003.
6. 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.
7. An expanded DOTS framework for effective tuberculosis control. WHO/CDS/TB/2002.27.
8. Centers for Disease Control and Prevention. Treatment of Tuberculosis, American
Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003:52
(No. RR-11):1-77.
9. Crofton J, Horne N, Miller F. Clinical Tuberculosis. The Macmillan press, Hong Kong,
1992.
10. Drug Information Handbook with International Trade names index 2008-2009. 17th

edition. American Pharmacist Association. Senior Editor: Charles F Lacy, Lora L Armstrong,
Morton P Goldman, Loonard L Lance.
11. 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).
12. Porter J.D.H., Mc Adam K.P.W. Tuberculosis Back to the Future John Wiley + Sons,
England, 1994.
13. Raviglione M : XDR-TB: entering the post-antibiotic era?, Int J Tuberc Lung Dis 2006 :
10(11) : 1185-1187.
14. The Sanford Guide to Antimicrobial Therapy 2009. 39th edition. Editors: David N Gilbert,
Robert C Moollering Jr, George M Eliopoulos, Henry F(Chip) Chambers, Michael S Saag.

.. 2556

43

15. Toman K. Tuberculosis Case-finding and Chemotherapy (Questions and answers). WHO,
Geneva, 1979.
16. WHO: An expanded DOTS framework for effective tuberculosis control Int J Tuberc
Lung Dis 2002: 6(5) : 378-388.
17. WHO: A Guide for Tuberculosis Treatment Supporters Document WHO/CDS/TB/
2002.300 WHO Geneva 2002.
18. WHO: What is DOTS : A guide to understanding the WHO-recommended TB Control
strategy Know as DOTS WHO/CDS/CPC/TB/99.270.
19. World Health Organization 2010. Treatment of tuberculosis: Guidelines. 4th edition.
WHO/HTM/TB/2009.420.
20. WHO Model Formulary 2008. Available at http://www.who.int/selection_medicines/
list/WMF 2008.pdf.
21. WHO Report 2012: Global Tuberculosis Control : Surveillance Planning Financing World
Health Organization, Geneva

44

.. 2556

5.1


1.

50

2.

(increased intracranial pressure)


1,000/..

haematuria, sterile pyuria

miliary

.. 2556

45

5.2

5.2.1
1-3

2

1.





(miliary (cavity)

2. >10 . ()

BCG Mycobacterium
tuberculosis (M. tuberculosis)

( > 5 .

) > 5 .



3. (

60-80%

30-40%)
(contact investigation)

3 1+2+3

5.2.2


( definite diagnosis)

46

.. 2556


()

5.3

5.3.1



1.

2-3



2.



3.

4. BCG
Mantoux test
2-3 0.1 .. 48-72

1) > 5 .

steroid

2) >10 .



4

3) >15 . BCG

BCG
5 80-90 <10 . 10-15 80-90
BCG > 10 .
10-14 . BCG >15 .

.. 2556

47


5.3.2 Interferon gamma

BCG

M. tuberculosis Interferon gamma

ELISPOT (T-spot TB) 96 100

BCG ELISPOT



Quanti FERON-TB Gold (QTF-G) 90

95 Latent Tuberculosis Infection Active TB

QTF-G

QTF-G

5.3.3

PCR
1-2 90 Primer
PCR
PCR
( PCR )

5.4


intermittent regimen
E 25 ././
(DOT)



5.4.1

Rapid Advice WHO/HTM/
TB/2010.13 Guideline for the programmatic management of drug-resistant tuberculosis
WHO/HTM/TB/2011.6

48

.. 2556


1. isoniazid

H: 10 ./. (10-15 ./.) max 300 ./
1

R: 15 ./.. (10-20 ./.) max 600 ./
1

Z: 35 ./. (30-40 ./.)
1

E: 20 ./. (15-25 ./.)
1

2.
(new patient regimen) H R, Z E
2 H R 4 (2HRZE/4HR)


2HRZE/10HR
( S E) 2HRZE/10HR

2HRZ/4HR

(retreatment regimen)
H R, Z, E S 2 H R, Z E 1 H
R, E 5 ( 2HRZES/1HRZE/5HRE)
default 2 treatment failure
5 (Gastric larvage)

(MDR regimen)
(MDR-TB)
4 fluroquinolone 1 18

> 6Km5LfxEtoCs+PAS/> 12 LfxEtoCs+PAS

14

Eto
PAS
Cs
Km
Lfx

././

15-20
150
10-20
15-30
7.5-10

()

2
2-3
1
1
2

(.<50 .)

500 .
8
500 .
750 .
800 .

(.>50 .)

1
12
1
1
800 .

