A Family Approach to the Treatment of Tuberculosis _____________________________________________ PHILIPPINE DATA ON TUBERCULOSIS • Approximately 15M Filipinos are infected with

TB • 75 Filipinos die of TB each day • About 200,000 to 600,000 are spreading the disease annually • The state of the TB problem has not changed significantly the past 14 years Inadequate case finding Poor case holding » Non adherence of patients » Non adherence of doctors and health providers Inadequate prevention programs Poor physician adherence » 70% of doctors initially follow but divert treatment resulting in more than 100 variations » Do doctors know what the NTP and DOTS is? _____________________________________________ Just a little review… BASIC FACTS ABOUT TUBERCULOSIS Caused by Mycobacterium tuberculosis • Transmitted via the airborne route mostly from infected persons when coughing The primary lesion in the lung & lymph nodes often heal spontaneously leaving a focus of dormant bacilli that can be reactivated at any moment in an individual’s lifetime • An infected person has a 5 - 10 % chance of developing full blown TB in his/her lifetime • A sputum (+) person infects 10-15 other persons annually • A 50 % chance of becoming infected from TB patient if time spent around him/her amounts to at least 8 hours a day for 6 months NATURAL COURSE OF TUBERCULOSIS All starts with exposure Infected droplet ALVEOLAR INOCULATION Multiplication of bacilli Cellular and humoral immune response Primary Infection Primary Infection • Subclinical usually with non specific symptoms • Subside in 2 – 3 weeks • Transient mycobacteremia seeding distant sites like the pulmonary apex, renal cortex, epiphyses of long bones or meninges Common Sites of Extra-Pulmonary Tuberculosis • Pleura • Central nervous system • Lymphatic system • Gastrointestinal system • Genitourinary systems • Bones and joints • Disseminated (miliary TB) Terminally:

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• • •

Wasting (consumption) Hemorrhage Respiratory failure

What is the probability that exposure leads to infection and disease? • Concentration of droplet nuclei in the environment • Duration of exposure Number of bacilli generated by the TB patient is influenced by: • Disease in the lungs, airways, larynx • Presence of cough or other forceful expiratory measures • Presence of the bacilli in the sputum • Extent of cavitation on chest radiograph • Patient who does not cover mouth/ nose when sneezing or coughing A person who is infected with PTB coughs or sneezes, releasing tiny particles of BACILLI . (This person may not even feel sick at the time.)  COUGHING  TALKING  SNEEZING

Test Sputum AFB smear Sputum M. TB Culture Chest xray Serologic Tests PPD test Sensitivity 50-60% 60 -90% 80% High* High* Specificity >95% > 99% 70% Mod* Mod to High* Field Use High Low Low to mod Low Low Cost Free to low High Low to mod. Mod. to high Low to mod Comments For diagnosis & easier response evaluation Takes weeks; needed for sensitivity test For screening only; needs to be confirmed Not well standardized; only as an adjunct Does not necessarily indicate active TB

PPD Testing 5 mm = recent close contact; patients with fibrotic or healed lesions on radiograph; HIV infected persons 10mm = patients with special medical conditions (8 mm) like DM, hodgkin’s disease  steroid use  high prevalence region or  travel to there residents of congested homes/living conditions 15mm = all others [classmates di ko alam bakit may 8mm jan. magulo din ppt ni dra.]

ATS and CDC TB in Children Gold Standard of Diagnosis  Triad:

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1. Exposure to an infectious case 2. (+) Tuberculin Test 3. Abnormal radiograph or PE (STARKE, PIDJ, Nov 2000) Adult versus Childhood TB Cinical Features TB Pathogenetic stage Pediatric TB Primary tuberculosis Adult TB Post-primary or Secondary or reactivation TB

Main diagnostic confirmation

Clinical features + history of Bacteriology (AFB smear exposure to a smear (+) and, if warranted, culture) case Serial chest x-ray Low, hence, low infectiousness 2-3 drugs Yes – by parent High load (esp. cavitary), highly infectiousness 4-5 drugs Yes – by health worker

