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DOTS MANAGEMENT

IN TUBERCULOSIS Zul Dahlan

Subdivision PulmonologyDepartment of Internal Medicine

Medical Faculty of Padjadjaran University

Hasan Sadikin Hospital , BANDUNG

Minilecture

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INTRODUCTION

Tuberculosis is an infectious disease that

remain to be a major health problem inthe world including Indonesia.

Indonesia like other countries had adaptedWHO DOTS strategy for national TB controland had succeed in variety of setting.

This presentation will disclose a few aspectin the implementation of DOTS in themanagement tuberculosis, in pulmonaryand extrapulmonary sites.

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MICROSCOPIC EXAMINATION

More objective and reliable than chest x ray

0

10

20

30

40

50

60

70

8090

100

AFB Exam Chest xray

98%

70%

Agreement of medicaPractitioner

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CHEST X-RAY EXAMINATION

Causing over- diagnosis of TB

0

10

2030

40

50

60

70

80

90

100

Suspect with positive

Chest x-ray

True positive TB case

OVER DIAGNOSIS

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FACTORS THAT PLAY ROLE IN THEMANAGEMENT OF TB

1. MYCOBACTERIUM: . SPECIES

- . VIRULENCE

2. HOST :. IMMUNITY . ADHERENCE

3. MANAGEMENT

& MEDICINE

CURED

INTERACTION

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ASPECT OF TREATMENT

FAILURE IN TUBERCULOSIS

1. ETIOLOGIC DIAGNOSIS :

- TB MANIFESTATION MICOBACTERIOSIS

2. HOST :

- IMMUNITY DEFICIENCY3. DRUG ASPECT :

- RESISTANT MYCOBACTERIUM

- ADHERENCE TO THERAPY

4. SOURCE OF INFECTION :

- EASIER TRANSPORTATION BETWEEN COUNTRIES

AFB/ PA/ DNA

EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY

- ADHERENCE TO TB THERAPY – DOTS METHOD

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. Pleura : 16,2 %. Meningeal : 9,9 %

. Peritonitis : 8,3%

. Spondylitis : 4,0 %

. Limphadenitis: 2,2 %

. Pericarditis : 1,0%

.Coxitis : 1.0 %. Supracondylus : 0.7 %

. Skin : 0,4 %

. Sinovitis : 0,3 %

. Hepar : 0,1 %

. Renal : 0,1 %

• PULMONARY TB 55 %

TB MANIFESTATION AT HASAN SADIKIN HOSPITAL

• EXTRAPULMONARY TB 45 %

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1. ETIOLOGY

TABLE - GROUP OF MYCOBACTERIUM FOUND IN

PATIENT DIAGNOSED TUBERCULOSIS

83,1%

16,9%

MTC49,3%

MNTB50,7%

SLOW

GROWING

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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

4 3 1 2 1 1 1 1 0 0 0

14

6 4 0

10

3 1 3 1 1 0 1 0 1 1 0

12

4 3 1

8

3 0 0 0 0 2 0 1 0 0 1 7

12 5 0

17

1 1 0 0 1 0 0 0 0 0 0 3

0 0 0 0

11 5 4 3 3 3 2 2 1 1 1

36 (50,7%)

22 12 1

35 (49,3%)

Mycobact‟rium Species

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2. HOST FACTOR

. GENETIC SENSITIVITY TO TB :- FAMILIAL SYNDROMES : DISSEMINATION POST BCG

- MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN FUNCTION

. INADEQUATE DRUGS DOSAGE

. COMPLIANCE

EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY

- ADHERENCE TO TB THERAPY –> DOTS METHOD

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COMPLIANCE

TB Patient frequently did not have their medicine

regularly and continuously because of :

Limited effort because of false understanding :

. Stopping medicine halfway because they are

feeling better TB relapse again

. “Taking the medicine too long “

. “Medicine too much”

High cost of therapy

Drug side effect/ untoward effect

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WITH TUBERCULOSIS :

- Treatment is more than treatment

- Treatment is prevention of :

