DOTS MANAGEMENT IN TUBERCULOSIS

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DOTS MANAGEMENT IN TUBERCULOSIS
Minilecture

• Zul Dahlan
• Subdivision Pulmonology
• Department of Internal Medicine
• Medical Faculty of Padjadjaran University
• Hasan Sadikin Hospital , BANDUNG

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• Female 40 yrs
• Cough for gt3 months
• 3 x to GP, only presciption
• No sputum or CXR
• She did CXR on her initiative
• Her sputum AFB pos

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INTRODUCTION

• Tuberculosis is an infectious disease that remain
  to be a major health problem in the world
  including Indonesia.
• Indonesia like other countries had adapted WHO
  DOTS strategy for national TB control and had
  succeed in variety of setting.
• This presentation will disclose a few aspect in
  the implementation of DOTS in the management
  tuberculosis, in pulmonary and extrapulmonary
  sites.

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DIAGNOSIS

• SPUTUM EXAMINATION
• . 3 times, Ziehl Neelsen smear
• POSITIVE RESULT
• Positive In 2 of 3 AFB smears, or
• Positive in 1 AFB smear and chest x- ray ()

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MICROSCOPIC EXAMINATION

• More objective and reliable than chest x ray

Agreement of medical Practitioner
98
70
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CHEST X-RAY EXAMINATION

• Causing over- diagnosis of TB

OVER DIAGNOSIS
Suspect with positive Chest x-ray
True positive TB case
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FACTORS THAT PLAY ROLE IN THE MANAGEMENT OF TB
INTERACTION

• 1. MYCOBACTERIUM
• . SPECIES
• . VIRULENCE

2. HOST . IMMUNITY . ADHERENCE
3. MANAGEMENT MEDICINE
CURED
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ASPECT OF TREATMENT FAILURE IN TUBERCULOSIS

• 1. ETIOLOGIC DIAGNOSIS
• - TB MANIFESTATION
  MICOBACTERIOSIS
• 2. HOST
• - IMMUNITY DEFICIENCY
• 3. DRUG ASPECT
• - RESISTANT MYCOBACTERIUM
• - ADHERENCE TO THERAPY
• 4. SOURCE OF INFECTION
• - EASIER TRANSPORTATION BETWEEN COUNTRIES

AFB/ PA/ DNA
EFFORT TO CONTAIN TUBERCULOSIS
- IDENTIFY MYCOBACTERIUM RESISTANCY -
ADHERENCE TO TB THERAPY DOTS METHOD
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TB MANIFESTATION AT HASAN SADIKIN HOSPITAL

• PULMONARY TB 55

• EXTRAPULMONARY TB 45

. Coxitis 1.0 . Supracondylus 0.7 .
Skin 0,4 . Sinovitis 0,3 .
Hepar 0,1 . Renal 0,1

• . Pleura 16,2
• . Meningeal 9,9
• . Peritonitis 8,3
• . Spondylitis 4,0
• . Limphadenitis 2,2
• . Pericarditis 1,0

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1. ETIOLOGYTABLE - GROUP OF MYCOBACTERIUM FOUND
IN PATIENT DIAGNOSED TUBERCULOSIS
FAST GROWING
16,9
MTC 49,3
MNTB 50,7
83,1
SLOW GROWING
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Table Frequency Species of Mycobacterium
Found in Various Organs
Organ
Mycobactrium Species
Lung Pleura Gland Peritoneum Total
I.M. NonTuberculosis -MNTB 1. M. gordonae
2. M. alvei 3. M. ratisbonen 4. M.
concordense 5. M.mucogenicum 6. M. avium 7.
M. fortuitum 8. Uncultured Mycob. 9.
M.peregrinum 10. M.septicum 11.
M.paratuberculosis   Total    II. M. Tuberculosis
Complex 1. M. africanum 2. M. tuberculosis
3. M. canetti   Total
4 3 1 2 1 1 1 1 0 0 0 14     6 4 0 10
3 1 3 1 1 0 1 0 1 1 0 12     4 3 1 8
3 0 0 0 0 2 0 1 0 0 1 7     12 5 0 17
1 1 0 0 1 0 0 0 0 0 0 3     0 0 0 0
11 5 4 3 3 3 2 2 1 1 1 36 (50,7)     22 12 1 35
(49,3)
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2. HOST FACTOR

• . GENETIC SENSITIVITY TO TB
• - FAMILIAL SYNDROMES DISSEMINATION
  POST BCG
• - MENDELIAN SENSITIVITY IMPAIRMENT OF
  IFN? FUNCTION
• . INADEQUATE DRUGS DOSAGE
• . COMPLIANCE