.. 2556

49


5.4.2

1-2 80 3 90
4 10-12
6
2-3
2-3

95 relapse 1
5.5


BCG

5

5.5.1 BCG

BCG
1,200 BCG
50 64
78
primary, reactivation exogenous
cell wall antigen recombinant technology
BCG BCG
.. 2496-2499 (.. 1953-1956) 2 .. 2497-2509 (.. 1954-1966)
6 ..2510 (.. 1967)
5-10 1-2

.. 2520 (.. 1977) EPI < 4
BCG 100% BCG 2

50

.. 2556

 BCG

BCG 10-14
(Prevalence) (
40/100,000 ) .. 2549 (.. 2006) 62/100,000
BCG
BCG

BCG



1 BCG

7 (. 1) BCG

( BCG

)





5.5.2

(Treatment of Latent Tuberculosis Infection: TLTI)

3
( )
1-2





12 8
120



(
) (Latent Tuberculosis Infection:

.. 2556

51

LTBI)
(TB elimination)

1 40-50 2
10-15
5-10

BCG > 10.
> 15 .
2 .. 2538-2540 (.. 1995-1997) .. 2542-2543 (.. 1999-2000)
5 BCG
9.1 8.2
>15 . 22.6 18.7 2
(retrospective) (prospective) .. 2547-2549
(.. 2004-2006) 1.64 61.4
1 20-30
(: LTBI)
90 19
recent infection

52

1. (infectious index case)

( contact
investigation)

.. 2556

DOTS

DOTS

< 5
Isoniazid
6-9

> 5
TT > 15 . Isoniazid 6-9
TT 10-14 .

HIV+
Isoniazid 9

<5 H 5-10 / 6-9 (

)
>5 >15 . H 5-10 /
6-9 10-14 .
H <10 .

8-10
> 10 . 6 .
(recent converter) H 6-9

.. 2556

53



H < 5



H 9

H H R 3 R
6

(MDR-TB)

[ 2

R Z (2RZ)

]

2. ( 3

TB elimination) H 6-9

< 5 >15 . ( BCG )

corticosteroid

>5 . (

corticosteroid >10 .)

old fibrotic lesion >10 .

recent converter 2

(MDR-TB)
2

54

.. 2556


1.


2.
3.

4.

5.

6.

7.

8.

: . 1
.. 2555.
.. 2551.
, , . .
..2553.
,
, : 5 .
, , .
2550: 28: 185-9.
,
2551: 29: 115-3.
, . .
2542: 2: 10-8.
American Academyof Pediatrics/Committee on Infectious Diseases. Tuberculosis.ln:
PickeringLK,ed 2000 red book: report of the Committee on Infectious Diseases. 25th

ed. Elk grove Village, II: AmericanAcademy of Pediattics 2000:595-611.
9. American Thoracic Society/Centers of Disease Control and Prevention/Infectious
Disease Society of America Treatment of tuberculosis, management of common side
effects .Am J Respir and Criti Care Med 2003:167 : 636-7.
10. G.A.Colditz T.F. Brewer. C.S. Berkey,M.E Wilson. E .Burdick H.V. Fineberg.F.Mosteller.
Efficacy of BCG vaccine in the prevention of tuberculosis Meta- analysis of the published
literature JAMA,271:698-702.
11. Graf P, Tuberculosis control in high-prevalence countries. Ln Davies PDO (ed) Clinical
Tuberculosis 1sted. Chapman & Hall Medical 1994: 3259.
12. Guidedance for national tuberculosis programmeson the management of tuberculosis
in children. WHO/HTM/TB/2006.

.. 2556

55

13. Guidelines for the investigation of contacts of persons with infectious tuberculosis:
Reccommendation from the National Tuberculosis Controller Association and CDC
MMWR 2005: 54 (RR15): 1-37.
14. Hames A, Maher D, Uplekar M Prevention of TB A Clinical manual for south east Asia
World Health Organization 1997: 133-8 WHO/TB/96.200 (SEA).
15. International Union Against Tuberculosis Committee on Prophylaxis .Efficacy of
variousdulations of isoniazid preventive therapy for tuberculosis five years of follow-up
in the IUAT trial. Bull lnt UnionTuberc Lung Dis 1982: 60:555-64.
16. Rapid advice Treatment of tuberculosis in children WHO/HTM/TB/2010: 13.
17. Rieder HL Contacts of Tuberculosis patients in high-incidence countries, Int J Tuberc
Lung Dis 2003, 7, S333-S336.
18. Srinavin S, Chotipitayasumondh T, Suwanjutha S.et al .BCG Efficacy,Pediatric Infect Dis
1991: 10: 359-65.
19. Starke JR Tuberculosis in children .Diagnosis and treatment Annals Nestle1997: 55: 10-23.
20. Treatment of Tuberculosis, Guidelines, 3rd Edition 2003/WHO/CDS/TB/2003.313.
21. Treatment of Tuberculosis , Guidelines, 4th Edition WHO/HTM/TB/2009:420.
22. VilarinoME, What is the role of treatment of latent tuberculosis infection in a tuberculosis
control programme? ln.Frieden T .(ed ) Toman,sTuberculosis case detection treatment
and monitoring 2nd edition WHO 2004: 220-5 WHO/HTM/TB/2004-334.
23. WHO.Guideline for the programmatic management ofdrug-resistance tuberculosis
WHO/HTM/TB 2006,361.
24. WHO report The Stop TB Strategy, Building on and enhancing DOTS to meet the TB
related Millenium Development Goals WHO/HTM/TB/2006:368(2006).
25. WHO Treatment of Tuberculosis Guidelines for National Programme, Clinical presentration,
approach to diagnosis and management of tuberculosis in children WHO2003:61-5.

