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TUBERCULOSIS TREATMENT: WHAT CHANGED IN THE LAST 5 YEARS?

TUBERCULOSIS TREATMENT: WHAT CHANGED IN THE LAST 5 YEARS?. Doç. Dr. Şeref ÖZKARA Atatürk Chest Diseases and CSER Hospital , Ankara. mahesh kumar. I have no conflict of interest. National standard regimens are used in TB treatment . National guidelines should be used. 2003. 2011.

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TUBERCULOSIS TREATMENT: WHAT CHANGED IN THE LAST 5 YEARS?

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  1. TUBERCULOSIS TREATMENT: WHAT CHANGED IN THE LAST 5 YEARS? Doç. Dr. Şeref ÖZKARA Atatürk ChestDiseasesand CSER Hospital, Ankara mahesh kumar

  2. I havenoconflict of interest.

  3. Nationalstandardregimensareused in TB treatment. Nationalguidelinesshould be used. 2003 2011

  4. TB ControlGuidelines in Turkey • 1932: “Instructionsfor TB ControlDispensaries” • 1953: TB dispensarydirectiveandforms. • 1963: New version of directiveandforms. • 1971-74: “Instructionsforthetreatment of smearpositivepatients”, TB DispensaryDirective, New forms. • 1985: Shorttermtreatmentdirective (continuationphaseconsists of intermittant 2 dosesperweek. • 1990: New TB dispensarydirective, dailytreatment

  5. TB ControlGuidelines in Turkey • 1996: National TB SymposiumResults. • 1998: “Diagnosis, TreatmentandFollow-up of TB Patients” Guidelines • 1999: “Guidelinesfor TB Control in Turkey (DraftforDiscussion)” • 2003: “Bookfor TB Control in Turkey” • 2007: TB DispensaryFormsareupdated • 2011: “TB DiagnosisandTreatmentGuidelines”

  6. WHO TreatmentCategories • WHO, 1993, 1997, 2003: guidelinesrecommended • Turkey, 1996: TB NationalSymposiumresults • WHO, 2009: Guidelinesrecommendedsame as Turkey’sguidelines

  7. WHO TreatmentCategories • Category I. • S(+) Pulm. TB newcase • XP-TB, seriousdisease • Category II. • Relapse, Returnafterdefaulter, Returnafterfailure • Category III. • S(-) Pulm. TB • XP TB, diseasenon-serious • Pediatric TB • Category IV. • ChronicTB

  8. WHO TreatmentCategoriesand TB TreatmentInTurkey, 1996 totoday • Category I. • S(+) Pulm. TB newcase, S(-) Pulm. TB • XP-TB seriousdisease, XP TB diseasenon-serious, • Pediatric TB • Category II. • Relapse, Returnafterdefaulter, Returnafterfailure • Category III. • S(-) Pulm. TB • XP TB, diseasenon-serious • Pediatric TB • Category IV. • Chronic TB, Returnafterfailure

  9. 1996 TURKEY MoH TB CONTROL DEPARTMENT REGIMENS New case • 2 HRZE / 4 HR* • 2 HRZS / 4 HR Relapseand Treatmentafterdefault • 2 HRZES / 1 HRZE / 5 HRE STANDARD TREATMENT IN TURKEY Treatmentfailure, Chroniccase • Referredto a MDR-TB treatmentcenter.

  10. DOTS STUDIES IN TURKEY AFTER 2000

  11. Relationswith WHO

  12. New RecordingSystem • Details in symptomregistry • Standardsforcasedefinitions • Treatment start date, personandinstitutionwhoinitiatedtx. • Standardsfortreatmentoutcome • Treatmentendingdate • Bacteriologicalsection is expanded • Contactsfrom inside home, outsidehome • DOT recordfordrugingestion • Detailedrecordingfortreatmentfollow-up

  13. Standard treatment • Treatmentsarenearlytotallystandard in Turkey in thelastyears. • Patientswho do not takeoneoremorethanonefothedrugs HRZ • Addingquinoloneorotherminor TB drugstotheregimen • Adding 1-2 drugsto a regimenduringworseningclinic

  14. Treatmentdelay • Patient’sanddoctor’sdelaystudiesareneeded • Thereare a fewstudiesfromhospitals. • Studiesarerequiredforpatientcohorts.