EFFORT TO CONTAIN TUBERCULOSIS -
IDENTIFY MYCOBACTERIUM RESISTANCY -
ADHERENCE TO TB THERAPY gt DOTS METHOD
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COMPLIANCE

• TB Patient frequently did not have their medicine
  regularly and continuously because of
• Limited effort because of false understanding
• . Stopping medicine halfway because they are
• feeling better ? TB relapse again
• . Taking the medicine too long
• . Medicine too much
• High cost of therapy
• Drug side effect/ untoward effect

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WITH TUBERCULOSIS - Treatment is more than
treatment - Treatment is prevention of .
further spreading of infection . further process
of disease
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DOTS Direct Observed Treatment Short-Course
POLITICAL COMMITMENT INCLUDING FINANCIAL SUPPORT
ACCURATE DIAGNOSIS,ADEQUATE PERIOD FREE ANTI TB
DRUGS TAKING DRUGS UNDER SUPERVISING
MONITORING AND EVALUATION
TAKING COMBINATION DRUGS ON SUFFICIENT DOSAGE,
REGULARLY, AND CONTINOUSLY
CURED
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BASIC PRINCIPLES OF ANTI TUBERCULOSIS DRUGS

• Drug is effective during active multiplication
  phase of mycobacterium, not in dormant phase
• Use combination of 4 5 drugs, for 6 mo. or
  more
• Use of still effective drug for etiologic
  mycobacterium
• Patient has to take the medicine regularly,
  continuously in adequate dosage and period

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CLASSIFICATION TB

• Related to 4 aspects
• - Organ involved in TB process lung/
  extra-lung
• - result of sputum examination AFB ()/ AFB
  (-)
• - Previous history of TB therapy
• . New/ exacerbation, relapse, migration/ drop
  out, failure
• - Degree of severity of disease mild or severe

DECISION ON CATEGORY OF THERAPY
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IMPLEMENTATION OF TB THERAPY

• Aspectaspect
• Decision on the category of TB therapy
• Therapy supervising
• . Healthcare officer, family, friend, etc
• Monitoring of sputum ACB, during
• - intensive period
• - the end of therapy/ 1 month before the
• - follow up of sputum conversion
• Monitoring of therapy
• - cured, drop out, not cure

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THE CHOICE OF ANTITUBERCULOSIS DRUG BASED ON
CATEGORIES
Alternative of Combined Drug Alternative of Combined Drug
Category Of therapy Classification and Type of TB Patient TB Intensive phase (daily or 3x / week) Late Phase
I New case AFB () New case AFB (-) Chest x-ray () with advanced lung damage/ severe disease New case of TB Severe extra pulmonary TB case 2 HRZE 2 HRZE 2 HRZE 4 HRZE 4 HR 6 HE
II Patients relapse failure drop out (after default) 2 HRZES / 1 HRZE 2 HRZES / 1 HRZE 5 H3R3E3 5 HRE
New case TB AFB (-) , Chest x-ray (), mild disease 2 HRZ 2 HRZ 4 H3R3 6 HE
III Mild new ekstrapulmonary case 2 HRZ 4 HR
IV Chronic case Consultation to specialist for secondary medicine Consultation to specialist for secondary medicine
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MULTI DRUG RESISTANCE TB(MDR TB)
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DEFINITION OF RESISTANCE

• Mono Resistant
• Resistant to 1 drug OATH/ R/ S/ E
• Multi Drug Resistance (MDR)
• Minimally resistant to INH and Rifampisin
• HR/ HRS/ HRE.
• Poly Resistant
• Resistant to a few OAT exept INH Rifampisin
  HSE/ SE/ HE.
• Extensive Drug Resistance (XDR)
• MDR resistant also to fluoroquinolon and
  kanamicin/ amikacin/ capreomicynMDRCiprokana/
  MDRciproami.

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Causes of Drug resistant TB

• Due to physician inappropriate drug, dosage
• and duration
• Due to patient compliance, malabsorption,
• financial,
• Due to drug substandard formulation, poor
• bioavailability
• Due to health care non availability source was
• MDR TB

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DOTS Plus

• Treatment of Poli/ MDR
• More difficult, costly, and more side effect
• Individualized
• - tailor made
• - Package

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MANAGEMENT OF MDR

• DOTS Plus Strategy Base on
• Anamnesis.
• Diagnosis berdasarkan laboratorium.
• Pengobatan berdasarkan laboratorium.
• Evaluasi pengobatan berdasarkan laboratorium.
• Evaluasi efek samping, faal hati, faal ginjal,
  dll berdasarkan laboratorium.
• Lama pengobatan min. 18 bln, dg tahap intensif 6
  bln paduan mengandung OAT suntik.

