Tb cpg sg bakap 2015

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TB CPG 3 rd Edition March 24 th 2013 Dr Ong Choo Khoon Chest Physician Hospital Pulau Pinang

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  1. 1. TB CPG 3rd Edition March 24th 2013 Dr Ong Choo Khoon Chest Physician Hospital Pulau Pinang
  2. 2. Launched 24th March 2013 2
  3. 3. World TB Day 2015 FIND TB. TREAT TB. WORKING TOGETHER TO ELIMINATE TB
  4. 4. TB: EPIDEMIOLOGY & INVESTIGATIONS 4
  5. 5. OBJECTIVES Epidemiology of TB Investigations of TB 5
  6. 6. TB AS A GLOBAL HEALTH ISSUE Fig 1: Ten leading causes of death 7 World Deaths in millions % of deaths Ischaemic heart disease 7.25 12.8% Stroke & other cerebrovascular disease 6.15 10.8% Lower respiratory infections 3.46 6.1% Chronic obstructive pulmonary disease 3.28 5.8% Diarrhoeal diseases 2.46 4.3% HIV/AIDS 1.78 3.1% lung cancers 1.39 2.4% Tuberculosis 1.34 2.4% Diabetes mellitus 1.26 2.2% Road traffic accidents 1.21 2.1% WHO Factsheet 2008
  7. 7. Among top three causes of death for women aged 15 to 44 One quarter of all deaths in people living with HIV Multi-drug resistant TB (MDR-TB) TB death rate dropped 41% between 1990 & 2011 8 INTRODUCTION: TB AS A GLOBAL HEALTH ISSUE
  8. 8. Fig 2: Estimated TB Incidence Rate, 2011
  9. 9. Fig 3: Number & Notification Rate of TB Cases, Malaysia 1960 - 2010
  10. 10. Fig 4: Number of TB Cases (2011)
  11. 11. Fig 5: Notification of New TB Cases in Malaysia, 2005 - 2011
  12. 12. Fig 6: Percentage of TB Cases among Children , 0 - 4 yrs & 5 - 14 yrs, 2000 - 2010
  13. 13. TB AMONG NON-MALAYSIAN Fig 8: Number & Proportion of TB Cases Among Non-Citizen, 1993 - 2010 Fig 9: Foreign Worker Screening & Proportion Unfit due TB, 2001 - 2010
  14. 14. MDR TB Year Notified TB Cases (All Forms) Isolates tested for DST MDR Cases % MDR (By number of culture positive tested for DST) 2004 15429 5083 13 0.3 2005 15875 6309 17 0.3 2006 16665 6386 42 0.7 2007 16918 6687 41 0.6 2008 17506 6264 56 0.9 2009 18102 7137 55 0.8 2010 19337 6963 51 0.7 2011 20666 10477 141 1.3 2012 22710 9722 74 0.8 MDR threat requires second line drugs which include injection route, longer treatment duration, more drug side effects, hospitalization, increase cost, unfavorable treatment outcome. Only 1/3 of TB cases tested for DST.
  15. 15. Top 10 Infectious Disease in Malaysia *Health Fact Sheet, MOH Malaysia 2011 ** Incidence of Dengue 2012 75.8 per 100,000
  16. 16. 1. Not achieving WHO estimated incidence case 2. WHO Estimation Notification Rate (NR) downwards trend 3. Actual NR increasing (CDR 2011: 85%, 2012 :95%)
  17. 17. 1. WHO estimated mortality rate (MR) is excluding TBHIV mortality 2. Actual MR : 1990-2011 including TBHIV mortality; 2012 excluding TBHIV mortality. 3. WHO estimated MR downward trend 4. Actual MR : plateau since 1990
  18. 18. KPI YBMK 2013 1) CURE RATE - 85% 2) CDR (ALL FORMS) 95%
  19. 19. CDR has improved over the years, contributed by increasing number of diagnosing & treatment centres , other resources including skills and knowledge of health personnel and expansion of services into public health.