. further spreading of infection

. further process of disease

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DOTS

Direct Observed Treatment Short-Course

ACCURATE DIAGNOSIS,ADEQUATE PERIOD

FREE ANTI TB DRUGS

TAKING DRUGS UNDER SUPERVISING

MONITORING AND EVALUATION

POLITICAL

COMMITMENT

INCLUDING

FINANCIAL SUPPORT

AKING COMBINATION DRUGS ON SUFFICIENT DOSAGE,

REGULARLY, AND CONTINOUSLY

CURED

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BASIC PRINCIPLES OF ANTI

TUBERCULOSIS DRUGS

Drug is effective during active multiplication

phase of mycobacterium, not in dormant phase

Use combination of 4 – 5 drugs, for 6 mo. or more

Use of still effective drug for etiologic

mycobacterium

Patient has to take the medicine regularly,

continuously in adequate dosage and period

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CLASSIFICATION TB :

Related to 4 aspects :- Organ involved in TB process : lung/ extra-lung

- result of sputum examination : AFB (+)/ AFB (-)

- Previous history of TB therapy :

. New/ exacerbation, relapse, migration/ drop out,

failure- Degree of severity of disease: mild or severe

DECISION ON CATEGORY OF THERAPY

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IMPLEMENTATION OF TB THERAPY

Aspect –aspect :

Decision on the category of TB therapy

Therapy supervising :

. Healthcare officer, family, friend, etc

Monitoring of sputum ACB, during :

- intensive period

- the end of therapy/ 1 month before the

- follow up of sputum conversion

Monitoring of therapy :

- cured, drop out, not cure

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THE CHOICE OF ANTITUBERCULOSIS DRUG BASED

ON CATEGORIES

Alternative of Combined Drug

CategoryOf therapy

Classification and Type of TBPatient TB

Intensive phase(daily or 3x /

week)

Late Phase

I New case AFB (+)

New case AFB (-)

Chest x-ray (+) with advanced lung

damage/ severe diseaseNew 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

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MULTI DRUG RESISTANCETB

(MDR TB)

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DEFINITION OF RESISTANCE

Mono Resistant:Resistant to 1 drug:: OAT:H/ R/ S/ E

Multi Drug Resistance (MDR) :

Minimally resistant to INH and Rifampisin:

H+R/ H+R+S/ H+R+E. Poly Resistant :

Resistant to a few OAT exept INH & Rifampisin:H+S+E/ S+E/ H+E.

Extensive Drug Resistance (XDR):MDR resistant also to fluoroquinolon and kanamicin/amikacin/ capreomicyn:MDR+Cipro+kana/ MDR+cipro+ami.

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Causes of Drug resistant TB

Due to physician – inappropriate drug, dosage

and duration

Due to patient – compliance, malabsorption,

financial,

Due to drug – substandard formulation, poor

bioavailability

Due to health care – non availability source was

MDR TB

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Treatment of Poli/ MDR :

More difficult, costly, and more

side effect

Individualized :

- “tailor made” - Package

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MANAGEMENT OF MDR

DOTS Plus Strategy Base on :

Anamnesis.

Diagnosis berdasarkan laboratorium.

Pengobatan berdasarkan laboratorium. Evaluasi pengobatan berdasarkan

laboratorium.

Evaluasi efek samping, faal hati, faal ginjal,dll berdasarkan laboratorium.

Lama pengobatan min. 18 bln, dg tahapintensif 6 bln paduan mengandung OATsuntik.