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Indonesia 22 High Burden Countries

1. India
2. China
3. Indonesia
4. Bangladesh
5. Nigeria
6. Pakistan
7. South Africa
8. Philippines
9. Russia
10. Ethiopia
11. Kenya
12. DR Congo
13. Viet Nam
14. UR Tanzania
15. Brazil
16. Thailand
17. Zimbabwe
18. Cambodia
19. Myanmar

• Penyebab kematian terbanyak penyakit infeksi
  (SKRT 1995)
• 583.000 kasus baru/tahun, 140.000 kematian /tahun
  (WHO)

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BACKGROUND OF TB PROBLEM IN DEVELOPING COUNTRIES

HIGH MORBIDITY AND MORTALITY RATE

• Annually there are 1 millions new TB patients
• And TB is responsible for an annual 3 millions
  death
• 97 patients located in developing c tries ?
  25 can be
• avoided
• In Indonesia TB is third major cause of
  mortality ( SKRT 95)

MANAGEMENT OF TB IS BASED ON

• Species of causal mycobacterium
• Infected organs
• Advanced and progression of diseases

THE STRATEGY IS TO MORBIDITY MORTALITY
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Estimated Annual Incidence of TB in Selected High
Burden Countries, 2000
World Health Organization
Population (thousands)
Cases (thousands)
Rate x105
Country 1. India 2. China 3. Indonesia 7.
Philippines 8. Pakistan 10. Russia 13. Viet
Nam 22. Afghanistan
1,008,937 1,275,133 212,092 75,653 141,256 145,491
78,137 21,765
184 107 280 330 175 132 189 321
1,856 1,365 595 249 247 193 148 70
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Background

• Indonesian situation
• - population 222,781,000
• - global rank 3
• - incidence 239 (239/100,000/year)
• - incidence of new cases 108
• (108/100,000/year)
• - prevalence 262 (262/100,000/year)
• - mortality 41 (41/100,000/year)
• - co-infection TB/HIV 0,8
• - MDR-TB 1,6

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• The Global Plan
• The Regional Plan
• Country Plans

A pessimist sees the difficulty in every
opportunity an optimist sees the opportunity in
every difficulty. Sir Winston Churchill
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Global Strategy to Stop TB 2006-2015

• 1. Pursuing quality DOTS expansion and
  enhancement
• Government commitment with long-term planning and
  adequate resources to reach targets
• Case detection bacteriology and strengthening
  of laboratory network
• Standardised treatment, under proper case
  management conditions including DOT and patient
  support
• Effective and regular drug supply system
• Monitoring system for supervision and evaluation,
  including impact measurement
• 2. Additional components1 Addressing TB/HIV and
  MDR-TB2. Contributing to health system
  strengthening3. Engaging all care providers
• 4. Empowering patients and communities
• 5. Enabling and promoting research

Stop TB Department
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The new Stop TB Strategy and the Regional
Strategic Plan, 2006-2015

• Sustaining and enhancing DOTS to reach all TB
  patients, improve case detection and treatment
  success
• Establishing interventions to address TB/HIV and
  MDR-TB
• Forging partnerships, including with communities,
  to ensure equitable access to international
  standards of TB care for all
• Contributing to strengthening health systems

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DOTS Success Story

• DOTS the internationally recommended control
  strategy was launched in 1994
• The DOTS framework has subsequently been expanded
  and implemented in 182 countries.
• DOTS implementation has helped countries to
  improve national TB control programmes (NTPs) and
  make major progress in TB control
• By 2004, more than 20 million patients
• had been treated in DOTS programmes
• worldwide and more than 16 million of them
• had been cured.

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Puskesmas yg melaksanakan DOTS
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Hospital distribution (absolute numbers)
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Coverage of DOTS Services in National TB Program
Source of Thy failure, MDR-TB, TB-HIV, XDR
GPs etc ??
HOSPITAL, LUNG CLINICS (N 1316) 37
PUSKESMAS (N 7489) 98.5
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The practices of TB care among doctors in private
sector

• Over diagnosis and under diagnosis
• Over treatment and under treatment
• Chest X-ray regarded as the most important
  diagnostic tool
• Sputum smear is mostly neglected
• Non standard tests gaining popularity (serology,
  PCR etc)
• Incorrect use of anti TB drugs (regimen, doses,
  duration, compliance)

Lead to substandard care and failure
Eur Respir J 2006 28 687690
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Involvement of All Health Personnel health
centers

