TB and DOTS肺结核与点ppt课件

1、TB: A Global Emergency 1/3 of the world (2 billion people) infected 1 person infected/second resulting in 30 million new infections, 8 million new cases Left untreated 1/3 die, 1/3 self-cure, 1/3 remain infectious TB kills 1 person every 10 seconds = 5000/day = 2-3 million each year 22 High Burden C

2、ountries India China Indonesia Bangladesh Pakistan Nigeria Philippines South Africa Ethiopia Vietnam Russian Federation Congo Brazil Tanzania Kenya Thailand Myanmar Afghanistan Uganda Peru Zimbabwe CambodiaTB: Clinical Features TB is caused by Mycobacterium tuberculosis TB can affect any organ syste

3、m: bone, kidney, CNS; 80% are pulmonary Classic pulmonary systems of active disease: cough 3 weeks duration, chest pain, bloody sputum Classic systemic symptoms: fever, night sweats, weight loss, malaise Treated for many years with long hospitalization, surgery, myriad of drugs leading to belief tha

4、t TB is not treatable or treatment worse than disease.TB Infection vs TB Disease TB infection organism is present, but dormant, cannot infect others TB disease person is sick and can transmit disease to others if in lungs 10% of individuals with TB infection will develop TB disease Each individual w

5、ith active TB can infect 10-15 people/yearWhen does TB infectionbecome disease? Most likely to occur in first two years after infection If person becomes immunocompromised HIV Cancer Chemotherapy Poorly controlled diabetes malnutritionThe 5 Essential Components of the DOTS Strategy Government commit

6、ment to a National TB Program Priority to detect infectious cases by sputum smear microscopy Standardized regimens of short-course chemotherapy, given under direct observation for , at least, the intensive phase Regular, uninterrupted supply of anti-TB meds Monitoring system for program supervision

7、and evaluation1. Political/Administrative Commitment Perception of TB as a priority problem with real solution Government acknowledges importance of disease Public commitment to National TB Program (NTP) Support for personnel, training, transportation, drugs2. Accurate Diagnosis=Sputum Microscopy Id

8、entification/cure of infectious cases (smear+) is highest priority of TB control Smear+s 4-20 times more infectious; may infect 10-15/year; more likely to die if untreated Timely results to reduce potential for transmission Quality assurance/training-national reference lab is keyDiagnosis of pulmona

9、ry TBCough 3 weeksAFB X 3Broad-spectrum antibiotic 10-14 daysIf symptoms persist, repeat AFB smears, X-rayIf consistent with TBAnti-TB TreatmentIf 1 positive, X-ray and evaluation If 2/3 positive: Anti-TB RxIf negative:Chest X-ray (CXR) as Diagnostic Tool No CXR pattern is typical Many TB cases are

10、missed (10-15% culture+s) Many non-TB cases misdiagnosed (40% diagnosed by CXR alone do not have active TB Previous MD training emphasized CXR as best diagnostic tool Often reaction to poor, inaccurate, or unavailable lab services020406080100Diagnosed by X-ray aloneActual casesX-ray-based evaluation

11、 causes over-diagnosis of TBNTI, Ind J Tuberc, 1974Over-diagnosis50%98%020406080100AFB MicroscopyX-rayMicroscopy is a more specific test than X-ray for TB diagnosisSpecificity3. Adequate Supply of Drugs Treatment requires regular doses of combination regimens for 6 months Identification of an adequa

12、te supply of appropriate drugs for patients prior to initiation of treatment essential If regimens incomplete, real chance of development of drug-resistant strains which are hard or impossible to cure Requires continuum of drug management services: selection, procurement, distribution, use.4. Direct

13、ly Observed TreatmentWhy? Many patients dont take medicines regularly, even if excellent health education provided Who? All patients. impossible to predict which patient will take medicine (1/3 not adherent) What? Observer watches and helps patient swallow tablets Where? Anywhere! (home, clinic, wor

14、k, school, etc) Who does it? HCW, community liaisons, teachers, Direct observation ensures treatment for entire course with the right drugs, in the right doses, at the right intervalsDOT is necessary even whendrug supply ensured 88%61%0%20%40%60%80%100%Chaulk CP. JAMA 2019;279:943-8Treatment Success

15、DOTNo DOTDOT prolongs survival ofHIV-infected TB patients Survived 56.7%Died43.3%SCC with DOTSCC without DOTSurvived85.4%Died14.6%5. Systematic Monitoring/AccountabilityRecording system is simple to use, essential, integrated component of DOTS enablingMonitoring of patient outcomesEvaluation of prog

16、ram performanceAnalysis of epidemiologic dataIdentification of areas for OREvery level of health system accountable for patient diagnosis and cure; “report card”TB RegisterTB and HIV/AIDSHIV negatively impacts TB and TB negatively impacts HIVHIV+ individuals infected with TB are 30 x more likely to

17、develop TB diseaseTB is leading cause of death among HIV+, accounting for 40% of AIDS deaths HIV increases the prevalence of active TB in HIV- and HIV+ populationsMultidrug-Resistant TB (MDRTB)Defined as resistance to INH and RIFCaused by inconsistent or partial treatment of susceptible TB (primary)

18、Cure rates 2 months Relatively ineffective at preventing emergence of resistance to other drugs3.4%10.3%020406080100PyrazinamideNo PyrazinamideRelapses (%)Pyrazinamide essential for first two months of 6/8-month treatmentAm Rev Respir Dis 1987;:1339-42RelapsesRole of Ethambutol/ Streptomycin Prevent

19、 emergence of resistance to other drugs given Hasten sputum conversion Bacteriostatic or weakly bactericidal against rapidly dividing organisms3%5%020406080100HIV-uninfectedHIV-infectedRelapse rates low with directly observed treatment in both HIV(+) and HIV(-) patientsAm J Respir Crit Care Med 2019:154:1034-38Relapse ratesRelapse (%)Adverse reactions to ant