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Management of Tuberculosis Patient in Hong Kong
(10 December 2000)
TB notification rate (per 100,000) (1952-1999)
800 700 600 500 400 300 200 100 0 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 Year
20 15 10 5 0 40
Percentage of elderly among TB patients (1961-1999)
35 30 25 65+(TB) 65+(population) 75+(TB) 75+(population) 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997
Year
Medical conditions of patients at the time of developing TB (notified in August 1999) (Total no.= 594) One or more medical conditions [Two medical conditions [Three medical conditions Total number of cases analysed = 594 (Apart from this: no reply received for 28 cases) 155 16 2 (26.09%) (2.69%)] (0.34%)]
Medical conditions of patients at the time of developing TB (notified in August 1999) (Total no.= 594) Medical conditions Diabetes mellitus On steroid Chronic renal failure On cytotoxic drug Leukaemia/ lymphoma Malignancy Alcoholism Drug addiction Pneumoconiosis Others Number 72 8 18 1 4 27 10 6 9 20 % 12.12
1.35
3 0.17
0.67
4.55
1.68
1.01
1.52
3.37
Drug resistance rate among cases seen at chest clinics during the period January to April 1999
Category E % resistant to R H S % resistant to 1 drug 2 drugs 3 drugs MDR-TB Total % resista nce Total no. of cases analyse d New cases Retreatment cases Overall 1.03
0.77
2.59
7.76
18.10
14.66
1.23
1.68
6.96
8.41
8.76
9.53
9.41
12.07
9.75
2.45
4.31
2.69
0.90
6.90
1.68
0.77
6.90
* 1.57
12.76
23.28
* 14.13
776 116 892
SOURCES OF CARE FOR PATIENTS WITH TUBERCULOSIS IN HONG KONG PATIENT WITH TUBERCULOSIS PRIMARY LEVEL Private Practitioner Department of Health TB & Chest Service
18 chest clinics ~7,000 new patients each year
Department of Health General out patient clinics Hospital Authority Accident and Emergency Departments SECONDARY LEVEL Private Hospitals Hospital Authority Chest Hospitals
5 hospitals 800 beds 7,000 in-patient episodes
Hospital Authority General Hospital Hospital Authority Specialist Out-patient Clinics
Classical symptoms suspicious of TB
• persistent cough for over 3 to 4 weeks • blood in sputum • weight loss • persistent fever • night sweating
Particular points to note in the history
• previous history of TB - previous ST pattern • coexisting medical illnesses • occupational history - e.g., health care worker, silicosis • contact history - e.g., ST of source case • smoking status • previous BCG (especially for child)
Physical examination
• often yields negative findings • general condition • cervical LN • pleural effusion • unilateral wheeze (endobronchial involvement) • help in differential diagnosis: e.g., finger clubbing favour CA lung
Diagnosis
• Chest X-ray: relatively simple, sensitive, but less specific – apical lesion: high positive predictive value – If sputum smear negative, usually needs serial film to assess activity of pneumonic shadow trial of antibiotics (ddx from other community acquired pneumonia) • Sputum examination for AFB (smear and culture) – on 2 to 3 consecutive mornings – identification and sensitivity tests should be done for positive culture isolates • Further tests may be required for difficult cases: – CT scan, bronchoscopy, needle lung biopsy – tuberculin test (usually limited use)
Before starting anti-TB drugs
• Note contraindication to use of anti-TB drugs – liver disease, renal disease, visual problem, hearing problem, drug allergy, concomitant medication • Young females: counselled on pregnancy-related issues – interaction with oral contraceptives – avoidance of pregnancy during anti-TB treatment • Pretreatment: LFT, RFT, HIV antibody (with consent), screening test for vision
Before starting anti-TB drugs (Cont’d)
• Health education: nature of disease, healthy lifestyle, drug-adherence, possible side effects of drugs (discoloration of body fluid) – supplemented with educational materials – self-reporting of side effects • Good rapport with patient
Public Health Functions
• Notification of TB • Contacts: – examination of close contacts – “stone-in-the-pond” principle – health education: maintenance of good bodily health and early awareness of suspicious symptoms • Health education on patient’s personal hygiene
TB Notification System in Hong Kong
(1) Prevention of the Spread of Infectious Diseases Regulations (under Quarantine and Prevention of Disease Ordinance)(Cap.141) (TB is a statutory notifiable disease since 1939) (Report to Department of Health) (2) Occupational Safety and Health Ordinance (E.g., health-care workers) (Prescribed period = 6 months) (Report to Labour Department)
Notification form available from:
- any chest clinics - DH homepage
Completed form sent back to:
- Wanchai Chest Clinic - Fax: 28346627 - Tel: 25726024
TB Notification
Aims: • Surveillance • Contact tracing and examination • Identification of clusters
Under-notification
• A common problem • The importance of the need to notify TB cases should be recognised.
Guidance Notes for notification of TB
• Leung CC, Tam CM. Guidance notes for notification of tuberculosis. Public Health & Epidemiology Bulletin 1999;8(4):36-9.
