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Tuberculosis in specialty training: How it should be?

Haluk C.Çalışır M.D.

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Tuberculosis in specialty training

• Pneumology • Public Health• Microbiology• Internal Medicine• Pediatrics• Infection Disease

• Associations have assemblies.– Turkish Thoracic

Society– KLİMİK

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Tuberculosis training

• Patient Care Seminars

• Literature clubs• Conferences• Courses• Congress• Research

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Pneumology TrainingTURKISH PNEUMOLOGY BOARD

• Knowledge: to provide an opportunity having knowledge and experience for the diagnosis, management and prevention of lung disease – Tuberculosis and control

• Skills: Knowledge and experience for microbiological examinations of respiratory secretions.

• Medicine for community, Health Politics, Occupational diseases of health care workers.

http://www.toraks.org.tr/board/prog_taslak.php

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Training for pneumologyTurkish Pneumology BOARD

• Internal rotations (35 mounts)– Respiratory Intensive Care (3 months)– Sleep laboratory (1 month)– Allergology (3 months)– In patients and out patients (28 months)– Tuberculosis (3 months)

• TB Ward (2 months)• TB Dispensary (1 month)

http://www.toraks.org.tr/board/prog_taslak.php

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Pneumolog(UEMS)

UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES

• Having experience for the epidemiology, prevention and management of both pulmonary and extra-pulmonary tuberculosis.

www.uems.net

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Pneumolog(UEMS)

UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES

• The specialist in pneumology must have gained broad theoretical and scientific knowledge of respiratory disease and conditions affecting the lung, as well as having a wide clinical experience.

www.uems.net

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Globally

• Diagnosis

• Management of treatment

• TB in Immunosuppressive patients

• Latent tuberculosis infection treatment Infection Control

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Tuberculosis Control and Medical SchoolsWHO/TB/98.236Report of a WHO WorkshopRome, Italy29-31 October 1997

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WHO/CDS/TB/2002.301Distribution: GeneralOriginal: English

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The Ministry of HealthNational Tuberculosis Control Programme

• 620 GP

• 70 Specialist

• 1303Health Care Workers

• 343 Administrative

• 355 Office staff

• 2691Total

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Turkish Pneumology BOARD Questionnaire (Kocabaş A, İtil O.)

• 41 University Hospital

• 9 Teaching Hospital

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2004

• 59 specialists were graduated from University Hospitals – Two of them working in TB dispensaries.

• 35 specialists were graduated from Teaching hospitals – Six of them working in TB dispensaries.

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Clinical Rotation in TB ward

• Peripheral University 26.7%

• Centrally located University 45.5%

• Teaching Hospital 22.2%

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Rotation in TB dispensary

• Peripheral University % 10 3 (0-3) months

• Centrally located University % 90.9 1 month

• Teaching Hospital % 0 0

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Clinical Rotations

• To TB Ward – University (41)

• 13 (%31.7)• Average:1.3 months

• To TB dispensary– University

• 4(%9.8)• Avarage:15 months

To TB Ward– Teaching Hospitals (9)

• 2 (%22.2)

• Average: 3 months

• To TB dispensary– Teaching Hospital

• 0

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Procedures during residency

• University– AFB Microscopy

• Average: 72• (0-500)

– Tuberculin test• Average : 82• (0-500)

• Teaching hospital– AFB microscopy

Average: 99• (0-400)

– Tuberculin test• Average :54• (0-150)

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TB Beds (2004)

• In 16 University hospitals – Average 11.2 beds– Total. 180 beds

• In 5 teaching hospitals– Average 155,4 beds– Total 777 beds.

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In patient TB Cases (2004)

• University (13)– Average 122,8– (2-916)– Total: 1591– Staying in hospital:

21 days– (10-33)– AFB: 532

• Teaching Hospital (5)– Average: 1785– (20-3748)– Total: 8926– Staying in

hospital:25– (17-35)– AFB: 27333

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TB managed in tertiary care in 2004

• University hospital: 1591

• Teaching hospital: 8926

• Total: 10517

• TB cases in Turkey: approx. 16000

• Percentage : 65%

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Specialist and tuberculosis control*

• Specialists may prescribe non standardized regimens.

• Specialists may give little importance to treatment supervision.

• Medical specialists should not be involved in the management of non complicated Smear (+) cases.

• Specialists may play roles for the management of complicated tb cases, preparing guidelines and advising to NTP

*Caminero. JA. Is the DOTS strategy sufficient to achieve tuberculosis control in low and middle income countries?2.Need for interventions among private physicians, medical specialists and scientific societies. INT J TUBERC LUNG DIS 7(7):623-30

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Training

…is a behavior changing process in a person

İnayet Aydın. Eğitim ve Öğretimde Etik. Pegem Yayıncılık. Kasım 2003,5

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What we want to change ?

• Diagnosis• Treatment• Side effect management• Prevention• Infection Control• Tuberculosis control• Tuberculosis

epidemiology• TB Policy

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Questions

• What is the role of specialist for tuberculosis control?

• Why Tuberculosis is important for Turkey?• If tuberculosis took part in training program

which indicator will change?• What is the importance of tuberculosis training

for health care?• What is the aim of TB training for the resident?

What kind of skills and knowledge will be changed?

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Why Tuberculosis is important for Turkey?

• Tuberculosis is a public health priority due to epidemiologic results.– Tuberculosis very common among young generations– Diagnosis – Management– Case finding– Morbidity, mortality and disability

• Drug resistance problem

– Wasting resources

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If tuberculosis took part in training program which indicator will change?

• Reliable and sustainable partnership for NTP

• Research

• Advise

• Patient care

• Providing training activities for NTP

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WHOIUATLDKNCVATSCDC

www.nationaltbcenter.edu/international

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International Standards for Tuberculosis Care*

• Any practitioner treating a patient for tuberculosis is assuming an important public health responsibility.

• To fulfill this responsibility, the practitioner must not only prescribe an regimen but, also, be capable of assessing the adherence of the patient to the regimen and addressing poor adherence when it occurs.

• By so doing, the provider will be able to ensure adherence to the regimen until treatment is completed.

*Tuberculosis Coalition for Technical Assistance.International Standarts for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance. 2006

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Conclusion

• 65-75% of the treatments initiated at the secondary and tertiary level.

• Complicated and non complicated patient management.

• Tuberculosis control training (?)

• Tuberculosis can be managed at the primary health care level.

• There is no systematic training program for primary health care providers. (Doctors, nurses, lab. Technicians and others)

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Recommendations

• National tuberculosis control program and its priorities should be prepared with wide consensus.

• A human resources development plan should be prepared based on the priorities.

• Epidemiology of disease, control and NTP priorities should be covered with clinical tuberculosis in the specialty training.

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Tuberculosis in residency training

Clinical tuberculosis– Pathogenesis– Diagnosis– Treatment

Tuberculosis Control– Epidemiology– Disease control– Statistics– NTP– Operational research

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Acknowledgments

• Prof. Dr. Ali Kocabaş

• Prof.Dr.Oya İtil

• Yrd. Doç. Dr. Hatice Şahin