TUBERCULOSIS: THE PAST AND THE PRESENT. “The captain of all these men of death” 5800 BCItalyTB...
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Transcript of TUBERCULOSIS: THE PAST AND THE PRESENT. “The captain of all these men of death” 5800 BCItalyTB...
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TUBERCULOSIS:
THE PAST AND THE PRESENT
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“The captain of all these men of death”
5800 BC Italy TB spondylitis
(female skeleton)
1000 BC Egypt TB spine /psoas abscess
(Nespharan mummy)
400 BC Greece “Phthisis”
(Hippocrates)
1300 AD Europe “Scrofula
(Arnold of Villanova)
1650 AD London “Consumption”
(London Bill of Mortalities)
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EUROPEINDUSTRIAL REVOLUTION:
1800 - 1900
Annual Incidence of Tuberculosis
800 / 100,000 [compare Malawi at 230 / 100,000]
“The White Plague”
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TB TREATMENT pre-chemotherapy
BC
(Hippocrates)
Venesection, leeches, emetics, blistering agents on the skin
AD
(Middle Ages)
Monarch’s touch for scrofula
Laennec – seaweed
AD 1840
(Sanatorium)
Fresh air, good diet, rest,
graded exercise
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Robert Koch
1882: Described the tubercle bacillus and linked it to cause of TB
1882: Ehrlich developed a more rapid stain “AFB”
1882: Ziehl and Neelsen developed the currently used “Z-N” stain
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Tuberculosis is an air-borne disease
It can be transmitted by cough
It is associated with poverty and crowding
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The Chest X-ray: 1895 Conrad Roentgen
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TB CHEMOTHERAPY
1944 Streptomycin (S)
1945 Para-amino salicylic acid (PAS)
1952 Isoniazid (H)
1954 Pyrazinamide (Z)
1960 Thiacetazone (T) for use in developing world
1962 Ethambutol (E)
1969 Rifampicin
1960s - Standard treatment: 12-24 months
1970s- Short course treatment: 6 – 8 months
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1970s – 1980s
“TB is a conquered disease”
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BUT:sharp increase in global TB in 1980s
• Disease flourished in the developing world, but no visibility because subsumed into primary health care
• TB control neglected everywhere
• Dissolution of the Soviet Union
• Advent of HIV and AIDS
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Entered human population in 1930s HIV-1 HIV-2
Sooty-Mangabey Monkeys Chimpanzees
1930s 1940s
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By December 2007 (26 years after AIDS was first recognised)
• 25 million people worldwide had died of the disease
• 33.2 million people worldwide living with the virus (HIV) in 2007
• 2.5 million people in 2007 were newly infected with the virus
• 2.1 million people in 2007 died from AIDS
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THE TB-HIVINTERACTION
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Risk of TB in persons withMycobacterium tuberculosis
Not HIV Infected
Life time risk = 5-15%
HIV Infected
Annual risk = 5-15%
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TB risk in HIV-infected person
Weeks Years
CD
4 C
ell
Co
un
t (
cell
s/m
m3)
0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11
1200
1100
1000
900
800
700
600
500
400
300
200
100
0
DeathAIDS
TB risk increases as CD4 count declines
TB risk doubles in first year of HIV
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DUAL INFECTION
• 14 million people co-infected with HIV and M.TB in the world
• 11 million people co-infected with HIV and M.TB in sub-Saharan Africa (80%)
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Growth in TB incidence in Eastern and Southern Africa, 1980-2004
0
100
200
300
400
500
600
700
1980 1985 1990 1995 2000 2005
Re
po
rte
d T
B c
as
es
/10
0,0
00
/ye
ar
Malawi
Botswana
Kenya
S Africa
Zimbabwe
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Estimated HIV prevalence in new adult TB cases
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2005. All rights reserved
HIV prevalence in TB cases, 15-49 years (%)
0 - 45 - 1920 - 4950 or moreNo estimate
Sub-Saharan Africa: 35% TB cases HIV-infected
Southern Africa: 60-80% TB cases HIV infected
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1990:
• Global TB incidence
= 8 million
• Global TB deaths
= 1-2 million
1993:
WHO (Dr Arata Kochi) declared “TB a global emergency”
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Framework for TB Control
“DOTS”• Sustained political commitment
• Case detection with smear microscopy
• Standardised short-course treatment
• Uninterrupted supplies of drugs
• Standardised monitoring and evaluation
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Dr. Karel Styblo
Director of IUATLD
Pioneered the “DOTS” TB Control Framework in the 1980s in Tanzania, Malawi, and Mozambique
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Find TB suspects through passive case finding
Obtain sputum for smear microscopy
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Get sputum to the laboratory
Sputum prepared with Z-N stain or fluorescence and examined by light microscopy
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Z-N stain: AFB on the slide = smear-positive PTB
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Algorithms for diagnosing smear-negative PTB and EPTB
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Get the patient registered and on TB Treatment as soon as possible
Implement directly observed treatment (DOT)
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Standardised TB Treatment
New Cases:
2RHZE/ 4RH is standard first line treatment
WHO recommended regimens - 2009
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Systems in place to ensure uninterrupted TB drug supplies
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Standardised monitoring, recording and reporting
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Quarterly supervision / monitoring of all TB Registration centres and collation of national data
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Targets for TB Control: set for 2000, then deferred to 2005
• To detect 70% of estimated smear-positive PTB cases• To cure 85% of detected smear-positive PTB cases
• In the absence of HIV, target achievement will lead to:-