  20. 20. TB Burden in General Population : 77 per 100,000 *HCW- Health Care Worker *DM-Diabetes Mellitus High Risk Groups
  21. 21. HIGH RISK GROUPS Close TB contacts Immunocompromised patients Diabetes mellitus HIV Chronic obstructive pulmonary disease End-stage renal disease Malignancy Malnutrition Substance abusers & cigarette smokers Poor people living in overcrowded conditions 25
  22. 22. INVESTIGATIONS FOR TB Sputum collection Lab investigations Imaging modalities 26
  23. 23. SPUTUM COLLECTION Sputum: At least 2 specimens At least one early morning specimen For patients who are unable to spontaneously expectorate adequate sputum specimens Sputum induction with nebulised hypertonic saline Fiberoptic bronchoscopy with bronchoalveolar lavage Gastric lavage 27
  24. 24. LAB INVESTIGATIONS FOR TB Sputum Ziehl-Neelsen staining for AFB Microscopy Light emitting diode-based fluorescencemicroscopy (LED FM) 28
  25. 25. LAB INVESTIGATIONS FOR TB Culture Drug-susceptibility testing 29
  26. 26. LAB INVESTIGATIONS FOR TB Molecular Nucleic Acid Amplification Test (NAAT) Line Probe Assay (LPA) 30
  27. 27. LAB INVESTIGATIONS FOR TB WHO policy statement (2011) commercial serological tests for TB provides inconsistent & imprecise estimates of sensitivity & specificity which can adversely impact patient safety 31
  28. 28. IMAGING IN TB - CXR Chest radiography primary imaging modality for PTB can suggest the possibility of the disease (not confirmatory) hallmark - consolidation with cavitation can be normal (up to 15%) Severity grading Minimal Moderate Advanced 33
  29. 29. IMAGING IN TB - CT SCAN Computerised tomography (CT) endobronchial spread, lymphadenopathy, pleural complication high clinical suspicion of TB with normal CXR HRCT 34
  30. 30. IMAGING IN TB - MRI In special circumstances (children & pregnant women) Better soft tissue characterisation Pleural & lymph node complications 35
  31. 31. TAKE HOME MESSAGE TB is prevalent in Malaysia High risk groups* should be considered to be screened for active tuberculosis Sputum culture is diagnostic for TB 36
  32. 32. TREATMENT OF TB IN ADULTS 37
  33. 33. TB IS AN ANCIENT DISEASE 38
  34. 34. INTRODUCTION Important to provide a standardised TB regimen for all TB cases This section will cover all aspects of treatment: New cases Previously treated cases Standard regimens & duration Extrapulmonary TB (EPTB) Adverse drug reactions (ADRs) & Multidrug- resistant (MDR-TB) 39
  35. 35. NEW CASES 6-month regimen consisting of 2 months of EHRZ (2EHRZ) followed by 4 months of HR (4HR) is recommended for newly-diagnosed PTB. 40
  36. 36. MAINTENANCE PHASE In new patients with PTB, WHO recommends daily dosing throughout the course of antiTB treatment. However, a daily intensive phase followed by thrice weekly maintenance phase is an option provided that each dose is directly observed & patient has improved clinically. A maintenance phase with twice weekly dosing is not recommended. 41
  37. 37. RECOMMENDED ANTITB DRUGS 42 DRUG RECOMMENDED DOSES Daily 3X a week Dose (range) in mg/kg body weight Maximum in mg Dose (range) in mg/kg body weight Maximum in mg Isoniazid (H) 5 (4 - 6) 300 10 (8 - 12) 900 Rifampicin (R) 10 (8 - 12) 600 10 (8 - 12) 600 Pyrazinamide (Z) 25 (20 - 30) 2000 35 (30 40) 3000 Ethambutol (E) 15 (15 - 20) 1600 30 (25 35) 2400 Streptomycin (S) 15 (12 - 18) 1000 15 (12 18) 1500
  38. 38. IMPORTANT POINTS Rifampicin should be used for whole duration of treatment. No significant difference in effectiveness & safety between rifampicin & other antibiotics in rifamycin group. Whenever possible, rifampicin dosage should not be lower than recommended dosage (8 - 12 mg/kg). Pyrazinamide beyond 2 months during intensive phase did not confer further advantage if organism is fully susceptible. 43
  39. 39. PREVIOUSLY TREATED CASES New cases who have taken treatment for more than 1 month & are currently smear or culture positive again (i.e. failure, relapse or return after default) 44
  40. 40. TREATMENT Recommend: retreatment regimen containing first- line drugs 2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR-TB in these patients or if such data is not available. Drug sensitivity test (DST) must be done for patients. When results become available, drug regimen should be adjusted appropriately. *This is WHO statement, no retrievable evidence available. 45
  41. 41. TO START OR NOT? Interruption in intensive phase: If 14 days, to restart from beginning i.e. Day 1 If