TB control in risk groups DOTS-plus

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TB control in risk groups DOTS-plus. Lucica Ditiu, Antalya, April 2005. Risk of being exposed: no. of cases capable of transmitting M.tb , duration of infectiousness, no. and duration of encounters between a source and susceptible persons - PowerPoint PPT Presentation

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  • TB control in risk groups DOTS-plus

    Lucica Ditiu, Antalya, April 2005

  • Risk of being exposed: no. of cases capable of transmitting M.tb, duration of infectiousness, no. and duration of encounters between a source and susceptible personsRisk of becoming infected: no. of droplets produced by an infectious case, the volume of air, the inhaling period Risk of becoming sick after infected

  • Risk groupsClose contacts of persons known or suspected to have TB, infants and children esp.Persons infected with HIVPersons with medical factors known to increase the risk of progression from infection to disease: silicosis, gastroectomy, diabetes mellitus, chronic renal failure, jejunoileal by-pass, some hematological disorders (leukemia, lymphomas), other malignancies, treatment with high dose corticosteroid therapy and other immunosuppressive, weight 10% or more below ideal body.Alcoholics and iv drug usersResidents of facilities such as: correctional institutions, prisons, mental institutions, nursing homes, long term facilities for elderlyForeign born persons from countries with high TB prevalence, recently enterred a countryHealth and other category of workers in hospitals and other health care facilities, especially serving the high risk groups

  • These groups are now high priority, may decline in risk over time!!!Responsibility of national public health officials to identify the risk groups using the national data

  • Risk of being exposed: no. of cases capable of transmitting M.tb, duration of infectiousness, no. and duration of encounters between a source and susceptible personsRisk of becoming infected: no. of droplets produced by an infectious case, the volume of air, the inhaling period IDENTIFY THE TB CASES AS QUICK AS POSSIBLE WHEN THEY PRESENT TO THE HEALTH CARE FACILITIESPLACE THE CASES ON EFFECTIVE TREATMENT, WITH THE REQUIRED FREQUENCY AND DURATIONIMPROVE/INTRODUCE INFECTION CONTROL MEASURES IN SPECIAL SETTINGS PRISONS, HOSPITALS, LABORATORIES

  • will not prevent the new TB cases to appear from individuals infected long time ago!

  • Latent TB Infection (LTBI)Identify LTBI skin test (only for infection!)Rule out active TB clinical history, physical examination, chest X-ray, bacteriological exam.Think about treatment of LTBI: can potentially reduce the risk of developing active TB versus hepatotoxicity, non-adherence, drug resistance (inefficient/creating), operational problems, cost.

  • Children under 5 years old contacts with positive TB case (household)INH 5 mg/kg for 6-12 mosPersons infected with HIV and M.tb (annual risk of developing TB among HIV + is 6-16% in comparison with a lifetime risk of 10% for HIV-)INH daily 9 mosRMP + PZM daily 2 mos

  • TB and HIVHIV is the most powerful factor known to increase the risk of TBHIV increases susceptibility to M.tb and the risk of progression from infection to diseaseBetween 1% and 70% (sub-Saharan African countries) of TB patients are HIV +

  • 75-85% of all HIV cases in Europe are male30-70% of all HIV cases are among younger than 25 years Groups vulnerable to HIV: IDU, immigrants, ethnic minorities, prisoners, sex workersMainly IDU-related HIV transmission in Eastern Europe Up to 30% of HIV infected females are IDU and 50% are partners of IDUSimilarities with the TB pattern: mostly males, younger in the East, older in the West, prisoners, immigrants

    HIV epidemic features in EUR

  • Russia 11th of the 22 TB high-burden countriesNew TB cases notified by area; EUR, 1980-02

  • New HIV cases notified by area; EUR, 1995-03

  • Diagnosis and treatment: Immunity only partial compromised features are typical for TBClinical: less cough, less haemoptysisBacteriology: proportion of smear negative is greater; fewr organisms in sputumChest X-ray: normal typical atypicalTB drugs: Short course chemotherapy with RMP, given under DOTNo thioacetazoneAttention to SM!ARVs: can determine development of active TB in a HIV+ LTBI or worsening the symptomsProtease inhibitors and Non Nucleoside Reverse Transcriptase / RMP.

  • DRUG RESISTANT TUBERCULOSIS IS A MAN MADE PROBLEM!RESISTANCE TO ANTI-TB DRUGS IS THE RESULT OF A CHROMOSOMAL MUTATIONDEVELOPMENT OF DRUG RESISTANCE IS THE RESULT OF INADEQUATE THERAPY PHYSICIAN ERROR, LACK OF DRUGS, LACK OF ADHERENCE (ADHERENCE TO SELF ADMINISTERED MEDICATION IS UNPREDICTABLE)

  • Drug Resistance Surveys3 Global Projects on DR (1997/35, 2001/58 and 2004/77 settings)New cases55.779 patients surveyed/75 settingsPrevalence of any resistance 0-57% in KazakhstanPrevalence of MDR TB 014.25% in KazakhstanIncreasing trends in MDR TB : Tomsk Region and PolandIncrease due to: poor/worsening TB Control, immigration of patients from areas of high resistance, outbreaks of DR and variations in surveillance methodologies.

  • Drug Resistance SurveysPreviously treated cases8,405 patients surveyed/66 settingsHighest prevalence of any resistance 82.1% in KazakhstanHighest prevalence of MDR TB 58.3% in OmanIncreasing trends for MDR TB : Estonia, Lithuania and Tomsk region.

