新編tbcontrolinriskgroupsdotsplus結(jié)核病控制風(fēng)險集團點加

1、TB control in risk groups DOTS-plus,Lucica Ditiu, Antalya, April 2019,,Risk of being exposed: no. of cases capable of transmitting M.tb, duration of infectiousness, no. and duration of encounters between a source and su

2、sceptible 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 groups,Close contacts of persons known or s

3、uspected 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, chron

4、ic 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

5、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 T

6、B 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

7、 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.

8、 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

9、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, HOSPIT

10、ALS, 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 histor

11、y, 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/creati

12、ng), 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

13、 comparison with a lifetime risk of 10% for HIV-)INH daily 9 mosRMP + PZM daily 2 mos,TB and HIV,HIV is the most powerful factor known to increase the risk of TBHIV increases susceptibility to M.tb and the risk of pro

14、gression 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 vu

15、lnerable 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 t

16、he 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 countries,New TB cases notified by area; EUR, 1980-02,,,,New

17、 HIV cases notified by area; EUR, 2019-03,,Diagnosis and treatment: Immunity only partial compromised – features are typical for TBClinical: less cough, less haemoptysisBacteriology: proportion of smear negative is gr

18、eater; 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 H

19、IV+ 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 MUT

20、ATIONDEVELOPMENT 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 Surveys,3 Globa

21、l Projects on DR (2019/35, 2019/58 and 2019/77 settings)New cases55.779 patients surveyed/75 settingsPrevalence of any resistance – 0-57% in KazakhstanPrevalence of MDR TB – 0–14.25% in KazakhstanIncreasing trends i

22、n 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 Sur

23、veys,Previously 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

24、and Tomsk region.,Prevalence of MDR by treatment status, ranked by new cases,5 components of DOTS - Plus,Sustained political commitmentDiagnosis of MDR-TB through quality-assured culture and drug susceptibility testing

25、 (DST).Appropriate treatment strategies that utilize second line drugs under proper management conditions. Uninterrupted supply of quality assured reserve antituberculosis drugs. Recording and reporting system desi

26、gned for DOTS-Plus programs.,Sustained political commitment,Long term investment in human and financial resourcesCoordination efforts between community, local governments and international agencies A well functioning D

27、OTS program Addressing the factors leading to the emergence of MDR-TB,Proper triage of patients for DST and DOTS-PlusMost programmes cannot do DST on all patient. Only patients with an increased risk for resistance are

28、 tested.Some programmes will use strategies that target MDR-TB risk groups (failures, chronics).In some settings with high prevalence of MDR-TB, DST may be done on all patients.Relationship with SNRL,Diagnosis of MD

29、R-TB through quality-assured culture and DST,Appropriate treatment strategies that utilize second-line drugs under proper management conditions,Rational treatment designDirectly observed treatmentMonitoring and managem

30、ent of side effectsHuman resources,Uninterrupted supply of quality assured second-line drugs,Many challenges for drug procurementRegimens are frequently adjusted (side-effects, DST results, lack of treatment response

31、)Short shelf life (18 – 36 months)Limited global production of quality-assured drugsDrug registration may be a lengthy and costly,Recording and reporting system,Enables patient registrationmonitoring (including cult

32、ure, DST, laboratory tests…etc)interim indicators final outcome analysiscomparison of different cohorts,DOTS-Plus is far more complicated than DOTS,,,,Laboratory capacity: diagnosis and monitoring (culture, DST)Trea

33、tment designDOT during 18-24 monthsManagement of (frequent) side-effectsOften difficult patient categoriesDrug procurement and managementDOTS-Plus recording & reporting system,,,GLC-approved projects by March 20

34、19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

35、,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Applications under review by the GLC

36、,,,,,,GLC-approved DOTS-Plus projects,,,,,,,,,,,,,,,Countries preparing application,,,,,,,,,,,,,,,,33 projects11,000 patients,GLC-approved projects in EURO,Georgia – AbkhaziaLatviaKyrgyzstanMoldovaGeorgiaEstonia,Ka

37、rakalpakstan, UzbekistanRomaniaRussian FederationArkhangelskOrelIvanovoTomsk,Preliminary results of DOTS-Plus projects,More than 3000 patients have been enrolled and 1100 have completed treatmentMDR-TB among new c

38、ases in projects assessed range from 1.5-17.1%57% of the MDR-TB cases treated are resistant to all first line-drugs and also to second-line anti-TB drugs All 5 first DOTS-Plus pilot projects assessed use individualise

39、d treatment regimens; average number of drugs used is 5Treatment success rates range from 61-82%Only 2% of patients have stopped treatment due to adverse events,,Preliminary resultsTreatment outcomes in some DOTS-Plus

40、 sites,Recent developments,From pilot phase to expansion phaseMainstreaming DOTS-Plus (including DRS) into DOTSDOTS-Plus not longer limited to so-called "hot spots"Cat 4 regimens recognised as the standar

41、d of care for MDR-TBPolitics: EB resolution 114.R1, GFATMDOTS-Plus guidelines are under revisionSLD are used almost everywhere!,,,Conclusion,DOTS is priority to stop MDR-TB creationDOTS-Plus should be built upon

42、and fully integrated with DOTS – new vision of TB controlThe GLC provides access to reduced-cost quality-assured second-line drugs and technical assistanceAll GFATM financial support for MDR-TB must go through the GLC,

43、,DOTS-Plus is feasible under routine programme conditionsCountry-specific: Frame-work approach!Cost-effective interventionAcceptable-good results, even in difficult patient categoriesMainstreaming DOTS and DOTS P

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