结核病的有效诊断治疗和控制英文

EffectiveDiagnosis Treatment andControlofTuberculosis WorldHealthOrganizationRegionalOfficeforSouth EastAsiaNewDelhi 2 South EastAsiaaccountsfornearly40 ofalltuberculosiscases 3 TBistheleadingsingleinfectiouscauseofdeathinSouth EastAsia Numberofdeaths 1000s DeathsfrominfectiousagentsinSouth EastAsia 4 TBisaLeadingKillerofWomen Deathsamongwomen 5 TuberculosisAGlobalEmergency TBkills5 000peopleaday 2 3millioneachyearOnethirdoftheworld spopulationisinfectedwithTBTBkillsmoreyoungwomenthananyotherdiseaseMorethan100 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 WorldHealthOrganization1996 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 AmJRespirCritCareMed1996 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 JAMA1998 279 943 8 TreatmentSuccess DOT NoDOT 40 DirectlyObservedTreatmentistheStandardofCare DOThasemergedasthestandardofcare Bayer Lancet 1995 EverypatientwithTBinthiscountryshouldreceiveDOT Iseman NEJM 1993 DOTseemsimperative wherethediseasehasbecomeepidemic Chaulk JAMA 1996 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 Lancet1996 347 358 62 Curerate Curerate 50 Treatmentoutcomes DOTSareas SouthEastAsia NewSmear Patients1997 25 8713087 70819 492949 0142 3033 5061 873 51 DOTStriplestreatmentsuc