  15. Drugprocurement • 1. and 2. linedrugsarefree of charge • TherearealsofreeLinezolid, clofazimine, capreomisin, andthiasetazon • Continuousprocurement, storageanddistribution • There is no periodwhendrugsareabsent • Drugs in free market • SocialSecurityAssociation’ssentence: “Prescriptionfor TB drugsare not paid.”

  16. DOT PACKAGE

  17. DOT IN TURKEY(TB controldispensaries)

  18. Türkiye’de DGT • Intheselast 4 Annual TB ControlReports it is writtenthat: DOT is applied (orinitiated) in 91% to 97.9% of thepatients.

  19. Questionsregarding DOT PERCENTAGE OF DOT APPLICATION • Percentage of DOT appliedtofulltreatmentperiod? • Percentage of DOT appliedtopartial time duringtreatment? WHO IS GIVING DOT? • Percentage of DOT givenbyhealthcareworkers. • By an officialperson • By a familymember • Weekly, monthly DOT! Signingthesheetandtakingthedrugstohome. Drugsgiventotherelatives of thepatient.

  20. Patientnonadherencetotreatment • Non-adherenceresults in unsufficienttreatment. • Failure, relapse, continuinginfectiousness, drugresistancemayappear. • Toincreaseadherence • Education • Goodmanagement of treatment • Socialandeconomicalsupporttothepatient • DOT • DGT, • Enablersandfacilitators • Iftheseare not enough, morerestrictiveprecautionsmay be used.

  21. PATIENTS TO BE HOSPITALIZED Infectiospatientsisolation do not requirehospitalization. • Genel durumu bozuk olanlar, ilerlemiş hastalığı olanlar, • Menenjit tüberkülozlu hastalar, • Önemli hemoptizisi olanlar, • Diyabeti kontrol altına alınamayan olgular, • Kronik böbrek ya da kronik karaciğer hastalığı olanlar, • Hastane tedavisi gereken ilaç yan etkileri • İlaç alerjisi, ilaca bağlı hepatit ve diğer • Yatış gerektiren ek hastalığı olanlar, • Tanının kesinleştirilmesi gereken şüpheli olgular, • Evsizler, bakıma muhtaç durumda olanlar.

  22. Who is responsible in treatment? It is thedutyandresponsibility of healthcareworkersandhealthsystem todiagnose, toinitiatecorrecttreatment, tomakepatientadherence, andtofinishthetreatmentwithsuccess.

  23. MDR-TB treatment POSITIVE • 4 hospitalsareresponsible • Lab.’s diagnosedrugresistanceearlier • Continuousprocurement of freedrugs PROBLEMS • DOT application • Socialandeconomicalsupporttothepatient

  24. REFERRAL TO THE MDR-TB TREATING HOSPITAL • Patientswithclinal/radiologicaldetoriation • Smearpositiveafter 3 months of treatment • MDR-TB suspectedpatient arereferredto a MDR-TB treatinghospital.

  25. Treatmentoutcomesarereportedandanalyzed.

  26. Treatmentresults of newcasesafter 12 months in Turkey. % SuccessDefaultDeathContinuingFailure

  27. Treatmentresults of previouslytreatedcasesafter 12 months in Turkey. % SuccessDefaultDeathContinuingFailure

  28. Treatmentoutcome, cohort of allpatients (percent) *1999 newcases 6%, previouslytreatedcases 4% weretransferredout.

  29. Treatmentresult, 2008

  30. RESULTS(SWOT) • Progress in TB control is a successstory. • It is especiallyimportantthatthishappenedduringHealthSector Reform (HSR) • Recording-reportingsystemandannualreports Weaksides • Problems in DOT application • Socialandeconomicalsupporttothepatients • TB ControlDept. is present in thenewsystem • Centraldrugprocurementwill be in place • There is Guidelines Threats: • Thispositivesmaychangtonegative. • HSR is also a threat.

  31. Thankyou. Dearmother, Youalwaysblamed us formakingyouillwithtuberculosis. Wefoundtheguiltybacilli.

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