结核病的有效诊断,治疗和控制.ppt

1,EffectiveDiagnosis,Treatment,andControlofTuberculosis,WorldHealthOrganizationRegionalOfficeforSouth-EastAsiaNewDelhi,2,South-EastAsiaaccountsfornearly40%ofalltuberculosiscases,3,TBistheleadingsingleinfectiouscauseofdeathinSouth-EastAsia,Numberofdeaths(1000s),DeathsfrominfectiousagentsinSouth-EastAsia,4,TBisaLeadingKillerofWomen,Deathsamongwomen,5,TuberculosisAGlobalEmergency,TBkills5,000peopleaday2-3millioneachyearOnethirdoftheworldspopulationisinfectedwithTBTBkillsmoreyoungwomenthananyotherdiseaseMorethan100,000childrenwilldieneedlesslyfromTBthisyearHundredsofthousandsofchildrenwillbecomeTBorphansthisyear,6,TBandAIDS,LifetimeRiskofTB,7,TBControl:The5componentsofDOTS,Politicalcommitment,Diagnosisbymicroscopy,AdequatesupplyofSCCdrugs,Directlyobservedtreatment,Accountability,8,Diagnosisofpulmonarytuberculosis,PatientswithTBfeelillandseekcarepromptlyActivecasefindingisunnecessaryandunproductiveMicroscopyisappropriatetechnology,indicatinginfectiousness,riskofdeath,andpriorityfortreatmentX-rayisnon-specificforTBdiagnosisSerologicalandamplificationtechnologies(PCR,etc.)currentlyofnoprovenvalueinTBcontrol,9,DiagnosisofPulmonaryTuberculosis,ThreespecimensoptimalSpotspecimenonfirstvisit;sputumcontainergiventopatientEarlymorningcollectionbypatientonnextdaySpotspecimenduringsecondvisit,10,Threesputumsmearsareoptimal,11,ReportingonAFBMicroscopy,12,DiagnosisofPulmonaryTB,13,MicroscopyismoreobjectiveandreliablethanX-ray,Inter-observeragreement,14,MicroscopyisamorespecifictestthanX-rayforTBdiagnosis,Specificity,15,X-ray-basedevaluationcausesover-diagnosisofTB,NTI,IndJTuberc,1974,Over-diagnosis,16,RoleofChestX-ray,NochestX-raypatternisabsolutelytypicalofTB10-15%ofculture-positiveTBpatientsnotdiagnosedbyX-ray40%ofpatientsdiagnosedashavingTBonthebasisofx-rayalonedonothaveactiveTB,TomanK.Tuberculosiscasefindingandchemotherapy.WHO,1979,X-rayisunreliablefordiagnosingandmonitoringtreatmentoftuberculosis,17,ProportionofpatientswithpulmonaryTBwhohavepositiveAFBsmears,AFBpositivityinTBpatients,18,X-rayfindingsinTBpatientswithHIVinfection,EarlyHIV,LateHIV(severeimmuno-compromise),19,DOTSmorethandoublesaccuracyofdiagnosisofTBinSEAR,Expectedrange,20,Prompttreatmentofinfectiouscasesreducesspreadoftuberculosis,Smear-positivepatientsusuallyseekcareSmear-positivepatientsare4-20timesmoreinfectiousUntreated,asmear-positivepatientmayinfect10-15persons/yearSmear-positivepatientsaremuchmorelikelytodieifuntreated,RouillonA.Tubercle1976;57:275-99,21,TreatmentCategories,22,Severeandlesssevereformsofextra-pulmonaryTB,TB/HIV,AClinicalManual,WorldHealthOrganization2019,23,Recommendedtreatmentregimens,Directobservationisrecommendedforallpatientsandisparticularlyessentialwhenintermittentregimensareused,24,Dosesoffirst-lineanti-TBdrugs,Alltheseanti-TBdrugsshouldbegivenasasingledailydose.Directobservationisrecommendedforallpatientsandisparticularlyessentialwhenintermittentregimensareused.ThiacetazoneisnoteffectivewhengivenintermittentlyandisnotrecommendedforuseinhighHIVprevalenceareas.,25,RoleofIsoniazid,Mainstayofanti-TBtreatmentLifesavinginTBmeningitisBactericidalforrapidlydividingorganismsPreventsemergenceofresistancetootherdrugsIntermittenttreatmentmoreeffectivethandailytreatmentinanimalmodelandequallyeffectiveinclinicaltrialsSafeandeffectiveforpreventivetreatment,26,RoleofRifampicin,Necessaryforshort-coursetreatmentEssentialforatleastfirst2monthsofregimensof6-9monthdurationBactericidalforrapidlydividingandslow-growingorganismsPreventsemergenceofresistancetootherdrugsIntermittenttreatmentmoreeffectivethandailytreatmentinanimalmodelandequallyeffectiveinclinicaltrials,27,RoleofPyrazinamide,Essentialfor6-and8-monthregimensNobenefitifgivenformorethan2monthsRelativelyineffectiveatpreventingemergenceofresistancetootherdrugs,28,Pyrazinamideisessentialforthefirsttwomonthsof6/8-monthtreatment,AmRevRespirDis1987;136:1339-42,Relapses,29,Pyrazinamidedoesnotgiveanyadditionalbenefitifgivenbeyondtwomonthsinshort-coursetreatment,AmRevRespirDis1991;143:700-6,CureRate(%),30,RoleofEthambutol/Streptomycin,PreventemergenceofresistancetootherdrugsgivenHastensputumconversionBacteriostaticorweaklybactericidalagainstrapidlydividingorganisms,31,RoleofThiacetazone,PreventemergenceofresistancetootherdrugsgivenBacteriostaticShouldnotbegiventoHIV+patientsbecauseofriskoffatalskinreactions,32,RelapseratesarelowwithdirectlyobservedintermittenttreatmentinbothHIV-positiveandHIV-negativepatients,AmJRespirCritCareMed2019:154:1034-38,Relapserates,Relapse(%),33,Adversereactionstoanti-TBdrugs,34,ManagementofLogistics,Adequatebufferstocksmustbemaintainedatnational,state/regional,andlocallevels,35,Drugrequirementsaredeterminedbasedon:,NumberofcasesindifferenttreatmentcategoriestreatedinpreviousyearStandardizedregimensusedExistingstocksEnsuringreserve(buffer)stocksateachlevel,36,Keysforeffectivedistributionandstorageofanti-TBdrugs,Storageconditions(temperatureandhumidity)Managementinsidethestores:appropriatespaceimplementationofFEFOprinciple(First-Expired,First-Out)reservestocksConditionsofhandlingandtransportationtotheperipherallevelImplementationofdrugaccountingsystematalllevelswheredrugsarestoredoradministered,37,DirectlyObservedTreatment,TreatmentobservermustbeaccessibleandacceptabletothepatientandaccountabletothehealthsystemObservationisaservicetopatientsandprovidersManypatientsdonottakemedicinesregularly,evenifexcellenthealtheducationisprovidedImpossibletopredictwhichpatientwilltakemedicine,38,DirectlyObservedTreatment(DOT)vsDOTS,Directlyobservedtreatment(DOT)isoneelementoftheDOTSstrategyAnobserverwatchesandhelpsthepatientswallowthetabletsDirectobservationensurestreatmentfortheentirecoursewiththerightdrugsintherightdosesattherightintervals,39,DOTisnecessaryevenwhendrugsupplyensured,ChaulkCP.JAMA2019;279:943-8,TreatmentSuccess,DOT,NoDOT,40,DirectlyObservedTreatmentistheStandardofCare,“DOThasemergedasthestandardofcare”(Bayer,Lancet,2019)“EverypatientwithTBinthiscountryshouldreceiveDOT”(Iseman,NEJM,1993)“DOTseemsimperativewherethediseasehasbecomeepidemic”(Chaulk,JAMA,2019),41,Whyisitnecessarytodirectlyobservetreatment?,Atleastonethirdofpatientsreceivingself-administeredtreatmentdonotadheretotreatmentImpossibletopredictwhichpatientswilltakemedicinesDOTnecessaryatleastintheinitialphaseoftreatmenttoensureadherenceandachievesputumsmearconversionATBpatientmissingoneattendancecanbetracedimmediatelyandcounseled,42,ModesofObservation,HealthcareworkersNon-governmentalorganizationsCommunityvolunteersReligiousleadersChildsurvivalworkers,laymidwives,etc.,DOTisfeasibleineachcommunitybyidentifyingandinvolvingthestrengthsofthecommunity.,43,DOTprolongssurvivalofHIV-infectedTBpatients,SCCwithDOT,SCCwithoutDOT,44,SystematicMonitoringandAccountability,Goodrecord-keepingisthecornerstoneofsuccessTheDOTSrecordingsystemenablesMonitoringofpatientoutcomesEvaluationofprogrammeperformanceAnalysisofepidemiologicdataOperationalresearchEverylevelofhealthsystemaccountableforpatientdiagnosisandcure,45,Treatmentoutcomesinsputumsmear-positivepatients,46,Supervision,EffectivesupervisionatalllevelsiskeytosuccessSupervisionistheprocessofhelpingstaffimprovetheirperformanceKeyareas:laboratoryworkpatientcategorizationdirectobservationdrugstorageandstockrecordkeepingreporting,47,DOTScanreducetheburdenofTB,Annualpercentagedeclineinincidence/prevalence,48,DOTScanreducedrugresistance,Decline(percent),49,ResultsofDOTSin112,842patientswithsmear-positivepulmonaryTBinChina,Lancet2019;347:358-62,Curerate,Curerate(%),50,Treatmentoutcomes,DOTSareas,SouthEastAsia,NewSmear+Patients2019,25,8713087,70819,492949,0142,3033,5061,873,51,DOTStriplestreatmentsu