Management of Tuberculosis Patient in Hong Kong

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Management ofTuberculosis Patientin Hong Kong

• (10 December 2000)

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Medical conditions of patients at the time
ofdeveloping TB (notified in August 1999) (Total
no. 594)

• One or more medical conditions 155 (26.09)
• Two medical conditions 16 (2.69)
• Three medical conditions 2 (0.34)
• Total number of cases analysed 594
• (Apart from this no reply received for 28 cases)

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Medical conditions of patients at the time
ofdeveloping TB (notified in August 1999) (Total
no. 594)

• Medical conditions Number
• Diabetes mellitus 72 12.12
• On steroid 8 1.35
• Chronic renal failure 18 3
• On cytotoxic drug 1 0.17
• Leukaemia/ lymphoma 4 0.67
• Malignancy 27 4.55
• Alcoholism 10 1.68
• Drug addiction 6 1.01
• Pneumoconiosis 9 1.52
• Others 20 3.37

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SOURCES OF CARE FOR PATIENTS WITH TUBERCULOSIS
IN HONG KONG
PATIENT WITH TUBERCULOSIS
Hospital Authority Accident and Emergency
Departments
Department of Health General out- patient clinics
Department of Health TB Chest Service 18 chest
clinics 7,000 new patients each year
PRIMARY LEVEL
Private Practitioner
Hospital Authority Chest Hospitals 5
hospitals 800 beds 7,000 in-patient episodes
Hospital Authority Specialist Out-patient Clinics
Private Hospitals
Hospital Authority General Hospital
SECONDARY LEVEL
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Classical symptoms suspicious of TB

• persistent cough for over 3 to 4 weeks
• blood in sputum
• weight loss
• persistent fever
• night sweating

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Particular points to note in the history

• previous history of TB - previous ST pattern
• coexisting medical illnesses
• occupational history - e.g., health care worker,
  silicosis
• contact history - e.g., ST of source case
• smoking status
• previous BCG (especially for child)

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Physical examination

• often yields negative findings
• general condition
• cervical LN
• pleural effusion
• unilateral wheeze (endobronchial involvement)
• help in differential diagnosis e.g., finger
  clubbing favour CA lung

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Diagnosis

• Chest X-ray relatively simple, sensitive, but
  less specific
• apical lesion high positive predictive value
• If sputum smear negative, usually needs serial
  film to assess activity of pneumonic shadow ?
  trial of antibiotics (ddx from other community
  acquired pneumonia)
• Sputum examination for AFB (smear and culture)
• on 2 to 3 consecutive mornings
• identification and sensitivity tests should be
  done for positive culture isolates
• Further tests may be required for difficult
  cases
• CT scan, bronchoscopy, needle lung biopsy
• tuberculin test (usually limited use)

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Before starting anti-TB drugs

• Note contraindication to use of anti-TB drugs
• liver disease, renal disease, visual problem,
  hearing problem, drug allergy, concomitant
  medication
• Young females counselled on pregnancy-related
  issues
• interaction with oral contraceptives
• avoidance of pregnancy during anti-TB treatment
• Pretreatment LFT, RFT, HIV antibody (with
  consent), screening test for vision

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Before starting anti-TB drugs (Contd)

• Health education nature of disease, healthy
  lifestyle, drug-adherence, possible side effects
  of drugs (discoloration of body fluid)
• supplemented with educational materials
• self-reporting of side effects
• Good rapport with patient

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Public Health Functions

• Notification of TB
• Contacts
• examination of close contacts
• stone-in-the-pond principle
• health education maintenance of good bodily
  health and early awareness of suspicious symptoms
• Health education on patients personal hygiene

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TB Notification System in Hong Kong

• (1) Prevention of the Spread of Infectious
• Diseases Regulations (under Quarantine and
  
• Prevention of Disease Ordinance)(Cap.141)
• (TB is a statutory notifiable disease
  since 1939)
• (Report to Department of Health)
• (2) Occupational Safety and Health Ordinance
• (E.g., health-care workers)
• (Prescribed period 6 months)
• (Report to Labour Department)

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• Notification form
• available from
• - any chest clinics
• DH homepage
• Completed form sent back to
• Wanchai Chest Clinic
• Fax [phone]
• Tel [phone]

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TB Notification

• Aims
• Surveillance
• Contact tracing and examination
• Identification of clusters

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• Under-notification
• A common problem
• The importance of the need to notify TB cases
  should be recognised.
• Guidance Notes for notification of TB
• Leung CC, Tam CM. Guidance notes for notification
  of tuberculosis. Public Health Epidemiology
  Bulletin 19998(4)36-9.

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Source of TB Notification
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Infectiousness of the TB patient

• Sputum smear a general guide to the
  infectiouness
• also severe cough, cavitatory disease
• To reduce risk of infection to others
• prompt initiation of treatment (infectivity
  reduced significantly after 2 weeks of treatment
  in which rifampicin is included)
• health education
• personal hygiene measures
• good indoor ventilation
• screening of close contacts
• sick leave assessed on a case-to-case basis
  (teachers, staff of elderly homes, etc.)