Source of TB Notification
8000 7000 6000 5000 4000 3000 2000 1000 0 1994 1995 1996 Year 1997 1998 1999 Private Sector Public Hospital Chest Hospital Chest Clinic
Infectiousness of the TB patient
• Sputum smear: a general guide to the infectiouness – also: severe cough, cavitatory disease • To reduce risk of infection to others: – prompt initiation of treatment (infectivity reduced significantly after 2 weeks of treatment in which rifampicin is included) – health education – personal hygiene measures – good indoor ventilation – screening of close contacts – sick leave assessed on a case-to-case basis (teachers, staff of elderly homes, etc.)
TUBERCULOSIS
CHEMOTHERAPY
D IRECTLY O BSERVED T REATMENT , S HORT COURSE to stop it at the source
do s s op
DOT (directly observed treatment)
• Strongly recommended by WHO, crucial for treatment success
Short course service programme (6 months) 2H 3 R 3 Z 3 E 3 / 4H 3 R 3 H = isoniazid Z = pyrazinamide S = streptomycin R = rifampicin E = ethambutol • Drugs: preferably taken in a single dose each time and not in split doses • Combined drug preparations: e.g., rifater, rifinah – useful alternatives, but have to be given daily – can avoid monotherapy – but do not allow flexible dosage adjustment
Treatment of tuberculosis
The Tuberculosis Control Coordinating Committee of the Hong Kong Department of Health and the Tuberculosis Subcommittee of the Coordinating Committee in Internal Medicine of the Hospital Authority, Hong Kong. Chemotherapy of tuberculosis in Hong Kong: a consensus statement.
Hong Kong Med J 1998;4:315-20
During anti-TB treatment
• Initial phase: follow up at least monthly (in chest clinic, while under DOT) – to reinforce patient education – watch out for adverse drug reactions – routine blood tests usually not necessary unless: clinical features suspicious of hepatitis, underlying liver disease, etc.
• CXR: at 2nd or 3rd month to assess progress • Sputum – If pretreatment sputum positive, recheck at 2nd month to assess conversion to negativity – If still positive at 2nd month, recheck at 3rd month
During anti-TB treatment (Cont’d)
• Treatment defaulters : being traced by health nurses – Identify the underlying reasons for default, and try to solve the problem as far as possible – Incentives/ enablers • Tracing back of treatment defaulters:
IMPORTANT
for treatment success and public health control of TB.
• Defaulters are a potential persistent source of infection in the community.
At the end of six month’s treatment
• Assessment: – Repeat chest radiograph – Sputum examination • Health education: – Maintenance of a healthy lifestyle, awareness of suspicious symptoms
Complicating issues
• Examples of complicating issues: – Extensive disease – Poor general condition – Diagnostic dilemma – Treatment failure due to non-adherence – Drug resistance – Concurrent medical diseases – Drug reactions • Consult when necessary, hospitalisation may be required
Tuberculosis -
Indications for hospital admission 1. Complications of pulmonary tuberculosis, e.g., pleural effusion, pneumothorax, etc.
2. Complications of treatment, e.g., severe reactions like drug intolerance, hypersensitivity reactions, hepatitis, etc.
3. Concomitant diseases, e.g., uncontrolled DM.
4. Psychosocial problems, e.g., alcoholics, drug addicts, previous defaulters.
5. Difficulty in attending clinics for DOT, e.g., elderly, hemiplegic, living in remote areas, etc.
6. Extrapulmonary TB for special investigation
Some points for caution
• ‘Addition phenomenon’ to be avoided – Not to add a single drug to a failing regimen • Desensitisation – May be required for drug-induced hypersensitivity, but be careful not to induce drug-resistance • Ethambutol to be avoided under age 6 unless necessary • Higher incidence of side effects of drugs in elderly
IMPORTANT
• Drug adherence is most important and is vulnerable because: – Long duration of treatment required – Disappearance of symptoms before treatment completion – Bulk of tablets: mistake, GI upset and other side effects – Stigma of TB: cannot accept the fact of being diagnosed as having TB – Health belief: e.g., use of herbal or alternative medicine • DOT is strongly recommended – Prevent failure, relapse, drug-resistance, spread of the disease, long-term sequelae of destroyed lung
TUBERCULOSIS
Reasons for failure of chemotherapy: • Non-compliance • Drug resistant tuberculosis • Drug toxicity • Failure of drug to reach site of action • Immunosuppressed
Conclusion
• Management of TB can be simple, but can go wrongly easily, which can result in serious consequences • Complicating issues may arise from time to time – Caution required, consult when necessary • Management: Clinical + Public Health measures + Good communication
Components of DOTS
1.
Government commitment to sustained TB control.
2. Sputum smear microscopy to detect infectious cases.
3. A standardized, short-course anti-TB treatment regimen of six to eight months, with direct observation of treatment for at least the initial two months. 4. A regular, uninterrupted supply of quality anti-TB drugs.
5. A MONITORING AND REPORTING SYSTEM to evaluate treatment outcomes for each patient diagnosed and the performance of the TB control programme as a whole.
Future activities
• Programme Forms (to be filled in for all TB patients starting from January 2001): – Baseline characteristics of TB patient – Clinical features and results of investigations – Treatment outcomes at various time points up to 2 year from DOS (date of starting treatment) • The collaboration of both the PUBLIC AND PRIVATE SECTOR in the evaluation process is very important and very much appreciated.