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DOTS MANAGEMENT IN DOTS MANAGEMENT IN TUBERCULOSISTUBERCULOSIS
Zul DahlanZul DahlanDepartment of Internal Medicine Department of Internal Medicine
Medical Faculty of Padjadjaran University Medical Faculty of Padjadjaran University
Hasan Sadikin Hospital , BANDUNGHasan Sadikin Hospital , BANDUNG
MinilectureMinilecture
INTRODUCTIONINTRODUCTION Tuberculosis is an infectious disease that Tuberculosis is an infectious disease that
remain to be a major health problem in in remain to be a major health problem in in the world including Indonesia. the world including Indonesia.
Indonesia like other countries had adapted Indonesia like other countries had adapted WHO DOTS strategy for national TB control WHO DOTS strategy for national TB control and had succeed in variety of setting.and had succeed in variety of setting.
This presentation will disclose a few aspect This presentation will disclose a few aspect in the implementation of DOTS in the in the implementation of DOTS in the management tuberculosis, in pulmonary management tuberculosis, in pulmonary and extrapulmonary sites.and extrapulmonary sites.
World Health Organization
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
Population (thousands)
Cases (thousands)
Rate x105
Estimated Annual Incidence of TB Estimated Annual Incidence of TB in Selected High Burden Countries, in Selected High Burden Countries,
20002000
Implementation of DOTS, 2000Implementation of DOTS, 2000
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2001
Not implementing DOTS
Implementation in 10 to 90% of popImplementation in > 90% of pop
Implementation in < 10% of pop
No report
Low incidence non-DOTS country
10 FACTS OF TUBERCULOSIS10 FACTS OF TUBERCULOSIS
1.1. Mortality caused by TB increase every years Mortality caused by TB increase every years 2.2. TB has killed more young and adults more than TB has killed more young and adults more than
other infectious diseases other infectious diseases 3.3. TB mortality rate about 2 – 3 millions people every TB mortality rate about 2 – 3 millions people every
year can be preventedyear can be prevented4.4. Every second at least one person will be infectedEvery second at least one person will be infected5.5. Every 10 seconds one person will dieEvery 10 seconds one person will die6.6. Every year 1 percent world population will be Every year 1 percent world population will be
infected infected 7.7. Totally one third of world population have been Totally one third of world population have been
infected by TBinfected by TB8.8. Without treatment 1 active TB patient will infect Without treatment 1 active TB patient will infect
10-15 persons in 1 year10-15 persons in 1 year9.9. Similar with influenza, TB spread through air while Similar with influenza, TB spread through air while
the patient coughing, talking or sneezing the patient coughing, talking or sneezing 10.10. Death caused by TB usually occur slowly related to Death caused by TB usually occur slowly related to