56

.. 2556

6.1




1.





10

2.
(recurrent tuberculosis)


(endogenous
reactivation or true relapse)

(exogenous re-infection)

/
6.2



1. (susceptibility)

.. 2556

57


2.



3.



4.

5.



6.

7.




1. /

2. /

3. /

4. /

5. /
6.3


.. 2543 (.. 2000)
12
.. 2547 (.. 2004)


72
.. 2548 (.. 2005)

58

.. 2556

UNAIDS

1
5
3

6.3.1

1.

2.





3.

4.



6.3.2

3 I /


1. (ICF)
/
/




/




.. 2556

59





(Counselor)

(.)

Cluster of differentiate
4 (CD4) > 200 cells/mm3 CD4




CD4 < 50 cells/mm3





4

1. (Any cough)

2. 1

3. 5% 1

4. 3 1





(
(7.82% [83/1061])

60

.. 2556

 (culture)
Xpert nucleic acid amplification, complete blood
count (CBC), cerebrospinal fluid (CSF) ultrasound

1. ()
.
.
. 5
.
2.
.



.


Ultrasound
. 5-10

.. 2556

61








.













3 4
TB/HIV
01 3 (Suspected tuberculosis)
1

.

6 ( 9
)

2. H

(isoniazid preventive therapy: IPT)

(LTBI)

(CDC-US) H
(LTI)

62

.. 2556


H 9

(>5 ) H

3.

(infection control: IC)





/
( 9 )

6.3.3.

1.





1-2



provider-initiated HIV testing and

counseling (PITC)









PITC

3 C

1) informed consent

2) counseling

3) confidentiality

.. 2556

63

64

CD4 count







2.


(
)

.. 2556






3. (co-trimoxazole

preventive therapy: CPT)

AIDS-defining illness
co-trimoxazole CD4
CD4 < 200 cells/l

4. (anti-retro viral therapy: ART)


CD4

CD4
IRIS drug interaction

15 (Primary prophylaxis)

CD4
CD4
(cells/l)

< 50

50-200*

> 200

(Primary prophylaxis)

Co-trimoxazole (Fluconazole)

Co-trimoxazole (Fluconazole**)

-

2 NRTIs+1 NNRTI 2

2 NRTsI+1 NNRTI 2 - 2

2 NRTIs+1 NNRTI 2

: * ( BMI , Kamofsky score ,

) 2-4

** CD4 < 100 cells/l

TB meningitis/HIV
2 CD4

.. 2556

65

1) Rifampicin (R) Cytochrome

P 450 (CYP 450) efflux multi transporter P-glycoprotein
NNRTIs Pls
2) IRIS

IRIS IRIS

3)

4)
5)

1) WHO (
CD4 )
2) R
3) R efavirenz (EFV) 600 mg/day
60 kg 800 mg/day 60 kg
4) EFV nevirapine (NVP)
(400 mg/day) R ( lead-in NVP)
5) EFV NVP
R
Pls-based regimen
6) NVP-containing Highly Active Anti Retrovial Therapy (HAART)
R NVP
EFV

66

.. 2556

5.
2
1. (comprehensive care)

2. (continuous care)

1. 2548 ISBN:
974-297-378-4.
2.
.. 2549/2550 ISBN 978-974-297-626-2.
3. . 2550.