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Indonesia :22 High Burden Countries1. India

2. China

3. Indonesia4. Bangladesh5. Nigeria

6. Pakistan

7. South Africa

8. Philippines

9. Russia

10. Ethiopia

11. Kenya

12. DR Congo

13. Viet Nam

14. UR Tanzania

15. Brazil

16. Thailand

17. Zimbabwe

18. Cambodia

19. Myanmar 20. Uganda

21. Afghanistan

22. Mozambique

Indonesia 10%

Bangladesh 4%

China

15%

India

30%

Other

28%

Philippines 3%

Pakistan 4%

Nigeria 3%

South Africa 2%

Russia 1%

Penyebab kematian terbanyak penyakit

infeksi (SKRT 1995) 583.000 kasus baru/tahun, 140.000 kematian

/tahun (WHO)

BACKGROUND OF TB PROBLEM IN

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BACKGROUND OF TB PROBLEM INDEVELOPING 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

World Health

E ti t d A l I id f TB i S l t d

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World Health

Organization

Country

1. India

2. China3. Indonesia

7. Philippines

8. Pakistan10. Russia

13. Viet Nam

22. Afghanistan

1,008,937

1,275,133212,092

75,653

141,256

145,491

78,137

21,765

184

107280

330

175

132

189

321

1,856

1,365595

249

247

193

148

70

Population(thousands

)

Cases(thousands

)

Rate x105

Estimated Annual Incidence of TB in SelectedHigh Burden Countries, 2000

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Background Indonesian situation :

- population : 222,781,000

- global rank : 3

- incidence : 239 (239/100,000/year)

- incidence of new cases : 108(108/100,000/year)

- prevalence : 262 (262/100,000/year)

- mortality : 41 (41/100,000/year)

- co-infection TB/HIV : 0,8%- MDR-TB : 1,6%

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The Global Plan

The Regional Plan

Country Plans

A pessimist sees the difficulty in every opportunity:

an optimist sees the opportunity in every difficulty.

Sir Winston Churchill

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Global Strategy to Stop TB 2006-

2015

1. Pursuing quality DOTS expansion and enhancement• Government commitment with long-term planning and adequate resources

to reach targets

• Case detection : bacteriology and strengthening of laboratory network

• Standardised treatment, under proper case management conditionsincluding DOT and patient support

• Effective and regular drug supply system

• Monitoring system for supervision and evaluation, including impactmeasurement

2. Additional components 1 Addressing TB/HIV and MDR-TB2. Contributing to health system strengthening3. Engaging all care providers

4. Empowering patients and communities

5. Enabling and promoting research Stop TB Department

Th S TB S d h R i l

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The new Stop TB Strategy and the Regional

Strategic Plan, 2006-2015

Sustaining and enhancingDOTS to reach all TBpatients, improve casedetection and treatmentsuccess

Establishing interventionsto address TB/HIV andMDR-TB

Forging partnerships,including with communities,to ensure equitable access

to international standards of TB care for all

Contributing tostrengthening healthsystems

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DOTS Success Story

DOTS the internationally recommended controlstrategy was launched in 1994

The DOTS framework has subsequently beenexpanded and implemented in 182 countries.

DOTS implementation has helped countries toimprove national TB control programmes (NTPs)and make major progress in TB control

By 2004, more than 20 million patients

had been treated in DOTS programmesworldwide and more than 16 million of them

had been cured.

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HEALTH CENTER INVOLVED IN DOTS

< 60 %

60 - 80 %

81 - 100 %

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Hospital distribution(absolute numbers)

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Coverage of DOTS Services in National TB

Program

PUSKESMAS

(N 7489)

98.5%

HOSPITAL,

LUNG CLINICS

(N 1316)

37%

GPs etc ??Source of Thy

failure, MDR-TB,

TB-HIV, XDR

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The practices of TB care among

doctors in private sector

Over diagnosis and under diagnosis

Over treatment and under treatment

Chest X-ray regarded as the most important

diagnostic tool Sputum smear is mostly neglected

Non standard tests gaining popularity (serology,PCR etc)

Incorrect use of anti TB drugs (regimen, doses,duration, compliance)

Eur Respir J 2006; 28: 687 –690

Lead to substandard

care and failure

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Extension of DOTS Service inHospital through Hospital DOTS

Extension of PPM (Public PrivateMix) (DPS, Jail, Army/ Police

Dept.) Extended of working cooperation

with LSM with Health Service

DOTS in Work Place

Extension of workingcooperation with MedicalProffesion to facilitate DOTS

ISTC & PCTC (Patients’ charter for TB Care)