chronic damage of lung and its complicationschronic damage of lung and its complications
10 FACTS ABOUT TUBERCULOSIS IN 10 FACTS ABOUT TUBERCULOSIS IN WOMEN AND CHILDWOMEN AND CHILD
TB IS THE CAUSE OF DEATH OF WOMEN MORE FREQUENTLY THAN TB IS THE CAUSE OF DEATH OF WOMEN MORE FREQUENTLY THAN CAUSE BY MATERNAL COMPLICATIONCAUSE BY MATERNAL COMPLICATION
TB IS CAUSE THE DEATH IN 1 MILLION WOMEN MORE THAN BY TB IS CAUSE THE DEATH IN 1 MILLION WOMEN MORE THAN BY OTHER INFECTION DISEASESOTHER INFECTION DISEASES
10% OF WOMAN AT REPRODUCTIVE AGE AT 1990 DIED BECAUSE OF 10% OF WOMAN AT REPRODUCTIVE AGE AT 1990 DIED BECAUSE OF TBTB
TB IS THE CAUSE OF DEATH OF 100.000 CHILDREN YEARLY, WHICH TB IS THE CAUSE OF DEATH OF 100.000 CHILDREN YEARLY, WHICH MAKE THEM ORPHAN AND BECOME FAMILY FUND GETTERMAKE THEM ORPHAN AND BECOME FAMILY FUND GETTER
TB ATTACK THE YOUNG AT PRODUCTIVE AGE TB ATTACK THE YOUNG AT PRODUCTIVE AGE
CHILDREN IS VERY SENSITIVE TO SUFFER SEVERE TB DISEASES, CHILDREN IS VERY SENSITIVE TO SUFFER SEVERE TB DISEASES, SUCH AS BRAIN TB AND SPINAL TBSUCH AS BRAIN TB AND SPINAL TB
WOMEN MOVEMENT HAS AN IMPORTANT ROLE IN TUBERCULOSIS WOMEN MOVEMENT HAS AN IMPORTANT ROLE IN TUBERCULOSIS ERADICATION PROGRAM IN VAROIUS PART OF THE WORLDERADICATION PROGRAM IN VAROIUS PART OF THE WORLD
BACKGROUND OF TB PROBLEM IN BACKGROUND OF TB PROBLEM IN DEVELOPING COUNTRIES DEVELOPING COUNTRIES
-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
* HIGH MORBIDITY AND MORTALITY RATE
FACTORS THAT PLAY ROLE IN THE FACTORS THAT PLAY ROLE IN THE MANAGEMENT OF TBMANAGEMENT OF TB
1. MYCOBACTERIUM: . SPECIES- . VIRULENCE
2. HOST : . IMMUNITY. ADHERENCE
3. MANAGEMENT & MEDICINE
CURED
INTERACTION
TREATMENT FAILURE IN TREATMENT FAILURE IN TUBERCULOSISTUBERCULOSIS
1. ASPECT OF ETIOLOGIC DIAGNOSIS :1. ASPECT OF ETIOLOGIC DIAGNOSIS :
- TB MANIFESTATION - TB MANIFESTATION MICOBACTERIOSISMICOBACTERIOSIS
2. HOST ASPECT :2. HOST ASPECT :
- IMMUNITY DEFICIENCY- IMMUNITY DEFICIENCY
3. DRUG ASPECT :3. DRUG ASPECT :
- RESISTANT MYCOBACTERIUM - RESISTANT MYCOBACTERIUM
- ADHERENCE TO THERAPY - ADHERENCE TO THERAPY
4. SOURCE OF INFECTION :4. SOURCE OF INFECTION :
- EASIER TRANSPORTATION BETWEEN COUNTRIES- EASIER TRANSPORTATION BETWEEN COUNTRIES
AFB/ PA/ DNA
EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY – DOTS METHOD
22. HOST FACTOR. HOST FACTOR
. GENETIC SENSITIVITY TO TB :. GENETIC SENSITIVITY TO TB : - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN- MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN FUNCTION FUNCTION
.. INADEQUATE DRUGS DOSAGEINADEQUATE DRUGS DOSAGE
.. COMPLIANCECOMPLIANCE
EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY –> DOTS METHOD
COMPLIANCECOMPLIANCE
Tb Patient frequently did not have their medicine Tb Patient frequently did not have their medicine regularly and continuously because of :regularly and continuously because of :
