《结核病的有效诊断，治疗和控制-英文.ppt》由会员分享，可在线阅读，更多相关《结核病的有效诊断，治疗和控制-英文.ppt（58页珍藏版）》请在三一文库上搜索。
1、Effective Diagnosis, Treatment, and Control of Tuberculosis,World Health Organization Regional Office for South-East Asia New Delhi,2,South-East Asia accounts for nearly 40% of all tuberculosis cases,3,TB is the leading single infectious cause of death in South-East Asia,Number of deaths (1000s),Dea
2、ths from infectious agents in South-East Asia,4,TB is a Leading Killer of Women,Deaths among women,5,Tuberculosis A Global Emergency,TB kills 5,000 people a day 2-3 million each year One third of the worlds population is infected with TB TB kills more young women than any other disease More than 100
3、,000 children will die needlessly from TB this year Hundreds of thousands of children will become TB orphans this year,6,TB and AIDS,Lifetime Risk of TB,7,TB Control: The 5 components of DOTS,Political commitment,Diagnosis by microscopy,Adequate supply of SCC drugs,Directly observed treatment,Accoun
4、tability,8,Diagnosis of pulmonary tuberculosis,Patients with TB feel ill and seek care promptly Active case finding is unnecessary and unproductive Microscopy is appropriate technology, indicating infectiousness, risk of death, and priority for treatment X-ray is non-specific for TB diagnosis Serolo
5、gical and amplification technologies (PCR, etc.) currently of no proven value in TB control,9,Diagnosis of Pulmonary Tuberculosis,Three specimens optimal Spot specimen on first visit; sputum container given to patient Early morning collection by patient on next day Spot specimen during second visit,
6、10,Three sputum smears are optimal,11,Reporting on AFB Microscopy,12,Diagnosis of Pulmonary TB,13,Microscopy is more objective and reliable than X-ray,Inter-observer agreement,14,Microscopy is a more specific test than X-ray for TB diagnosis,Specificity,15,X-ray-based evaluation causes over-diagnosi
7、s of TB,NTI, Ind J Tuberc, 1974,Over- diagnosis,16,Role of Chest X-ray,No chest X-ray pattern is absolutely typical of TB 10-15% of culture-positive TB patients not diagnosed by X-ray 40% of patients diagnosed as having TB on the basis of x-ray alone do not have active TB,Toman K. Tuberculosis case
8、finding and chemotherapy. WHO, 1979,X-ray is unreliable for diagnosing and monitoring treatment of tuberculosis,17,Proportion of patients with pulmonary TB who have positive AFB smears,AFB positivity in TB patients,18,X-ray findings in TB patients with HIV infection,Early HIV,Late HIV (severe immuno
9、-compromise),19,DOTS more than doubles accuracy of diagnosis of TB in SEAR,Expected range,20,Prompt treatment of infectious cases reduces spread of tuberculosis,Smear-positive patients usually seek care Smear-positive patients are 4-20 times more infectious Untreated, a smear-positive patient may in
10、fect 10-15 persons/year Smear-positive patients are much more likely to die if untreated,Rouillon A. Tubercle 1976;57:275-99,21,Treatment Categories,22,Severe and less severe forms of extra-pulmonary TB,TB/HIV, A Clinical Manual, World Health Organization 1996,23,Recommended treatment regimens,Direc
11、t observation is recommended for all patients and is particularly essential when intermittent regimens are used,24,Doses of first-line anti-TB drugs,All these anti-TB drugs should be given as a single daily dose. Direct observation is recommended for all patients and is particularly essential when i
12、ntermittent regimens are used. Thiacetazone is not effective when given intermittently and is not recommended for use in high HIV prevalence areas.,25,Role of Isoniazid,Mainstay of anti-TB treatment Life saving in TB meningitis Bactericidal for rapidly dividing organisms Prevents emergence of resist
13、ance to other drugs Intermittent treatment more effective than daily treatment in animal model and equally effective in clinical trials Safe and effective for preventive treatment,26,Role of Rifampicin,Necessary for short-course treatment Essential for at least first 2 months of regimens of 6-9 mont
14、h duration Bactericidal for rapidly dividing and slow-growing organisms Prevents emergence of resistance to other drugs Intermittent treatment more effective than daily treatment in animal model and equally effective in clinical trials,27,Role of Pyrazinamide,Essential for 6- and 8-month regimens No
15、 benefit if given for more than 2 months Relatively ineffective at preventing emergence of resistance to other drugs,28,Pyrazinamide is essential for the first two months of 6/8-month treatment,Am Rev Respir Dis 1987;136:1339-42,Relapses,29,Pyrazinamide does not give any additional benefit if given
16、beyond two months in short-course treatment,Am Rev Respir Dis 1991;143:700-6,Cure Rate (%),30,Role of Ethambutol/ Streptomycin,Prevent emergence of resistance to other drugs given Hasten sputum conversion Bacteriostatic or weakly bactericidal against rapidly dividing organisms,31,Role of Thiacetazon