Involvement of A l l Health Personnel &

health centers

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ISTC TB Training Modules

2009

Audience: all health care practitioners, publicand private

Scope: diagnosis, treatment, and public

health responsibilities; intended tocomplement local and national guidelines

Rationale: sound tuberculosis control requires the effective engagement of all

providers in providing high quality care and incollaborating with TB control programs

ISTC: Key Points

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ISTC Objectives

The Standards are intended that all care

provider delivered high quality care:

for patients of all ages, those with sputum

smear (+), sputum smear (-), and extra

pulmonary TB

TB caused by drug-resistant M

tuberculosis complex

TB + HIV

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2009

ISTC: Key Points (Edition 1)

17 Standards Differ from existing guidelines: standards

present what should be done, whereas,guidelines describe how the action is to be

accomplished Evidence-based, living document

Developed in tandem with Patients’ Charter

for Tuberculosis Care

Handbook for Using the International Standards for Tuberculosis Care

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2009

ISTC: Key Points (Edit. 2- 2009)

21 Standards

Original Standards were renumbered andnew Standards were written

Evidence-based, living document, will requirefuture revisions as well

ISTC Tuberculosis Training Modules andFacilitator‟s Guide were updated and

developed to be in agreement with Edition 2of the ISTC

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2009

ISTC Standard 1

All persons withotherwise

unexplained

productivecough lasting

two-three weeks

or more shouldbe evaluated for

tuberculosis

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The Indonesian Version of ISTC

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ISTC in Indonesia

Indonesian Standard for TuberculosisControl

Is accepted and being endorsed byseveral profession organization

In socialization phase

Has been disseminated and implementedin Jakarta, West Java, East Java, andCentral Java as pilot project

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Goals

Equitable quality DOTS for all- To standardize the care of TB patients in

variety of different providers

- To provide high quality of care- Improve CDR, cure rate

- Prevention of MDR

- Reduce mortality

- Cover co-infection TB/HIVThe first priority is to endorse and implement ISTC

among private physicians and hospitals

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DOTS PROGRAM AT HASAN SADIKIN HOSPITAL

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DOTS PROGRAM AT HASAN SADIKIN HOSPITALBANDUNG

TB PATIENTS

OTHER

CLINICS

NEURO

CLINIC

ORTHO

PAEDICCLINIC

INTERNAL

MEDICINECLINIC

PEDIATRIC

CLINIC

TBE (+)THERAPY (+)

TBP +/- TBE

THERAPY

TBP +/- TBE

THERAPY

DOTS

CORNER

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Concl sion 1

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Conclusion 1 1.

TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM ININDONESIA WITH A HIGH MORBIDITY AND MORTALITY RATE .

2. STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN EFFECTIVEMETHOD TO ERADICATE UBERCULOSIS. IT MUST BE DONENATIONALLY AND SUPPORTED BY WHOLE COMMUNITY WITH

ADEQUATE PERSONNEL, MEDICINE, AND FINANCIAL.

3. RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHERSPECIES MAY HAMPER THE ERADICATION OF TUBERCULOSIS

AND MYCOBACTERIOSIS.

ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC AGENTMUST BE DONE WHICH WILL BE HELPFUL IN TREATING THERESISTANT SPECIES.

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Conclusion 2

The result of Indonesian National TBProgram was encouraging

However, Puskesmas gave the biggest

contribution to successful outcome The problems lie on Hospitals and Private

providers

The Implementation of ISTC expected tobe complimentary to existing DOTSprogram

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TB Epidemic

DOTS

HIV Epidemic

W ki f h

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Working groups of the

Stop TB Partnership

1. DOTS Expansion

2. DOTS-Plus

3. TB/HIV

4. Drugs

5. Diagnostics

6. Vaccines

7. Advocacy, Communication & Social

Mobilization

GP2Analysis of

costs and

benefits

Stop TB Department

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THANK YOU

WIPE OUT MYCOBACTERIUM

……….. THE VICIOUS ENEMY

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