  • Prevalence of MDR by treatment status, ranked by new cases

    Chart4

    14.256.4

    14.220.8

    13.743.6

    13.240.2

    12.245.3

    10.424.4

    9.453.3

    9.327.1

    7.836.6

    4.924.8

    New

    Previous

    % Prevalence MDR

    Sheet1

    Trends AnyR Rtmt199419951996199719981999200020012002

    Hong Kong11.69.212.87.79.211.2

    Canada3.23.73.24.2

    Switzerland1510.53.5

    Slovakia10.84.11.8

    Tomsk Oblast31384647.9

    Cuba17.472.6

    Estonia19.23948.345.342.137.5

    France6.76.29.411

    Sheet1

    19941994199419941994199419.2

    1995199519951995199519951995

    11.6199619961996199617.41996

    9.23.2151997199719971997

    12.83.7199810.831739

    7.73.210.54.11999199948.3

    9.24.23.51.8382.645.3

    11.220012001200146200142.1

    200220022002200247.9200237.5

    Hong Kong

    Canada

    Switzerland

    Slovakia

    Tomsk Oblast

    Cuba

    Estonia

    year

    % prevalence resistance

    RMP resistance among previously treated cases

    Tables

    19941994199419941994199419.2

    1995199519951995199519951995

    11.6199619961996199617.41996

    9.23.2151997199719971997

    12.83.7199810.831739

    7.73.210.54.11999199948.3

    9.24.23.51.8382.645.3

    11.220012001200146200142.1

    200220022002200247.9200237.5

    Hong Kong

    Canada

    Switzerland

    Slovakia

    Tomsk Oblast

    Cuba

    Estonia

    % prevalence resistance

    Trends in RMP resistance among previously treated cases

    Hotspots

    Trends R Rtmt199419951996199719981999200020012002

    Hong Kong..91/783 (11.6).34/266 (12.8)17/220 (7.7)19/207 (9.2)19/169 (11.2).

    Canada...5/156 (3.2)5/135 (3.7)4/124 (3.2)5/119 (4.2)..

    Switzerland...6/40 (15.0)6/57 (10.5)2/57 (3.5)..

    Tomsk Oblast....72/232 (31.0)46/121 (38.0)64/139 (46.0)56/117 (47.9)

    Slovakia....16/157 (10.8)5/122 (4.1)2/110 (1.8)..

    Cuba..4/23 (17.4).3/43 (7.0)1/38 (2.6)..

    Estonia5/26 (19.2)...32/82 (39.0)43/89 (48.3)53/117 (45.3)45/107 (42.1)36/96 (37.5)

    France.13/195 (6.7).4/65 (6.2)10/106 (9.4)9/82 (11.0)..

    MDR N

    SettingNewPrevious

    Kazakhstan14.256.4

    Israel14.220.8

    Tomsk Oblast13.743.6

    Karakalpakstan, UZB13.240.2

    Estonia12.245.3

    Liaoning Province10.424.4

    Lithuania9.453.3

    Latvia9.327.1

    Henan Province7.836.6

    Ecuador4.924.8

    MDR P

    SettingPreviousNew

    Oman58.30

    Kazakhstan56.414.2

    Lithuania53.39.4

    Estonia45.312.2

    Tomsk Oblast43.613.7

    Orel Oblast42.22.6

    Karakalpakstan, UZB40.213.2

    Egypt38.42.2

    Henan Province36.67.8

    14.256.4

    14.220.8

    13.743.6

    13.240.2

    12.245.3

    10.424.4

    9.453.3

    9.327.1

    7.836.6

    4.924.8

    New

    Previous

    % Prevalence MDR

    MDR Hotspots ranked by prevalence among new cases

    00

    00

    00

    00

    00

    00

    00

    00

    00

    00

    New

    Previous

    Setting

    % Prevalence MDR

    MDR Hotspots

    00

    00

    00

    00

    00

    00

    00

    00

    00

    00

    New

    Previous

    Setting

    % Prevalence MDR

    MDR Hotspots

    58.30

    56.414.2

    53.39.4

    45.312.2

    43.613.7

    42.22.6

    40.213.2

    38.42.2

    36.67.8

    Previous

    New

    % Prevalence MDR

    MDR Hotspots ranked by prevalence among previously treated cases

  • Chart6

    58.30

    56.414.2

    53.39.4

    45.312.2

    43.613.7

    42.22.6

    40.213.2

    38.42.2

    36.67.8

    Previous

    New

    % Prevalence MDR

    Settings with MDR prevalence above 30% in previously treated cases

    Sheet1

    Trends AnyR Rtmt199419951996199719981999200020012002

    Hong Kong11.69.212.87.79.211.2

    Canada3.23.73.24.2

    Switzerland1510.53.5

    Slovakia10.84.11.8

    Tomsk Oblast31384647.9

    Cuba17.472.6

    Estonia19.23948.345.342.137.5

    France6.76.29.411

    Sheet1

    19941994199419941994199419.2

    1995199519951995199519951995

    11.6199619961996199617.41996

    9.23.2151997199719971997

    12.83.7199810.831739

    7.73.210.54.11999199948.3

    9.24.23.51.8382.645.3

    11.220012001200146200142.1

    200220022002200247.9200237.5

    Hong Kong

    Canada

    Switzerland

    Slovakia

    Tomsk Oblast

    Cuba

    Estonia

    year

    % prevalence resistance

    RMP resistance among previously treated cases

    Tables

    19941994199419941994199419.2

    1995199519951995199519951995

    11.6199619961996199617.41996

    9.23.