• Extension of DOTS Service in Hospital through
  Hospital DOTS
• Extension of PPM (Public Private Mix) (DPS, Jail,
  Army/ Police Dept.)
• Extended of working cooperation with LSM with
  Health Service
• DOTS in Work Place
• Extension of working cooperation with Medical
  Proffesion to facilitate DOTS
• ISTC PCTC (Patients charter for TB Care)

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ISTC Key Points

• Audience all health care practitioners, public
  and private
• Scope diagnosis, treatment, and public health
  responsibilities intended to complement local
  and national guidelines
• Rationale sound tuberculosis control requires
  the effective engagement of all providers in
  providing high quality care and in collaborating
  with TB control programs

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ISTC Objectives

• The Standards are intended that all care provider
  delivered high quality care
• for patients of all ages, those with sputum smear
  (), sputum smear (-), and extra pulmonary TB
• TB caused by drug-resistant M tuberculosis
  complex
• TB HIV

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ISTC Key Points (Edition 1)

• 17 Standards
• Differ from existing guidelines standards
  present what should be done, whereas, guidelines
  describe how the action is to be accomplished
• Evidence-based, living document
• Developed in tandem with Patients Charter for
  Tuberculosis Care
• Handbook for Using the International Standards
  for Tuberculosis Care

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ISTC Key Points (Edit. 2- 2009)

• 21 Standards
• Original Standards were renumbered and new
  Standards were written
• Evidence-based, living document, will require
  future revisions as well
• ISTC Tuberculosis Training Modules and
  Facilitators Guide were updated and developed to
  be in agreement with Edition 2 of the ISTC

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ISTC Standard 1

• All persons with otherwise unexplained productive
  cough lasting two-three weeks or more should be
  evaluated for tuberculosis

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The Indonesian Version of ISTC
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ISTC in IndonesiaIndonesian Standard for
Tuberculosis Control

• Is accepted and being endorsed by several
  profession organization
• In socialization phase
• Has been disseminated and implemented in Jakarta,
  West Java, East Java, and Central Java as pilot
  project

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Goals

• Equitable quality DOTS for all
• - To standardize the care of TB patients in
• variety of different providers
• - To provide high quality of care
• - Improve CDR, cure rate
• - Prevention of MDR
• - Reduce mortality
• - Cover co-infection TB/HIV
• The first priority is to endorse and implement
  ISTC among private physicians and hospitals

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RESPIROLOGY TEAM
WORKING TEAM ON PULMONARY EXTRAPULMONARY TB
ERADICATION PROGRAM
DOKTER/PERAWAT/ PARAMEDIS
TRAINING
PULMONARY EXTRAPULMONARY TUBERCULOSIS CENTRAL
CLINIC
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DOTS PROGRAM AT HASAN SADIKIN HOSPITAL BANDUNG
TB PATIENTS
OTHER CLINICS
INTERNAL MEDICINE CLINIC
NEURO CLINIC
ORTHOPAEDIC CLINIC
PEDIATRIC CLINIC
TBP /- TBE THERAPY
TBP /- TBE THERAPY
TBE () THERAPY ()
DOTS CORNER
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MEDICAL PRACTITIONER
SOCIAL WORKER
FARMACY- OFFICER
DOTS CORNER
DATA COLLECTING REPORTING OFFICER
LABORATORY OFFICER
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Conclusion 1

• TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM
  IN INDONESIA WITH A HIGH MORBIDITY AND MORTALITY
  RATE .
• STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN
  EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT
  MUST BE DONE NATIONALLY AND SUPPORTED BY WHOLE
  COMMUNITY WITH ADEQUATE PERSONNEL, MEDICINE, AND
  FINANCIAL.
• RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHER
  SPECIES MAY HAMPER THE ERADICATION OF
  TUBERCULOSIS AND MYCOBACTERIOSIS.
• ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC
  AGENT MUST BE DONE WHICH WILL BE HELPFUL IN
  TREATING THE RESISTANT SPECIES.

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Conclusion 2

• The result of Indonesian National TB Program was
  encouraging
• However, Puskesmas gave the biggest contribution
  to successful outcome
• The problems lie on Hospitals and Private
  providers
• The Implementation of ISTC expected to be
  complimentary to existing DOTS program

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(No Transcript)
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Working groups of the Stop TB Partnership

• DOTS Expansion
• DOTS-Plus
• TB/HIV
• Drugs
• Diagnostics
• Vaccines
• 7. Advocacy, Communication Social Mobilization

Stop TB Department
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THANK YOU
WIPE OUT MYCOBACTERIUM .. THE VICIOUS ENEMY