Bacillary load Treatment DOT Mandatory

BASIC PRINCIPLES OF TREATMENT OF TB • Give the safest, most effective therapy in prescribed duration • Choose multiple drugs to which the organisms are (likely) susceptible • Never add single drug to failing regimen • Ensure complete adherence to therapy – DOTS for all! • with proper treatment 95% will be cured • after 2-3 weeks of correct treatment, patient no longer highly contagious

TB TREATMENT: WHY MULTIPLE DRUGS? Characteristics Site in the Lungs TB Subpopulations & Drug Activity Inside cavities Inside closed lesions Intracellular Macrophage Acidic pH; phagosomes

Type of Milieu

Aerated, high Low PO2; PO2 acidic- pH 6.5 Rapid 10

Growth rate Size of pop. Drugs active

slow 10

slow 104-6 HRZE



 •
• • •

Natural Resistance: A predictable random mutation in untreated M. TB Isoniazid: Rifampicin: Strep SO4: Pyrazinamide 1 in 104 1 in 107 1 in 104 1 in 103

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1 in 105

Likelihood of a bacillus spontaneously developing resistance to 2 unrelated agents is the product of individual drug resistance probabilities

 Acquired Resistance: A predictable forced mutation in patients on anti-TB drugs Monotherapy - leads to resistance to the drug • Amplifier effect in MDR-TB - resistance to some drugs in the combination regimen leads to the development of resistance to the remaining drugs.
 May individualize according to: • bacterial burden local resistance rates • drug availability • affordability NTP: DRUG DOSAGE ADJUSTMENT Drug Isoniazid Rifampicin Dose per kg body weight and maximum dose 5 (4-6) mg/kg, and not exceed 400mg daily 10 (8-12) mg/kg, and not to exceed 600mg daily

Pyrazinamide 25 (20-30) mg/kg, and not to exceed 2g daily


15 (15-20) mg/kg, and not to exceed 1.2g daily

Streptomycin 15 (12-18) mg/kg, and not to exceed 1g daily

TB Treatment in Children and Infants Children: In most cases, treat with same regimens used for adults Infants: Treat as soon as diagnosis suspected Pregnancy, Lactation and TB Treatment  During Pregnancy - HRE x 9 mos. (12 months if cavitary)  Past acute hepatitis - HRE up to 6 mos. after sputum Hepatitis Virus (+) usual short course  Chemotherapy  Alcoholism

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 Chronic liver disease - RIF + INH + 1 or 2 non hepatotoxic drugs Strep or EMB  Hepatic Failure - Strep + EMB + if necessary, lower doses of INH or RIF  Acute Hepatitis - Defer treatment until hepatitis resolves; if not possible give 3SE / 6H conversion PZA and SM are contraindicated  During Lactation No anti-TB drug contraindicated Caution if both mother and baby are using INH * add Vit B6 at 25 mg/kg/day if INH is used  Liver Disease and TB treatment  Extra pulmonary TB Treatment Recommendation: 2HRZE / 4-7HR * For TB Meningitis, Miliary TB and bone/joint TB: 2HRZE / 10 HR  Renal Failure and TB treatment Safest regimen: 2HRZ/4HR If needed, the following may be used or added in Normal doses but less frequent intervals: Strep, EMB, Kanamycin, Capreomycin, Cycloserine,Thioacetazone Give Vit. B6 with the INH Grade C recommendation  HIV (+) Patient and TB treatment Susceptibiltiy test available: 2HRZE / 4-7HR (or up to 6 mos. after sputum conversion) Susceptibiltiy test NOT available: 9HRZE ( 12 mos. if cavitary) * Strict DOT for all cases Chemoprophylaxis in Tuberculosis Regimens: INH alone - 6 - 9 month INH + EMB - When primary drug resistance to INH is high Grade A recommendation Surgery for Extrapulmonary TB 1. Ventricular decompression for hydrocephalus 2. Drainage of TB adenitis 3. Renal TB drainage 4. Pelvic TB clean-up surgery 5. TB epididymitis and orchitis 6. TB pericarditis 7. Osteoarticular TB 8. Pott’s disease All Level 4 Evidence Indications for Resectional Surgery in Tuberculosis Group A B Indication Failure to convert Previous Criteria Despite 4-6 mos. good regimen or more after a standard Tx or 1 or