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TUBERCULOSISCHEMOTHERAPY

• DIRECTLY OBSERVED TREATMENT,
• SHORT COURSE
• to stop it at the source

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TB
TB
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DOT (directly observed treatment)

• Strongly recommended by WHO, crucial for
  treatment success

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• Short course service programme (6 months)
• 2H3R3Z3E3 / 4H3R3
• H isoniazid R rifampicin
• Z pyrazinamide E ethambutol
• S streptomycin
• Drugs preferably taken in a single dose each
  time and not in split doses
• Combined drug preparations e.g., rifater,
  rifinah
• useful alternatives, but have to be given daily
• can avoid monotherapy
• but do not allow flexible dosage adjustment

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Treatment of tuberculosis

• The Tuberculosis Control Coordinating Committee
  of the Hong Kong Department of Health and the
  Tuberculosis Subcommittee of the Coordinating
  Committee in Internal Medicine of the Hospital
  Authority, Hong Kong. Chemotherapy of
  tuberculosis in Hong Kong a consensus statement.
• Hong Kong Med J 19984315-20

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During anti-TB treatment

• Initial phase follow up at least monthly (in
  chest clinic, while under DOT)
• to reinforce patient education
• watch out for adverse drug reactions
• routine blood tests usually not necessary unless
  clinical features suspicious of hepatitis,
  underlying liver disease, etc.
• CXR at 2nd or 3rd month to assess progress
• Sputum
• If pretreatment sputum positive, recheck at 2nd
  month to assess conversion to negativity
• If still positive at 2nd month, recheck at 3rd
  month

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During anti-TB treatment (Contd)

• Treatment defaulters being traced by health
  nurses
• Identify the underlying reasons for default, and
  try to solve the problem as far as possible
• Incentives/ enablers
• Tracing back of treatment defaulters IMPORTANT
  for treatment success and public health control
  of TB.
• Defaulters are a potential persistent source of
  infection in the community.

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At the end of six months treatment

• Assessment
• Repeat chest radiograph
• Sputum examination
• Health education
• Maintenance of a healthy lifestyle, awareness of
  suspicious symptoms

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Complicating issues

• Examples of complicating issues
• Extensive disease
• Poor general condition
• Diagnostic dilemma
• Treatment failure due to non-adherence
• Drug resistance
• Concurrent medical diseases
• Drug reactions
• Consult when necessary, hospitalisation may be
  required

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Tuberculosis- Indications for hospital admission

• 1. Complications of pulmonary tuberculosis, e.g.,
  pleural effusion, pneumothorax, etc.
• 2. Complications of treatment, e.g., severe
  reactions like drug intolerance, hypersensitivity
  reactions, hepatitis, etc.
• 3. Concomitant diseases, e.g., uncontrolled DM.
• 4. Psychosocial problems, e.g., alcoholics, drug
  addicts, previous defaulters.
• 5. Difficulty in attending clinics for DOT, e.g.,
  elderly, hemiplegic, living in remote areas, etc.
• 6. Extrapulmonary TB for special investigation

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Some points for caution

• Addition phenomenon to be avoided
• Not to add a single drug to a failing regimen
• Desensitisation
• May be required for drug-induced
  hypersensitivity, but be careful not to induce
  drug-resistance
• Ethambutol to be avoided under age 6 unless
  necessary
• Higher incidence of side effects of drugs in
  elderly

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IMPORTANT

• Drug adherence is most important and is
  vulnerable because
• Long duration of treatment required
• Disappearance of symptoms before treatment
  completion
• Bulk of tablets mistake, GI upset and other
  side effects
• Stigma of TB cannot accept the fact of being
  diagnosed as having TB
• Health belief e.g., use of herbal or alternative
  medicine
• DOT is strongly recommended
• Prevent failure, relapse, drug-resistance, spread
  of the disease, long-term sequelae of destroyed
  lung

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TUBERCULOSIS

• Reasons for failure of chemotherapy
• Non-compliance
• Drug resistant tuberculosis
• Drug toxicity
• Failure of drug to reach site of action
• Immunosuppressed

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Conclusion

• Management of TB can be simple, but can go
  wrongly easily, which can result in serious
  consequences
• Complicating issues may arise from time to time
• Caution required, consult when necessary
• Management
• Clinical Public Health measures Good
  communication

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Components of DOTS

• 1. Government commitment to sustained TB control.
• 2. Sputum smear microscopy to detect infectious
  cases.
• 3. A standardized, short-course anti-TB treatment
  regimen of six to eight months, with direct
  observation of treatment for at least the initial
  two months.
• 4. A regular, uninterrupted supply of quality
  anti-TB drugs.
• 5. A MONITORING AND REPORTING SYSTEM to evaluate
  treatment outcomes for each patient diagnosed and
  the performance of the TB control programme as a
  whole.

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Future activities

• Programme Forms (to be filled in for all TB
  patients starting from January 2001)
• Baseline characteristics of TB patient
• Clinical features and results of investigations
• Treatment outcomes at various time points up to 2
  year from DOS (date of starting treatment)
• The collaboration of both the PUBLIC AND PRIVATE
  SECTOR in the evaluation process is very
  important and very much appreciated.

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The collaboration of public and private sector in
the control of tuberculosis is very
important.THANK YOU!