17、e,Prevent emergence of resistance to other drugs given Bacteriostatic Should not be given to HIV+ patients because of risk of fatal skin reactions,32,Relapse rates are low with directly observed intermittent treatment in both HIV-positive and HIV-negative patients,Am J Respir Crit Care Med 1996:154:
18、1034-38,Relapse rates,Relapse (%),33,Adverse reactions to anti-TB drugs,34,Management of Logistics,Adequate buffer stocks must be maintained at national, state/regional, and local levels,35,Drug requirements are determined based on:,Number of cases in different treatment categories treated in previo
19、us year Standardized regimens used Existing stocks Ensuring reserve (buffer) stocks at each level,36,Keys for effective distribution and storage of anti-TB drugs,Storage conditions (temperature and humidity) Management inside the stores: appropriate space implementation of FEFO principle (First-Expi
20、red, First-Out) reserve stocks Conditions of handling and transportation to the peripheral level Implementation of drug accounting system at all levels where drugs are stored or administered,37,Directly Observed Treatment,Treatment observer must be accessible and acceptable to the patient and accoun
21、table to the health system Observation is a service to patients and providers Many patients do not take medicines regularly, even if excellent health education is provided Impossible to predict which patient will take medicine,38,Directly Observed Treatment (DOT) vs DOTS,Directly observed treatment
22、(DOT) is one element of the DOTS strategy An observer watches and helps the patient swallow the tablets Direct observation ensures treatment for the entire course with the right drugs in the right doses at the right intervals,39,DOT is necessary even when drug supply ensured,Chaulk CP. JAMA 1998;279
23、:943-8,Treatment Success,DOT,No DOT,40,Directly Observed Treatment is the Standard of Care,“DOT has emerged as the standard of care” (Bayer, Lancet, 1995) “Every patient with TB in this country should receive DOT” (Iseman, NEJM, 1993) “DOT seems imperative where the disease has become epidemic” (Cha
24、ulk, JAMA, 1996),41,Why is it necessary to directly observe treatment?,At least one third of patients receiving self-administered treatment do not adhere to treatment Impossible to predict which patients will take medicines DOT necessary at least in the initial phase of treatment to ensure adherence
25、 and achieve sputum smear conversion A TB patient missing one attendance can be traced immediately and counseled,42,Modes of Observation,Health care workers Non-governmental organizations Community volunteers Religious leaders Child survival workers, lay midwives, etc.,DOT is feasible in each commun
26、ity by identifying and involving the strengths of the community.,43,DOT prolongs survival of HIV-infected TB patients,SCC with DOT,SCC without DOT,44,Systematic Monitoring and Accountability,Good record-keeping is the cornerstone of success The DOTS recording system enables Monitoring of patient out
27、comes Evaluation of programme performance Analysis of epidemiologic data Operational research Every level of health system accountable for patient diagnosis and cure,45,Treatment outcomes in sputum smear-positive patients,46,Supervision,Effective supervision at all levels is key to success Supervisi
28、on is the process of helping staff improve their performance Key areas: laboratory work patient categorization direct observation drug storage and stock record keeping reporting,47,DOTS can reduce the burden of TB,Annual percentage decline in incidence/prevalence,48,DOTS can reduce drug resistance,D
29、ecline (percent),49,Results of DOTS in 112,842 patients with smear-positive pulmonary TB in China,Lancet 1996;347:358-62,Cure rate,Cure rate (%),50,Treatment outcomes, DOTS areas, South East Asia, New Smear+ Patients 1997,25,871 308 7,708 19,492 94 9,014 2,303 3,506 1,873,51,DOTS triples treatment s
30、uccess in South East Asia,52,DOTS is succeeding in South East Asia,More than 500,000 TB patients treated with DOTS in South-East Asia More than 50,000 lives saved More than 2 million TB infections prevented More than 200,000 TB cases prevented More than US$150 million saved,53,DOTS in the context of
31、 HIV,DOTS can: Prolong life and improve its quality Stop the spread of TB Prevent emergence of MDRTB Reverse the trend of MDRTB,Failure to use DOTS in the face of HIV can lead to explosive spread of TB, with cases tripling and drug resistance increasing rapidly,54,Economic benefits of DOTS: Indonesi
32、a,55,DOTS is Expanding in South East Asia,56,The Sooner DOTS is Implemented, the Faster TB Will be Controlled in South-East Asia,57,Deaths from TB (thousands),Deaths from TB with and without rapid DOTS expansion, SE Asia, 2000-2020,58,DOTS is accelerating in South-East Asia, but needs to become more extensive and intensive,Target Zone,750,000 more new ss+ patients need to be treated yearly,