4. .. 2553
1. . .
5. 2549 Orane group
086-924-3434.
6. 2554
.
7. Interim Policy on Collaborative TB/HIV Activities, World Health Organization 2004.
8. Self-study modules on tuberculosis, US-Center for Disease Control and Prevention,
p 19, March 1995.
9. WHO policy on collaborative TB/HIV activities. Guidelines for national programmes and
other stakeholders. WHO 2012.
10. World Health Organization. Guidelines for intensified tuberculosis case-finding and
isoniazid preventive therapy for people living with HIV in resource-constrained settings,
department of HIV/AIDS and Stop TB department, ISBN 978-924-150070-8 ,World
Health Organization, Geneva, Switzerland : 2011.

.. 2556

67

11. World Health Organization. Policy on TB infection control in health-care facilities,

congregate settings and households, WHO 2009.
12. World Health Organization. Management of TB: Training for health facility (A: Introduction).
WHO/CDS/TB/2003.314a. Geneva, Switzerland: WHO, 2003.
13. World Health Organization. Strategic framework to decrease the burden of TB/HIV.
WHO/CDS/TB/2002.296. Geneva, Switzerland: WHO, 2002.
14. World Health Organization & UNAIDS. Guidance on Provider-initiated HIV testing and
Counseling in health facilities. HIV/AIDS Programme, strengthening health services to
fight HIV/AIDS, ISBN 978 92 4 159556 8, WHO 2007.

68

.. 2556

.. 2528 (.. 1985) 6

isoniazid (H) streptomycin (S)
rifampicin (R)
(multidrug resistant tuberculosis: MDR-TB)




(extensively drug resistant tuberculosis: XDR-TB)




7.1

mono-resistance

poly drug- resistance H

R

multidrug-resistance (MDR) 2

H R

extensive drug- resistance (XDR) 4

H R aminoglycoside

fluoroquinolone

.. 2556

69

7.2

(culture)
(drug susceptibility testing: DST)

1.



2
(treatment

after default sputum smear positive)



(treatment after failure)

2. 3

3.

MDR-TB

MDR-TB





(migrants)
7.3



culture DST
(MDR-TB)


MDR-TB DST
culture DST
MDR-TB


1 (first-line DST: FLDST)
MDR-TB
2 (second-line DST: SLDST) XDR-TB

70

.. 2556





Xpert MTB/RIF molecular test
R Xpert MTB/RIF
R
MDR-TB R R
H MDR-TB
Xpert MTB/RIF 2
R (
culture DST solid media liquid media line probe assay)

Xpert MTB/RIF
MDR-TB
MDR-TB Xpert MTB/RIF

1. MDR-TB

1.1.



1.2. 3 5

1.3. MDR-TB

Xpert MTB/RIF, LPA /

4 MDR-TB

direct smear Xpert MTB/RIF

5 MDR-TB

direct smear Xpert MTB/RIF

6 MDR-TB

direct smear Xpert MTB/

RIF LPA LPA

7 MDR-TB

Xpert MTB/RIF

.. 2556

71

72

.. 2556

4. Algorithm for MDR-TB suspects (high risk of MDR-TB), smear positive For sites with Xpert MTB/RIF

 .. 2556

73

5. Algorithm for MDR-TB suspects (high risk of MDR-TB), smear negative For sites with Xpert MTB/RI

74

.. 2556

6. Algorithm for MDR-TB suspects (high risk of MDR-TB) For sites without Xpert MTB/RIF

 .. 2556

75

7. Algorithm for PLWHA and other MDR suspects (not high risk of MDR-TB)
7.1 For sites with Xpert MTB/RIF

76

.. 2556

7.2 For sites without Xpert: Clinical judgement with Standard test (Molecular LPA or Liquid or solid culture & DST)

 Xpert MTB/RIF

MTB detected, RIF resistance detected

R
MTB detected , RIF resistance not detected
R
MTB not detected R
MTB detected, RIF resistance indeterminate
R
invalid error

7.4 MDR-TB

MDR-TB DST MDR-TB
DST MDR-TB (TB03)

MDR-TB

1. MDR-TB: new MDR-TB new case

new case

1.1

1.2 1

1.3 2 3

3 DST MDR-TB

2. MDR-TB: relapse FLD

DST MDR-TB

3. MDR-TB: treatment after default (TAD) FLD

> 2 DST

MDR-TB

4. MDR-TB: treatment after failure (TAF) of new patient regimen

FLD ( 5

) DS MDR-TB

.. 2556

77


5. MDR-TB: treatment after failure(TAF) of retreatment regimen

FLD 5 DST

MDR-TB

6. MDR-TB: transfer in (SLD)

(transfer out)

7. MDR-TB: others 1-6 .

( ) .



.

2

1.

2.

3.

4. (DOT)

(first line drugs: FLD)

5.