Limited effort because of false understanding : Limited effort because of false understanding :
. Stopping medicine halfway because they are. Stopping medicine halfway because they are
feeling better feeling better TB relapse again TB relapse again
. “Taking the medicine too long “. “Taking the medicine too long “
. “Medicine too much”. “Medicine too much” High cost of therapy High cost of therapy Drug side effect/ untoward effect Drug side effect/ untoward effect
WITH TUBERCULOSIS :WITH TUBERCULOSIS :
- - Treatment is more than treatmentTreatment is more than treatment
- Treatment is prevention of :- Treatment is prevention of :
. further spreading of infection. further spreading of infection
. further process of disease. further process of disease
BASIC PRINCIPLES OF ANTI BASIC PRINCIPLES OF ANTI TUBERCULOSIS DRUGSTUBERCULOSIS DRUGS
Drug is effective during active multiplication phase of Drug is effective during active multiplication phase of
mycobacterium, not in dormant phasemycobacterium, not in dormant phase
Use in combination of 4 – 5 drugs, for 6 months of Use in combination of 4 – 5 drugs, for 6 months of
therapy or more therapy or more
The use of still effective drug for etiologic mycobacteriumThe use of still effective drug for etiologic mycobacterium
Patient has to take the medicine regularly, continuously in Patient has to take the medicine regularly, continuously in
adequate dosage and periodadequate dosage and period
1. Political commitment of policy makers, including provision of financial support
2. Diagnosis TB initiated by microscopic examination
3. Short term TB therapy using combination of anti tuberculosis drug (ATD) under direct supervising of drug taking supervisors (PMO)
4. Continuous supply of ATD for patients
5. Data collecting And Reporting for future supervising and evaluation of TB eradication program
5 COMPONENTS OF DOTS STRATEGY
DOTSDOTS
Direct Observed Treatment Short-CourseDirect Observed Treatment Short-Course
ACCURATE DIAGNOSIS,ADEQUATE PERIOD
FREE ANTI TB DRUGS
TAKING DRUGS UNDER SUPERVISING
MONITORING AND EVALUATION
POLITICAL
COMMITMENT
INCLUDING
FINANCIAL SUPPORT
TAKING COMBINATION DRUGS ON SUFFICIENT DOSAGE, REGULARLY, AND CONTINOUSLY
CURED
DIAGNOSISDIAGNOSIS
SPUTUM EXAMINATION :SPUTUM EXAMINATION :
. 3 times, Ziehl Neelsen smear. 3 times, Ziehl Neelsen smear
POSITIVE RESULT :POSITIVE RESULT :
Positive In 2 of 3 AFB smears, orPositive In 2 of 3 AFB smears, or
Positive in 1 AFB smear and chest x- ray (+)Positive in 1 AFB smear and chest x- ray (+)
MICROSCOPIC EXAMINATIONMICROSCOPIC EXAMINATION
More objective and reliable than chest x ray More objective and reliable than chest x ray
0102030405060708090
100
AFB Exam Chest xray
98%
70%
Agreement of medical Practitioner
CHEST X-RAY EXAMNATION CHEST X-RAY EXAMNATION Causing over- diagnosis of TBCausing over- diagnosis of TB
0102030405060708090
100
Suspect with positive Chest x-ray
