Tuberkulosis Anak, DOTS, ISTC

Finny Fitry Yani

Courtesy :

UKK Respirologi Anak IDAI

World problems of Tuberculosis (TB)

• Global problem

• Neglected Childhood TB

• Low Case Detection Rate

• Lack of holistic approach of TB management

• Non-standardized management

Global burden of tuberculosis (TB)

• 1/3 of the population of the world have been infected • Prevalence: 17.22 million (1990s ) 11.1 million (2008 ) • New cases/year: 9.3 million (2007) 9.4 million (2008)

TUBERCULOSIS PROGRAMS

GOAL:

• to break the chain of the transmission for eliminating the disease from society.

Strategies:

1)case finding and treatment of active disease

2)treatment of LTBI

3)vaccination with BCG

National TB Programs (NTPs)= P2 TB Kemenkes

Focus on adult cases

Pediatric TB

DOTS (Directly Observe Treatment Short-course)

• A global strategy to combat world TB problems

• Developed by WHO and IUATLD

• Introduced in early 1990, implemented in Indonesia since 1994s

DOTS coverage in 2006: 98%

Komitmen Politis dan dukungan

semua pihak

1

WHO 1991

5 KOMPONEN DOTS

2

Diagnosis

mikroskopik

ANAK??

3

Pengawas Menelan Obat

4

Ketersediaan Obat

5

Pencatatan Pelaporan

Cure rate tinggi (pemutusan

rantai transmisi)

Paling cost effective (Bank

Dunia)

Rekomendasi WHO

Tujuh Strategi Utama Program Nasional Penanggulangan TB

”Equitable Quality DOTS Expansion Indonesia”

Ekspansi “Quality DOTS” 1. Perluasan & Peningkatan pelayanan DOTS

berkualitas

2. Menghadapi tantangan baru, TB-HIV, MDR-TB dll

3. Melibatkan Seluruh Penyedia Pelayanan

4. Melibatkan Penderita & Masyarakat

Didukung dg Penguatan Sistem kesehatan

5. Penguatan Policy & Kepemilikan Daerah

6. Kontribusi thd Sistem Pelayanan Kesehatan

7. Penelitian Operasional

SEMBUH

TB management in Indonesia

PHCs

Government Private

Private practices

Private hospitals

Government hospitals

Healthcare providers

BP4 RSP

GP Pulm

DOTS strategy

HOSPITAL DOTS LINKAGE (HDL)

TB IN HOSPITALS • Case finding : high

(DIY: hospital 36%; PHCs 27%; BP4 37%)

• Have no working area

• Case holding: low high dropped out (>50%)

• Low cure rate (< 50%)

SITES OF DIAGNOSIS OF TB

IN HOSPITAL

District Health

Service Hospitals

Lung Clinics PPTI Clinics,

WP,Lapas/Rutan

Community

Leader

PKK, PPTI

NGO

Private Doctors CHC

PRM / PPM

EXTERNAL NETWORKING

Option of TB management in HDL

Option Suspect finding

Diagnosis Treatment initiation

Continuing treatment

Consultation Recording and reporting

1.

2.

3.

4.

Hospital/non PHC

PHC

Alur Rujukan Penderita Tuberkulosis

Rumah Sakit Puskesmas

Koordinator

HDL Kab/Kota

Penderita, OAT,

TB.01, surat

rujukan (TB.09)

Wasor TBC

Kab/Kota

informasikonfirmasi

(TB.09)

REFERAL SYSTEM IN HDL

World problems of Tuberculosis (TB)

• The second global cause of death from infectious

agents

• Neglected Childhood TB

• Low Case Detection Rate

• Lack of holistic approach of TB management

• Non-standardized management

Non-standardized management

Diagnosis

Treatment

Public Health

irrational treatment

over diagnosis

underdiagnosis

contact tracing

Recording and reporting

ISTC (International Standard for TB care)

• Differ from existing guidelines

– standards what should be done

– guidelines how the action is to be accomplished

• Evidence-based, living document

• As a complementary of the existing guideline

Purpose of ISTC

ISTC

Diagnosis

Treatment

2 standards Public Health

6 standards

9 standards

Standards for Diagnosis Pediatric considerations

Standard 1

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

•COUGH is NOT the main symptom of TB •Other symptoms should be considered:

•weight loss or FTT in the last two months •fever >2 weeks with unexplained causes •Close contact with adult Pulmonary TB

Pediatric consideration

Standard 4

All persons with

chest radiographic

findings suggestive

of TB should have

sputum specimens

submitted for

microbiological

examination.

Collecting sputum in children is challenging

If possible, perform induced sputum

or gastric lavage

Pediatric consideration

Standard 6

The diagnosis of

intra-thoracic TB in

symptomatic

children with

negative sputum

smears should be

based on the

finding of chest

radiograph

The appearance of

lymphadenopathy is

subtle and may be

difficult to detect

especially in

malnourished children

and when there is HIV-

related pulmonary disease.

Pediatric consideration

Standards for Treatment pediatric considerations

Standard 8

All patients (incl those

with HIV infection) .....

regimen using drugs of

known bioavailability.

The initial phase should

consist of two months

of isoniazid, rifampicin,

pyrazinamide, and

ethambutol.

•Triple drugs:

INH, Rif and PZA

•Four or five drugs for severe TB

Pediatric consideration

Standards for Public Health

ISTC Standard 16

All providers of care for patients with TB should ensure that persons (especially children under 5

year of age and persons with HIV infection) who are in close contact with patients who have infectious

TB are evaluated and managed in line with international recommendations.

ISTC Standard 16

Children under 5 years of age and persons with HIV infection who have been in contact with an infectious case should be evaluated for both latent infection with M. tb and for active TB.

ISTC Standard 17

All providers must report both new and retreatment TB cases and their treatment outcomes to local public health authorities, in conformance with applicable legal requirements and policies.

Together in partnership we are more than the sum of our parts!