6. SLD

78

.. 2556

7.5
16

40 . 40-49 .
50 .
(./)
(./)

(./)

Group 1: First-line oral anti-tuberculosis agents

Pyrazinamide 20-30 mg/kg/day

( 500 ) 1

1,000

1,500

2,000

Ethambutol15 - 20 mg/kg/day
( 400,500 )
1

800

1,000

1,200

Streptomycin 15 mg/kg/day
1

Sm

500

750

1,000

Amikacin 15 mg/kg/day
1

Am

500

750

1,000

Kanamycin 15 mg/kg/day
1

Km

500

750

1000

Capreomycin 15 mg/kg/day
1

Cm

500

750

1000

Ofloxacin 15-20 mg/kg/day

( 100, 200, 300 )
1

Ofx

600

600

800

Levofloxacin 750 mg/day

( 250, 500 )
1

Lfx

750

750

750

Moxifloxacin ( 400 mg)

7.5-10 mg/kg/day 1

Mfx

400

400

400

Group 2: Injectable anti-tuberculosis agents

Group 3: Fluoroquinolones

.. 2556

79

 16 ()

40 . 40-49 .
50 .
(./)
(./)

(./)

Group 4: Oral bacteriostatic second-line anti-tuberculosis agents

Ethionamide 15-20 mg/kg/day

( 250 )
2-3 *

Eto

500

750

750

Prothionamide 15-20 mg/kg/day

( 250 ) 1

Pto

500

750

1,000

Cycloserine 10-20 mg/kg/day

( 250 .)
2 ( 12 .)

Cs

500

500

750

Para-Amino Salicylic acid 200 mg/kg/day PAS

( 1000 ) 2

8,000
(8 gm.)

10,000
(10 gm.)

12,000
(12 gm.)

Trd

600

600

600-900

Terizidone ( 300 .)
15-20 mg/kg/day

Group 5: Anti-tuberculosis agents with unclear efficacy

Clofazimine ( 50,100 .)

Cfz 100-300
300 4-6
100

Linezolid ( 600 .)

Lzd 600 .

Amoxycillin/Clavulanate

Amk/Clv 875/125 .
2 500/125 . 3

Thioacetazone

Thz 150 .

Clarithromycin ( 500 .)

Clr 500 . 2

Imipenem/cinlastatin
High-dose isoniazid 16-20 mg/kg/day

Ipm/Cln 500-1000 . 6 .

H
600
800
1000
High-dose

: * Eto 250 ./ 1-2 250 .

2 1-2 3-4 15-20 mg/kg/day

80

.. 2556

 mono-drug resistance poly-drug resistance

culture DST
MDR-TB

17

()

H ( S)

R, Z E

69

fluoroquinolone

H Z

R, E fluoroquinolone

9-12

H E

R, Z fluoroquinolone

9-12

H, E, fluoroquinolone,
Z 2

12-18

R E (S)

H, Z fluoroquinolone
2-3

18

(6 )

R Z (S)

H, E fluoroquinolone
2-3

18

(6 )

H, E, Z (S)

R, fluoroquinolone
1
2-3

18

(6 )

MDR-TB

MDR-TB
DST MDR-TB molecular test
MDR-TB Empirical MDR-TB
culture DST DST
(individualized or tailored regimen)
> 6Km5LfxEtoCs + PAS/> 12 LfxEtoCs+PAS

.. 2556

81


( 5 ) 6
4
18

8
4 20
18


(MDR-TB regimen)
DOT


MDR-TB
, (central nervous
system)

H, Z, Pto, Eto 100% Cs

80-100%

R (10-20%)

E PAS



Km, Am, S aminoglycoside


7.6 MDR-TB



direct smear culture

2

DST
6




culture conversion culture 2
30 (culture conversion)

82

.. 2556

7.7
7.7.1 (Interim outcome)
6

culture 6 culture 2

30

(died), > 2 (defaulted),

(transfer out)
7.7.2 (final outcome)

1. (cured) culture 5

12 30

2. (completed) Culture 12



3. (failed)

culture 2 5 12



culture 1 3





4. (died)

5. > 2 (defaulted ) 2

6. (not evaluated)




direct smear culture
2 3 6
6 2
7.8 MDR-TB

(close contact) MDR-TB
(indoor living space)

.. 2556

83



4

MDR-TB MDR-TB
TST (tuberculin
skin test) IGRA Test direct smear, culture
DST


MDR-TB 2

7.9 XDR-TB

XDR-TB

1. 1 (Z, E Rifabutin)

2. (12 )



3. Fluoroquinolone generation Moxifloxacin

4. 4 ( Eto/ Pto, Cs, PAS)

5. 5 (Clofazimine, Linezolid, Thioacetazone, high-dose H, Clarithomycin)

2

6. H DST

7. (localized disease)

8. (Infection control )

9.

10.