True positive TB case
OVER DIAGNOSIS
TB CLASSIFICATION TB :TB CLASSIFICATION TB :
Related to 4 aspects :Related to 4 aspects :
- Organ involved in TB process : lung/ extra-lung - Organ involved in TB process : lung/ extra-lung
- result of sputum examination : AFB (+)/ AFB (-)- result of sputum examination : AFB (+)/ AFB (-)
- Previous history of TB therapy :- Previous history of TB therapy :
. New/ exacerbation, relapse, migration/ drop. New/ exacerbation, relapse, migration/ drop
out, failureout, failure
- Degree of severity of disease: mild or severe - Degree of severity of disease: mild or severe
DECISION ON CATEGORY OF THERAPY
IMPLEMENTATION OF TB THERAPYIMPLEMENTATION OF TB THERAPY
Aspect–aspect :Aspect–aspect : Decision on the category of TB therapyDecision on the category of TB therapyTherapy supervising :Therapy supervising :
. Healthcare officer, family, friend, etc. Healthcare officer, family, friend, etc
Monitoring of sputum ACB, duringMonitoring of sputum ACB, during : :
- intensive period - intensive period
- the end of therapy/ 1 month before the - the end of therapy/ 1 month before the
- follow up of sputum conversion - follow up of sputum conversion
Monitoring of therapy :Monitoring of therapy :
- cured, drop out, not cure - cured, drop out, not cure
THE CHOICE OF ANTITUBERCULOSIS DRUG BASED THE CHOICE OF ANTITUBERCULOSIS DRUG BASED ON CATEGORIESON CATEGORIES
Alternative of Combined Drug
CategoryOf 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
Ward patients : Ward patients : 696 patients 15 – 24 years (34.1 %)696 patients 15 – 24 years (34.1 %)
Admitted TB at various departments :Admitted TB at various departments :Internal medicine : 76.1 %Internal medicine : 76.1 %Pediatric Pediatric : 8.5 %: 8.5 %NeurologyNeurology : 6.4 %: 6.4 %Orthopaedic Orthopaedic : 4.6 %: 4.6 %SurgerySurgery : 2.9 %: 2.9 %GynaecologyGynaecology : 0.6 %: 0.6 %
TB PREVALENCE AT RS HASAN SADIKIN ’95 - 98
. Pleura . Pleura : 16,2 %: 16,2 %
. Meningeal . Meningeal : 9,9 %: 9,9 %
. Peritonitis . Peritonitis : 8,3% : 8,3%
. Spondylitis . Spondylitis : 4,0 %: 4,0 %
. Limphadenitis: 2,2 %. Limphadenitis: 2,2 %
. Pericarditis . Pericarditis : 1,0%: 1,0%
. . Coxitis Coxitis : 1.0 %: 1.0 %
. Supracondylus. Supracondylus : 0.7 %: 0.7 %
. Skin. Skin : 0,4 % : 0,4 %
. Sinovitis : 0,3 %
. Hepar : 0,1 %. Renal : 0,1 %
• PULMONARY TB 55 %
TB MANIFESTATION AT HASAN SADIKIN HOSPITAL
• EXTRAPULMONARY TB 45 %
457 patients (M=53 %, W=46.4 %)457 patients (M=53 %, W=46.4 %)30.7 % UMUR 21 – 30 yrs30.7 % UMUR 21 – 30 yrs15.7 % > 60 yrs15.7 % > 60 yrsAFB (+) culture (+) = 14.9 %AFB (+) culture (+) = 14.9 %culture (+) = 12.7 %culture (+) = 12.7 %
TB PATIENTS TB PATIENTS
26.3 % 26.3 % 73.6 % 73.6 % DROP OUT DROP OUT CONTINUE CONTINUE
36.8 % 36.8 % 63.2 % 63.2 % REGULAR NOT REGULARREGULAR NOT REGULAR
34.3 %34.3 % 65.7 %65.7 % CUREDCURED NOT CURED NOT CURED
OUPATIENT CLINIC OF INTERNAL MDICINE DEPARTMENT OF ASAN SADIKIN HOSPITAL 1993