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relapse Multi-Drug Resist High risk for relapse

more during MDR treatment 2 Resistance to 4 or more drugs Destroyed lung or lobe

Corticosteroids in TB treatment Indications:  Miliary TB with ARDS and DIC  TB meningitis when complicated  TB pericarditis All Level 4 evidence DELAY IN CONSULTATION • Misinterpretation of symptoms • Protean manifestations of TB • Health care delivery system weaknesses the control of tuberculosis lies in adequate case holding STIGMA “pandidirihian ako” “hindi na ako puede magtrabaho” “wala sa lahi namin yan!” OTHERS Historical : “consumption” Body image: The emaciated hungry look ADHERENCE IS THE KEY TO CONTROL OF TUBERCULOSIS DOTS Improved Adherence Revised National TB Control Program Components of DOTS 1. Political will and support 2. Microscopy center 3. Sufficient medicines 4. Accurate and complete documentation 5. DOTs partner Direct Observation of Treatment (DOT) Who can be the treatment partner ??? • Staff of the health center such as midwife or nurse • Member of the community such as BHW or local government official or former TB patient • Member of the patient’s family Background Information: Philippines • 84 million population (2004) • Department of Health sets policies, standards, guidelines - TB Unit - Centers for Health Development • Health program implementation is the mandate of LGUs( Devolution ) - Rural Health Units (RHUs); Health Centers - Barangay Health Stations (BHSs) TB Situation  One of the 22 high-burdened countries

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   

(WHO TB Watchlist) 3rd (151/100,000) in the Western Pacific - Case Notification of all cases 6th leading cause of deaths (1998) 6th leading cause of morbidity Prevalence of Smear (+) cases – 3.1 /1,000 (240,000 cases)

What had been done? 1910 - PTS organized 1930 - TB Commission established 1954 - TB Law passed 1978 - Nationwide implementation of NTP 1987 - SCC in Blister-packs introduced 1992 - Local Government Code implemented 1994 - PhilCAT organized 1996 - D.O.T.S. strategy pilot-tested 2002 - D.O.T.S. nationwide (98% coverage) 2003 - GDF & GFATM grant approvals - PPM NTP Objectives

 

Increase Case Detection Rate from 61% (2003) to 70% Increase Cure Rate from 77% (2002) to 85%

Directly Observed Treatment Short-course (D.O.T.S.)  Political commitment  Quality microscopy service  Regular availability of drugs  Standardized records & reports  Supervised treatment Program Components  CASE FINDING Objectives: To identify TB symptomatics To identify & diagnose TB cases early Passive Casefinding – TB symptomatics present themselves at the health facility. Active Casefinding - purposive effort to find TB cases among the symptomatics who don’t seek consultation. Major Policies on Case finding: • Direct sputum smear microscopy shall be the primary NTP diagnostic tool. • All TB symptomatics must undergo sputum examination, with or without X-ray results. Only contraindication is massive hemoptysis. • Three sputum specimens must be submitted 1st spot, early morning, 2nd spot • Passive case finding shall be implemented in all health centers, health stations. • Sputum microscopy work shall be performed only by adequately trained health personnel. • Quality control of smear examination must be observed. Validation system must be established.

Caseholding Objectives:  To render as many Smear (+) cases as noninfectious & cured as early as possible.

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To treat seriously-ill Smear (-) cases & other potentially infectious cases.

Classification of TB Cases based on location of lesions:  Pulmonary Smear (+)  Smear (-)  Extra-pulmonary TB cases:  Based on history of anti-TB treatment  Important in determining tx regimen TYPES OF TB CASES:  New - no tx or <1m tx  Relapse – previous TB treatment & Sm(+) again  Transfer - in - change tx facility  Return After Default - interrupted tx / Sm (+)  Treatment Failure - still (+) on 5th month  Others - became (+) on 2nd m; - interrupted tx / Sm(-) Treatment Regimens
TB Treatment TB Patients To Be Regimen Given Treatment I DRUGS AND DURATION Initial Phase Continuation Phase 4 HR/

