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The Graduate Practitioner orientationon Tuberculosis

Venue: Civil Surgeon Office, Faridpur

Date:28 th January 2014

Organized by: Civil Surgeon office , Faridpur & NTP.

Presented by:

Dr Karuna Kanta Dey, Consultant. Damien Foundation.


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Tuberculosis

Definition Tuberculosis is an infectious disease, caused by Mycobacterium tuberculosis or AFB or Tubercle bacilli

Mode of Spread of Tuberculosis bacilli The bacilli usually enter the body by inhalation through

the lungs through coughing, sneezing and spitting and

spread to other parts of the body via the blood stream, thelymphatic system, or through direct extension to otherorgans


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In 1882, Robert Kochdiscovered a staining technique

that enabled him to see Mycobacteriumtuberculosis .

What excited the world was the

accompanying certainty that now the fightagainst humanity's

deadliest enemycould really begin.


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in 1993,the World Health

Organization (WHO)declared TB a

"global emergency."


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Still Now

Tuberculosis is the leading

infectious diseasecause of deathand

represents more than a quarter ofthe world's preventable deaths.


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Tuberculosis: Estimates in Bangladesh

ARTI: 2.14% 50% of adult population infected Incidence rate all cases: 223 / 100 000 / yr Incidence rate (New P+): 100/ 100 000 / yr >300,000 New Sm+ PTB cases expected per year 70,000 estimated deaths due to TB every year Ranks 6 th on the list of 22 highest TB burden

countriesOne TB death every 10 minutes

One New TB case every 2 minutes


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TB High Burden Country: 5 in SEA-Region

1. India2. China3. Indonesia4. South Africa5. Nigeria6. Bangladesh7. Ethiopia8. Pakistan9. Philippines10. DR Congo,11. Russian Federation

12. Vietnam13.Kenya14. Tanzania15. Uganda16. Brazil17. Mozambique18. Thailand19. Myanmar20. Zimbabwe21. Cambodia &22. Afghanistan


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TB Burden: Global Cases (all forms), 2012

80%

(SEAR = 38%)

20%

All OtherCountries

1. India (22%)

2. China

3. Indonesia (7%)

4. Nigeria

5. South Africa

6. Bangladesh (4%)

7. Pakistan

8. Ethiopia

9. Philippines

10.Kenya

11.DR Congo

12.Russia Federation

13.Vietnam

Top 22Countriesharbor 80%of Global TBburden


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NTP Bangladesh: Goals & Objectives

Goal: to reduce the incidence of TB until it is no longer a public health

problem, by diagnosing and treating effectively as many TB patients aspossible, especially those whose sputum is smear-positive (Infectiouscases)

Objectives : to increase

40%

85%

10%

70%

1991 2005 1991 2005

Cure RateDetection Rate


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Detection of New Smear Positive Case: 72% National average

during 2011

Treatment success rate : 92%

40%

85% 92%

10%

70% 72%

1991 2005 2010 1991 2005 2011

Cure RateDetection

Rate

Source is Smear positive TB

One person with infectious TBinfects between 10 and 15 people on

average in one year.


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Transmission of infection Transmission occurs by airborne

spread of infectious droplets. The

source is sputum smear-positive TB

Coughing produces tiny infectious

droplets (droplet nuclei). One cough

can produce 3,000 droplet nuclei.

Transmission generally occurs

indoors, where droplet nuclei can stay

in the air for a long time.


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Contact with TB Bacilli

90% NOT SICKWITH TB

10% DEVELOP

TB

Immediately5%

Later inLife 5%


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Prevalence of different types of TB

In Endemic countriesEP15%

Pulmonary85%

Sm ve; 1/3

Sm +ve; 2/3

WHY SPUTUMMICROSCOPY?


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Suspect PTB:

Cough for 3 weeks or more Haemoptysis of any duration

Low grade Fever (evening) Loss of weight/wasting Chest pain, dysponea

Refer suspects/cases to UHC/CDC for sputum

Examination (Diagnosis) & Treatment.


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Suspects: Cough 3 weeks or more

3 X Sputum for AFB If 2/3+ve

If 1 +ve,X-Ray &evaluation

If Negative, Broad Spectrum Antibiotic 10-14 days

( Exclude Quinolones )

If symptoms persist,repeat AFB smears, X-Ray

If consistent with TB

Anti-TB Treatment

Diagnostic Algorithm


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Role of Chest X-ray No chest X-ray pattern is absolutely typical

of TB

10-15% of culture-positive TB patients notdiagnosed by X-ray 40% of patients diagnosed as having TB on

the basis of x-ray alone do not have activeTBX-ray is unreliable for diagnosing andmonitoring treatment of tuberculosis


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NTP Regimens :

TreatmentCategory

Present Regimen Indication

Cat 1 2EHRZ/4HR All New cases

Cat 2 2SEHRZ1EHRZ/5EHR NOT NEWcases


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Types of Patients

New : Patients who never took treatment before or took treatment


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DOTS Strategy: 5 basic components

to ensure necessary politicaland financial support

cost effective diagnosis:

focus on smear-positives,passive case finding,direct microscopyof sputum for AFB

effective treatment of TB:short-course, standardized,multi-drug, directly

observed treatment (DOT)Cure is the best prevention

to ensure uninterruptedsupply of drugs and labreagents

to follow the patient and monitorthe progress of treatment;standard forms, cards and registers;cohort analysis