CLINIICAL STUDY OF TB CLINIICAL STUDY OF TB LYMPHADENITIS AT LYMPHADENITIS AT HASAN SADIKIN HASAN SADIKIN HOSPITALHOSPITAL
1.1. TB CULTURE FROM LYMPHADENITIC TB CULTURE FROM LYMPHADENITIC TISSUE – TISSUE – MISNADIARLY - 1994MISNADIARLY - 1994
- 27 SPECIMEN : - 43.5% MTC- 27 SPECIMEN : - 43.5% MTC - 56,5% MNTB- 56,5% MNTB
2.2. PCR + SEQUENCING OF GEN 16S rDNA PCR + SEQUENCING OF GEN 16S rDNA SEGMENT OF MYCOBACTERIUM – SEGMENT OF MYCOBACTERIUM – 2003 - ZUL DAHLAN2003 - ZUL DAHLAN
ELECTROFOREGRAMELECTROFOREGRAM
NCBINCBI results results ofof BLAST BLAST BLASTN 2.2.1 APR-13-2001BLASTN 2.2.1 APR-13-2001 QUERY = QUERY = ((576 LETTERS576 LETTERS))DATABASE : nt DATABASE : nt 958, 081 SEQUENCES; 4, 118, 683, 734 TOTAL LETTERS 958, 081 SEQUENCES; 4, 118, 683, 734 TOTAL LETTERS
Distribution of 638 Blast Hits on the Query SequenceMouse-over to show define and scores. Clik to show alignments
0 100 200
< 40 40 - 50 50 - 80 80 - 200 >= 200
300 400 500
Color Key for Aligment scores
Sequences producing signficant alignments Score(bits)
EValue
gi |175326|gb|M29563.1|MSGRR16SI M.gordonae 16S ribosomal RNA 480 e-133gi | 44345|emb|X52923.1|MGO16SRN Mycobacterium gordonae 16S… 478 e-132gi | 885642 |gb| U17276.1|MSU17276 Mycobacterium sp ( strain 33 …. 476 e-131gi |15620526 |gb| AF330038.2|AF330038 Mycobacterium montefiore … 438 e-120gi |12044813 |emb| AJ276890.1| AMY27690 Mycobacterium cf trip … 430 e-118
Table – Frequency Species of Mycobacterium Found in Various Organs
Organ
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
43121111000
14
640
10
31311010110
12
431
8
30000201001
7
1250
17
11001000000
3
000
0
115433322111
36 (50,7%)
22121
35 (49,3%)
Mycobact’rium Species
TABLE - GROUP OF MYCOBACTERIUM FOUND TABLE - GROUP OF MYCOBACTERIUM FOUND IN IN MULTIORGAN IN PATIENT MULTIORGAN IN PATIENT DIAGNOSED DIAGNOSED TUBERKULOSIS TUBERKULOSIS
83,1%
16,9%
MTC49,3%
MNTB50,7%
SLOW GROWING
FAST GROWING
WORKING TEAM ON PULMONARY & EXTRAPULMONARY TB ERADICATION
PROGRAM
TRAINING DOKTER/PERAWAT/
PARAMEDIS
PULMONARY & EXTRAPULMONARY
TUBERCULOSIS CENTRAL CLINIC
TEMPORARILY EVERY MONDAY MORNING
RESPIROLOGY TEAM
DIRECTOR
Director of Dr. Hasan Sadikin Hospital
COORDINATOR
RESPIROLOGY TEAM, RSHS/FKUP
PULMONOLOGY CLINIC
CLINIC OF INTERNAL MEDICINE & OTHER
DEPARTMENT
CLINIC
Doctor
REPORTING
Paramedic
DRUG
FARMACY
HOME VISIT
Social worker
Labora-
tory
DOTS CORNER CENTRAL DOTS CLINIC OF TUBERCULOSIS
DOTS PROGRAM AT HASAN SADIKIN HOSPITAL BANDUNG
TB PATIENTS
OTHER CLINICS
NEURO
CLINIC
ORTHOPAEDI
C CLINIC
INTERNAL MEDICINE
CLINIC
PEDIATRIC CLINIC
TBE (+)
THERAPY (+)
TBP +/- TBE
THERAPY
TBP +/- TBE
THERAPY
POJOK DOTS
DIAGNOSIS/ CATEGORICAL THERAPYDIAGNOSIS/ CATEGORICAL THERAPY
PATIENT PATIENT PATIENTS PATIENTS TB/ TBETB/ TBE CHILD CHILD
PATIENTSPATIENTS
ADULTADULTAFB (+)/ (-)AFB (+)/ (-)
DRUGSDRUGS
AMBULATORY SUPERVISING AMBULATORY SUPERVISING PATIENTSPATIENTS
EDDUCATION EDDUCATION PMOPMO
DOTS CORNER
HOME VISITHOME VISITOPTIONALOPTIONAL