XDR-TB

84

( 11 )

.. 2556


1. 3. 2549-2550
.
2. 2546:
24: 95-100.
3.
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.. 2556

87

8.1

18
2551 (.. 2008)

2539 (..1996)
(144 ) 2544 (.. 2001)
(Tuberculosis Coalition for Technical Assistance and International
Committee of the Red Cross, 2009 (..2552))

8.1.1





(Screening Pathway)



( 1 ) 1

88

.. 2556

 (Screening method)

.) (Symptom screening)

2 1


1
1
1
6

2

.)





2

()
2

(Patient initiative Pathway)

(Screening method)

8.1.2

.. 2556

89

 2550 (.. 2007) 70

13




(DOT)

8.1.3 (Collaborative TB/HIV activities)

41

2551 (..2008)

71

.

(Pre-test counseling)

(Post-test counseling)

.

Pre-test Post-test counseling

.



Co-trimoxazole

90

.. 2556


CD4

CD4
CD4

1-2

3-8

6

8.1.4 (TB recording reporting)

(TB03)
4 TB07, TB07/1, TB08 TB/HIV01 M/XDR-TB
PMDT 03, PMDT 07 PMDT 07/1
5

8.1.5 (referral system)


10-16

(discharge planner)

(discharge planner)

.. 2556

91

8.1.6 (supervision, monitoring and evaluation)



(on the job training)
2






(mentor)





3 5

(TB prevalence survey)
(TB drug resistant surveillance)
8.2

(migrant
worker) (Cross - border population)
Carrier

92

.. 2556





.. 2539 43 1,451
372,242 390 100,000 5-6

1.



2.



3. (referral system)

4.






1. (registered migrant worker)

( )

2.

( )

3. (illegal migrant worker)

4. Cross border population

.. 2556

93


8.2.1

1.



()



2.



3.



4. (screening pathway)





8.2.2

(NTP)



()

8.2.3 (monitoring and evaluation)

1.



2.

94

. DOTS (Public-Private Partnership

for TB control). :
9-11 2547
.
. . :
.
2546. 2-4 2546
.

.. 2556

3. .DOTS: .
:
9 -112547
.
4. .
1 . :
9-11 2547
.
5. .
.. 2545.
:
9 - 11 2547
.
6. (2551). . ISBN 978 974-297-771-9. : .9. (2552).
2549-2550. ISBN 978-974-297 861-7. : .
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13. Tuberculosis Coalition for Technical Assistance and International Committee of the
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96

.. 2556

10

9.1


particle droplet nuclei
1-5
(alveoli)
alveolar macrophages
(dormant bacilli ) (latent TB infection)
( 5-10 )

.. 2556

97






















(recent infection)

10



silicosis
9.2





3

1.

2.

3.

9.2.1



Expose

98

.. 2556

1)




2)


3)


7
3.1
3.2
3.3
3.4.
3.5.
3.6.
3.7.
4)
(TB suspect)

2



5)

.. 2556

99










6)









2-3




7)







8)

MDR-TB

surgical

mask 2



9)





9.2.2

100

.. 2556


1)





(Natural Ventilation)

()

(Mechanical Ventilation)

(
)

)

(

)



)





)

High-Efficiency Particulate Air (HEPA) Filter

(Ultraviolet Germicidal Irradiation UVGI)

)



2)

(direct ultraviolet germicidal irradiation

fixture)

.. 2556

101


(upper room or shielded

ultraviolet germicidal irradiation fixture)

3) HEPA

9.2.3





MDR-TB bronchoscopy

102

1. surgical mask
mask
surgical mask
()

.. 2556

2.
1 HEPA mask, N.95
bronchoscopy

9.3




1.

2.

(Tuberculin skin test)

2.1

6

1

2.2 1-3 (two-step test)

2 boosted reaction 2.1 2

tuberculin

1-2 (tuberculin conversion)

1-2




1
6


9.4


(risk assessment, development of the TB Infection-Control plan, and periodic
reassessment)

.. 2556

103

104

.. 2556



(drug susceptibility testing )

1.


2.

,
. , 2529:
17: 131-136. . .
, .
, 2550, :
.