1. Government Commitment2. Case Detection through sputum microscopy3. Short-Course Chemotherapy4. Supply System5. Recording and Reporting


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25%

95%

60%50%

2%10%

25%

2%

30%

No Treatment (after 5years)

DOTS Non-DOTS

Cured

Dead

Chronic

Tuberculosis: outcome in differentconditions

Likely

MDR


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Prevention & Control Early Diagnosis = Reduced time of transmission Prompt, Effective Treatment = Reduced time of

transmission & Elimination of source of infection= No transmission = Reduced burden of disease

Improving housing conditions allowing properventilation & sunlight = reduced bacterialconcentration in the air, bacteria killed by sunlight

= reduced infection Improved Immunity through balanced diet (Poor people, can they have balanced diet?)


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Does BCG prevent TB infection or

TB Disease? BCG contains live attenuated TB bacilli BCG vaccination means artificially infecting the

child with an aim to produce antibody against TB bacilli

If TB bacilli is inhaled, immune cells capture the bacilli in lung & thus prevent from rapid spreadwithin & outside the lungs. So no TB meningitis

& no Milliary TB (the two dreadful TB in child) In high endemic countries BCG is not given toadults because they are already exposed to TB

bacilli.


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Different ACSM Activities Carried out in 2013:

Name of the Activities

2013Planned Done

Session Participants Session Participants

TB Club Meeting 319 7975 319 8096

Orientation of Non Graduate PPs 76 1900 76 1898

GP Orientation 23 460 23 355

Orientation on TB & HIV 16 400 16 396

Women Group Orientation 4 100 4 100

Retraining of Multipurpose Health Staff ofSR

2 40 2 40

Training on MDR TB Management 1 20 1 19

Folksong 24 0 24 0

Observe World TB Day 27 0 27 0


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Trends of TB suspect & New P+VE Case / 100000 population & positivity rate since 2009 to 2013

753663 630 620 657

38 35 33 35 31

5.36 5.8 5.65 5.93 5.13

1

10

100

1000

Suspect New P(+) Case Posit. Rate

Suspect 753 663 630 620 657

New P(+) Case 38 35 33 35 31

Posit. Rate 5.36 5.8 5.65 5.93 5.13

2009 2010 2011 2012 2013


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TB Case Notification/100000 pop. (All Forms) Since 2009-2013

31

3533

3538

3344

5

11

9101011

1616161514

6565 646667

0

10

20

30

40

50

60

70

80

P+ New P+ Re P - New EP New All Forms

P+ New 38 35 33 35 31

P+ Re 5 4 4 3 3

P - New 11 10 10 9 11

EP New 14 15 16 16 16

All Forms 67 66 65 65 64

2009 2010 2011 2012 2013


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Trend of Died , Default & Failure Rate Among New P(+)ve Cases Since: 2008-2012

2%

4% 4%

88% 87% 89% 89% 91%

2%

3% 3% 2%

4% 4%3%

4%3%

3%4%3%

1%

10%

100%

Cured Default Failure Died

Cured 88% 87% 89% 89% 91%

Default 2% 3% 3% 2% 2%

Failure 4% 4% 3% 4% 3%

Died 3% 4% 3% 4% 4%

2008 2009 2010 2011 2012


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Chemo prophylaxis

No of child eligible for chemo during 2013 653

No. of child received chemo during 2013 562

No. of child received chemo in 2012

% completed chemo of cohort 2012

406

369

(91%)


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MDR-TB in Bangladesh

No national survey/surveillance data

WHO 2012 : MDR TB among New Case 2.1%,

Among Retreatment 28%.

Difficult to diagnose & treat; less effective,

costly, extra burden on health system;Preventable (Results from inadequatetreatment at NTP and/or private level).
http://f/Publications/Books/TB%20BD%20WHO%2009.pdfhttp://f/Publications/Books/TB%20BD%20WHO%2009.pdf


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DF MDR TB project Trial project TO DEVELOP a cost effective

standard MDR TB treatment regimen

Globally NO Randomized Controlled ClinicalTrial on treatment of MDR TB (limitations)

Current recommendations (WHO regimen) based on expert opinion


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Information on MDR TB of Greater Faridpur.

Year Total started Cured Died Default Failure

2007 28 26 2 0 0

2008 17 14 1 2 0

2009 29 25 3 1 0

2010 17 14 2 0 1

2011 22 18 0 2 22012 17 17 0 0 0

2013 24 (01 XDR)


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Fi i l i ti ti t (X FNAC / Bi MDR


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Financial investigation support (X-ray, FNAC / Biopsy, MDRand other test) for P-ve, EP, MDR & Child TB Suspect

(The investigations must be advised by Doctor)

Investigation Description Amount

X-ray & otherInvestigation &

travel fare 1500/

FNAC, Biopsy &

other

Investigation &travel fare 3000/

MDR TB & otherInvestigation &

travel fare 3000/


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Together we canMake it happen


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Please Join us tomake Bangladesh aTB free country withyour expertise

Our Appeal


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