SOCIAL WORKER
LABORATORYOFFICER
MEDICALPRACTITIONER
DATA COLLECTINGREPORTING
OFFICER
FARMACY-OFFICER
NATIONAL TRIAL ON DOTS NATIONAL TRIAL ON DOTS STRATEGYSTRATEGY
TRIAL ON 3 PROVINCE - 1995 :TRIAL ON 3 PROVINCE - 1995 :
Sulawesi, Jambi, Jawa TimurSulawesi, Jambi, Jawa Timur
Target :Target : Cure Rate > 85 %Cure Rate > 85 % Involvement 70%Involvement 70%
5 years continuous trial result : 5 years continuous trial result :
50% incidence decreased50% incidence decreased
TB CASES IN HASAN SADIKIN TB CASES IN HASAN SADIKIN HOSPITALHOSPITAL
Prevalence of new TB cases at hospital clinics:Prevalence of new TB cases at hospital clinics:
. Year 2000 : 3443 cases. Year 2000 : 3443 cases
. Year 2001 : 3354 cases. Year 2001 : 3354 cases
DOTS has been implemented since September, DOTS has been implemented since September,
1999 : 1999 :
. Patients visited clinic more regularly,which. Patients visited clinic more regularly,which
improved the cure rate from 34,7% to 86,5%improved the cure rate from 34,7% to 86,5%
APPLICATION OF DOTS AT RSHS- 1994JABAR HELATH
OFFICE- 1994
50 PACKET ATD
CATEGORY I
JPS – BK
(TH. 2000)
MEMBER OF
ASKES (KANWIL)
- Registration to Clinic
- Cytopathological
- pathologic exam.
- Culture and resistancy
COMPLETED NOT COMPLETED
Regitration
Free registration
Half cost is supported
Half cost by Askes- Cytopathological - pathologic exam. Culture and resistancy
STARTING
Personal payment wih
- Registration to Clinic- Cytopathological / pathologic exam. Culture and resistancy
- Examination
RESULT OF 50 PACKET OF ATD RESULT OF 50 PACKET OF ATD CATAGORY I AT HASAN SADIKIN CATAGORY I AT HASAN SADIKIN
HOSPITAL/ RSHS 1999HOSPITAL/ RSHS 1999
RESULT CASES INFORMATIONRESULT CASES INFORMATION Cure 45 Cure 45 Failure 1 Failure 1 Move out 2Move out 2Default Default 2 2 cases: allergic to ATD 2 2 cases: allergic to ATD
2 Cases: do not control2 Cases: do not control
KESIMPULANKESIMPULAN
1.1. TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM IN INDONESIA WITH A HIGH MORBIDITY PROBLEM IN INDONESIA WITH A HIGH MORBIDITY AND MORTALITY RATE .AND MORTALITY RATE .
2.2. STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT MUST BE DONE NATIONALLY AND SUPPORTED BY MUST BE DONE NATIONALLY AND SUPPORTED BY WHOLE COMMUNITY WITH ADEQUATE PERSONNEL, WHOLE COMMUNITY WITH ADEQUATE PERSONNEL, MEDICINE, AND FINANCIAL.MEDICINE, AND FINANCIAL.
3.3. RESISTANT MYCOBACTERIUM TUBERCULOSIS AND RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHER SPECIES MAY HAMPER THE ERADICATION OF OTHER SPECIES MAY HAMPER THE ERADICATION OF TUBERCULOSIS AND MIKOBACTERIOSIS. ON THIS TUBERCULOSIS AND MIKOBACTERIOSIS. ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC AGENT MUST BE DONE WHICH WILL BE HELPFUL IN AGENT MUST BE DONE WHICH WILL BE HELPFUL IN TREATING THE RESISTANT SPECIES.TREATING THE RESISTANT SPECIES.
THANK YOU THANK YOU
WIPE OUT MYCOBACTERIUM
……….. THE VICIOUS ENEMY
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