.. 2556

105

3. ,
. .. 2549, : .
4. , .
.. 2554, :
.
5. ,
. .. 2553,
: .
6. ,
. 2552, : .
7. American Thoracic Society, Diagnostic Standards and Classification of Tuberculosis in
Adults and Children, in Am J Respir Crit Care Med. 2000. p. 1376-1395.
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Tuberculosis in the United States. Am J Respir Crit Care Med, March 2005. 172:
p. 1169-1227.
9. Centers for Disease Control and Prevention, TB Elimination. May 2007, Centers for
Disease Control and Prevention. p. 1-3.
10. Centers for Disease Control and Prevention (CDC), Tuberculosis Infection Control in
the Era of Expanding HIV care and Treatment. 2006.
11. Worlld Health Organization, Guidelines for the Prevention of tuberculosi in Health
Care Facilities in Resource-Limiied Setting. 1999.
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Congregate Setting and Households. 2009.
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Setting. 2009.
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106

.. 2556

 10

The Stop TB Strategy

6 (Engage all
care providers)
(Public-Private Mix: PPM) (ISTC)



()

/
DOTS

.. 2556

107

()

10.1

10.1.1



( 3 )

10.1.2




( 11 )

10.1.3

(NTP)

108

.. 2556

10.1.4

10.1.5

DOT

(Multidrug-Resistant Tuberculosis: MDR-TB)
DOT

10.1.6

6-8

2 (refer) (transfer)

10.2

1.



/

1 3

2. (hospital TB coordinator)

(infectious
control nurse: IC nurse)

.. 2556

109


3. /

3.1 /

/

/



/

3.2

./





3.3 /



4. /

5.


/




6.


/
10.3 / (Public Private
MIX: PPM)

110

.. 2556






1.





/











2.



3.





4.

(TB network meeting/DOTS meeting)



3 4 /

5.







6.

3

.. 2556

111


1.



2.



3.



4.



5.




6.

7.

8.

112

DOTS (Public-Private Partnership

for TB control) :
. 9-11 2547
.
:
.
2546. 2-4 2546
.
DOTS
:
. 9-11 2547
.

:
.
9-11 2547 .

.. 2545
:
9-11 2547
.
. 2553.
.
.
2551. .
.
2558. 2: 2554.
.

.. 2556

9. .
.. 2550. . 1 .. 2550.
10. 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.
11. Centers for Disease Control and Prevention. Treatment of Tuberculosis, American
Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003: 52
(No. RR-11): 1-77.
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edition. American Pharmacist Association. Senior Editor: Charles F Lacy, Lora L Armstrong,
Morton P Goldman, Loonard L Lance.
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Robert C Moollering Jr, George M Eliopoulos, Henry F(Chip) Chambers, Michael S Saag.
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Programmes. 3rd Edition. WHO, Geneva, 2003. WHO/CDS/TB/2003.313WHO Model
Formulary 2008.
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Geneva. WHO/CDS/TB/2003.313 WHO Model Formulary 2008.
17. WHO Model Formulary 2008.
18. World Health Organization 2010. Treatment of tuberculosis: Guidelines. 4th edition.
WHO/HTM/TB/2009.420

.. 2556

113

 11

(supervision) (monitoring) (evaluation)

(supervision)

3












(evaluation)
1
interim evaluation
11.1

11.1.1

1




(quality)
(reliability) (verification)

114

.. 2556


11.1.2 (.)

. 1 3

.





(on-the-job-training)

1. (strength)

2. (room for improvement)

3. ()
18

RTC

PTC+RTC

DTC/TB clinic

:

1.







2.

3.

RTC (Regional TB Coordinator: )

PTC (Provincial TB Coordinator: )
DTC (District TB Coordinator: )
TB Clinic:
RTC PTC () .
.. DTC TB clinic
DTC TB clinic .

.. 2556

115

11.2

3 ,





)




)
















11.3

116

.. 2556

 19

1.

(case detection rate
for all form of TB)

2.

(sputum conversion
rate)

( (
) )

3.
(
(treatment ()
)
success rate)

4. ( (
(defaulted rate)
) )

5. (
)
(failure rate)

6. (death rate) (
)

(
7.
(transferred out rate) )

8.

()
(HIV testing rate)

(
)

(
)

(

)
died
(
)

()

.. 2556

117

 19 ()

9.

(HIV positive rate)

10.
(ART rate) ()

(
)

(
)

11.
co-trimoxazole
(CPT rate)

()

co-trimoxazole

CD4 < 200

cell/mm3
( CD4
)

12.

(TB screening rate)

13.

11.4

1. (DOT Card)

DOT
DOT 1 1 DOT


2. (TB 01)

118

.. 2556


(.) .


DOT
(TB 09)

3. (TB 03)


(DTC: District TB coordinator )
TB Clinic
DTC 3 4
( TB 07)
( TB 07/1) ( TB 08)
( TB-HIV01)

1. DTC



2. 1



TB clinic

3. -

( )

3.1. ()

2

3.2. 6

3.3.

3.4. 5



3.5.

3.6.