40% decrease in infected contacts5-10% decrease in TB incidence
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GLOBAL PROGRESS: Twelve years of DOTS
• 1995: DOTS Programmes initiated worldwide
• 2007: 180 countries used DOTS
37 million patients treated under DOTS
Global TB incidence rate falling slightly
Global TB case detection rate = 63%
Global TB treatment success rate = 85%
WHO Global Tuberculosis Report 2009
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PROGRESS IN AFRICA REGION:
By 2007:
• TB case detection rate = 47%
• TB treatment success rate = 75%
WHO Global Tuberculosis Report 2009
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EFFECT OF HIV ON TB CONTROL IN AFRICA
Programme delivery
• increased TB cases• hot spots of transmission• stigma • illness in health staff
Patient management
• difficult TB diagnosis• increased mortality • increased recurrent TB• spread of MDR- XDR-TB
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Poverty
MalnutritionImmune deficiency
Tuberculosis
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Malnutrition and low body weight
Immune deficiency and low CD4 cell count
Tuberculosis
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In the TB patient:
• Wasting
• Vitamin A deficiency
• Trace element deficiency
• Low levels of protein
Micronutrient deficiencies are worse in those with the lowest BMI
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Nutrition - clinical outcomes
• study in Malawi -1181 patients
• risk factors for early death =
age >35, HIV, low BMI
In first 4 weeks of TB therapy:
• BMI<17 = 11% death
• BMI >17 = 6.5% death
Zachariah et al, 2002
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BUT……
No evidence that nutritional supplementation on its own can improve
TB treatment outcomes
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Poverty and TB…
• The poor are at greater risk for TB
• The poor face barriers to accessing care:-– Financial – user fees, diagnostic tests, transport– Geographic - distance to health services– Cultural – stigma, poor education, traditional– Health system – poor treated worse than the rich
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Household characteristics of 770 smear-positive Pulmonary TB patients in Malawi
• Live in mud-built houses 36%• No piped water in house 75%• No electricity in house 92%
• Household income (<$10/m) 45%
Claessens et al, IJTLD, 2002
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TB in Prisons
• High risk of TB transmission
• Overcrowding and poor conditions
• Poor people
• High HIV prevalence
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Zomba Central Prison
May and July 1996
Aim:
To determine prevalence of PTB in the prison
Method :
Active screening of prisoners in cells
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Zomba Central Prison
• Screened for TB 914 (70%)• On TB treatment 14• Interviewed about cough 900• Cough > 1 week 238• Gave sputum samples 222• Diagnosis smear+ve PTB 18• Diagnosis smear-ve PTB 15
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Zomba Central Prison
PREVALENCE OF PTB
47 / 914 (5%)
[75% of TB patients tested were HIV-positive]
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Conclusion
• High prevalence of TB in the central prison
• Strong association with HIV
• No TB control system in prison
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Four main steps towards change in policy and practice
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Step 1: write up and disseminate findings
August 1996 Study completed
November 1996 Study written up as report and as draft paper
December 1996 Report presented to Chief Commissioner of Prisons; agreement to allow publication; instructions to improve TB control in Malawi prisons
November 1997 Paper published in Lancet
[1997; 350: 1284-1287]
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Move fast at the end of the study with writing up
Ensure dissemination to the people who make decisions
Publish in a peer-reviewed journal – improves credibility of the findings
Activities
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Step 2: ensure TB prison control is an important part of TB Programme Objectives
Jan-Jun 1997 •TB Prison control part of the Objectives of TB control under “improving equity”•Identify specific budget line for Prison TB control
Nov 1997 First meeting of NTP and Prison Medical Staff. Minutes copied to Chief Commissioner of Prisons and Secretary for Health
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Ensure topic is integrated into Disease Programme planning and objectives
Identify funding lines to support activities
Ensure there is leadership and clarity at all levels so that the new programme work commences well
Activities
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Step 3: Build monitoring and evaluation and accountability into the new activity
1999 - 2002
6-monthly meetings between NTP and Prison Medical Staff with minutes
Incorporate supervision for prison TB control into quarterly NTP activities
Invite prison medical staff to annual TB meetings and training sessions
Invite NGOs to assist with Prison TB control
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Support the new programme work through routine activities
Activities
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Step 4: publicise the new programme work at meetings and in papers
Number of New Prisoners 130,588
Number (%) with cough > 1 week 11,863 (9%)
Number Smear-positive PTB 516
Number Smear-negative PTB 603
Number EPTB 71
Cure rate (%) in smear-positive PTB 62%
Int J Tuberc Lung Dis 2003; 8: 614-617
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Summary of the basic steps for getting research into policy and practice
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Before you start the research, think ahead to…
What you would like to see happen How you think your vision can be made
sustainable Who you will need for support Who you will need to validate any policy
changes Who will need to put policy changes into
practice
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Then, after the study….
1. Write up and disseminate findings
2. Ensure the topic becomes an important part of TB programme objectives
3. Build monitoring and evaluation, and accountability into the new activity
4. Publicise new programme work in meetings and as articles