New smear-positive PTB; new smear- 2 HRZE/ negative PTB with extensive parenchymal involvement; extrapulmonary TB Previously treated smear-positive PTB; relapse; treatment failure; treatment after interruption New smear-negative PTB (other than in Category I 2 HRZES/ 1 HRZE





4 HR/

Schedule of Sputum Follow-up Examinations CAT I : 2nd, (3rd), 4th, 6th CAT II : 3rd, (4th), 5th, 8th CAT III : 2nd Major Policies on Case Holding • No patient shall be initiated into treatment unless a case holding mechanism for the treatment compliance has been agreed upon by the patient & health workers. • The national &/or local governments shall ensure the provision of drugs to all sputum (+) TB cases. • No patient shall be initiated into treatment unless a case holding mechanism for the treatment compliance has been agreed upon by the patient & health workers. • The national &/or local governments shall ensure the provision of drugs to all sputum (+) TB cases. Supervised Treatment • A mechanism of ensuring treatment compliance • TB patient is motivated to take his drugs • Cured

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Treatment Partner: Watches the patient take his drugs daily Reports & traces the patient if he defaults Provides health education regularly Motivates the patient on sputum ff-ups Who will undergo supervised treatment ?  Priority are the Smear (+) TB cases Who could serve as Treatment Partner ?  Health Staff, Barangay Health Worker, Community Volunteer, Family Member Where will D.O.T. take place ?  Health facility  Treatment Partner’s House  Patient’s House How long is treatment supervised ?  Daily drug intake is supervised during the entire course of treatment. RECORDS and REPORTS  NTP Laboratory Request Form  Laboratory Register  NTP Treatment Card  NTP Identification Card  TB Case Register  NTP Referral Form Reports  Quarterly Report on Laboratory  Quarterly Report on Casefinding  Quarterly Report on Treatment Outcomes Major Policies on Recording / Reporting  Shall rely on all government health facilities, including government hospitals.  Shall include all cases of TB, classified according to internationally accepted case definitions.  Shall include private physicians & private clinics, after agreement with parties concerned has been made.

Shall allow the calculation of the main indicators for evaluation. (Cure Rate, Case Detection Rate)

Program Indicators CASEFINDING Proportion of Sputum (+) (60%) = Total No. Sputum (+) cases discovered Total No. of Pulmonary TB cases Proportion of 3 sputum examination (90%) = No. TB symptomatics with 3 specimens Total no. TB symptomatics examined Positivity (15-20%) = No. Sputum (+)s discovered_______ Total no. TB Symptomatics examined Case Detection Rate (CDR=70%) = No. of New Sputum (+) cases discovered

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TP x 145/100,000 (Incidence) COHORT ANALYSIS • A group of patients having the same attributes at a certain period of time to determine treatment outcome. • Treatment Outcomes: Cure Rate = 85 % Completion Rate • Tx Failure Rate • Death Rate • Trans-Out Rate Defaulter Rate

Cure Rate = Total no. New Sputum (+)cases who got CURED Total no. New Sputum (+) cases evaluated General Attributes: New, Pulmonary Sputum (+) case Differentiating Attribute - CURED (Tx Outcome) Cure - New Sputum (+) case, completed tx, Sputum (-) at the end of treatment TREATMENT OUTCOMES Cured Completed  Completed tx BUT no sputum ff-up result at end of treatment Treatment Failure  Smear (+) at 5 mos. of tx Defaulter  Interrupted tx for 2 months or Transfer Out  Change in tx facility Died  Transpires during course of tx. more and not retrieved back

SUMMARY 1. Described the TB health situation the Philippines. 2. Described the various forms of TB , it’s diagnosis & management. 3. Described the National TB Control Program of DOH. Student Activity: Group 1 – Role play – Disclosure to a patient that he/ she has TB Group 2- Role play – Convincing the patient to undergo 6 months TB treatment Group 3- Role play – Health education to group of mothers on how to prevent TB in the home

Page 11 of 7 End of Tran Ei classmates snsya na, hndi yung mismong powerpoint yung pnagkopyahan namin nito. Pnahiram lang kami ng sec A. Inayos na lang namin sa abot ng aming makakaya para mas maintindihan. Salamat! =)


(Hehe toxic pa din ang filler! Haha. Hi na lang sa inyong lahat!)

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