3.7. HIV CD4

3.8.
.. 2556

119


4. (TB 04)

././.
TB clinic

5. (TB 05)

1: 2 (3) 5


6 (PTB-)


2

2: 3 (4) 5


8

6. 3

4
( TB 07)
( TB 07/1) ( TB 08)
3-6 (TB-HIV01)

( TB 07) DTC

(3 )





(

7 )

(

) (

)

( TB 07/1)

DTC

(, ,

)



(3 ) 6-9

()

120

.. 2556


( TB08) DTC





() TB/HIV+

TB/HIV- unknown (3 )

12-15

4-8 (TB-HIV01)

3-6



2

/

4
4 3 1 4 (quarterly
report)

1 : 1 - 31

2 : 1 - 31

3 : 1 - 30

4 : 1 - 31
5

3
5
8 5
1/2554
2/2554
3/2554
4/2554
1/2555
1 .. - 31 .. 1 .. - 31 .. 1 . - 30 .. 1 .. - 30 .. 1 .. - 31 ..
54
55
55
55
55

1-7 .. 56

1 (TB 07)
4 (TB/HIV 01)
2 (TB 07/1)
3 (TB 08)

.. 2556

121


1. 3 0-3 (case

finding on new and previously treated of tuberculosis patients)

3 :




()

3



2. 3

6-9 (sputum conversion rate)

3



()

3. 3 12-15

(treatment outcome)

3

: ,

: ,



()

4. 3

3-6 (TB-HIV 01)

3 /

5.

M/XDR TB
(TB 03)
TB 03

M/XDR TB
/ (M/XDR TB register PMDT 03)
M/XDR-TB 1 . . .
.

122

.. 2556

. DST
.
. M/XDR-TB
3

1. M/XDR TB PMDT 07 3

(detection) (enrollment) M/XDR TB

1 12-15

2. (interim results) PMDT 07/1

6 6 M/XDR TB

1

18-24

3. (final outcomes) PMDT 08 12

M/XDR TB

1 36-48

(A guide on recording
and reporting forms and registers of Programmatic Management of Drug-resistant TB:
PMDT)

1.

2.


3.


4.

, .. 2551,
: .
,

.
2553, : .
. (A guide on recording and
reporting forms and registers of Programmatic Management of Drug-resistant TB: PMDT).
(2556).
Management of tubercolosis training for district TB coordinators monitor and evaluate
TB control WHO 2005 (WHO/HTM/TB/2005.347g).

.. 2556

123

(DOT Card)

DOT Card

124

.. 2556

.. 2556

125

 3-6

126

.. 2556

TB 01

.. 2556

127

TB 01

128

.. 2556

TB 03

.. 2556

129

TB 03

130

.. 2556

TB 05

.. 2556

131

TB 07

132

.. 2556

TB 07/1

.. 2556

133

TB 08

134

.. 2556

TB-HIV 01

.. 2556

135

PMDT 03 1

136

.. 2556

PMDT 03 2

.. 2556

137

PMDT 07

138

.. 2556

PMDT 07/1

.. 2556

139

PMDT 08

140

.. 2556

 2
/

(Culture)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

(NTRL)
()

.
1

.. 2556

141

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51

142

8
9

.. 2556

52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74

10

11

12 ( 12 )

IOM

: .. 2556 (.. 2013)

.. 2556

143

/

1 (FLDST)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

144

(NTRL)
()

.

1

2
3

.. 2556

21
22
23
24
25
26
27
28
29
30
31
32
33

7
8
9
10

11
12 ( 12 )
(AFRIMS)

: .. 2556 (.. 2013)

.. 2556

145

/

2 (SLDST)

1
2
3
4

(NTRL)

: .. 2556 (.. 2013)

146

.. 2556

(International
Standards for Tuberculosis care:
ISTC)
1.
1


2


3


4
5












6

2 - 3

2 3 1




2 ( 1 )

(: Fluoroquinolone

)




( )
( Gastric washing
Induced sputum)

(
Interferon- gamma release assay)

.. 2556

147

2.
7






8










9












10






11












12








13

148

( )
Bioavailability
Isoniazid, Rifampicin, Pyrazinamide
Ethambutol Isoniazid Rifampicin

( )
(Directly Observed Treatment:
DOT)

(2 )
2
3

3
Isoniazid
Rifampicin

( MDR-TB/XDR)

4
18 - 24

.. 2556

3.
(HIV&CO-Morbid condition
14




15




16


17

Co-trimoxazole

Isoniazid 6-9

4.
18




















19


20


21

1.
2.
3.
4.


5

(Multi Drug Resistance/Extensively Drug Resistance Tuberculosis:
M/XDR-TB

5
(Isoniazid)

.. 2556

149

 .. 2556

150

.. 2556

.

















.

12

.. 2556

.. 2556

151

152

.. 2556