Transcript Beyond Sputum Cups and Four Drugs

Beyond Sputum Cups and Four
Drugs
The Responsibility of the Practicing
Clinician in the Community Control of
Tuberculosis
V. R. Koppaka, MD, PhD
Division of TB Control
“...protection, improvement, and preservation of the
public health and of the environment are essential to
the general welfare of the citizens of the
Commonwealth. For this reason, the State Board of
Health and the State Health Commissioner, assisted
by the State Department of Health, shall administer
and provide a comprehensive program of preventive,
curative, and restorative services...and abate hazards
and nuisances to the health and...”
VAC §32.1-2
Priorities in Control of
Tuberculosis
• Detection of all cases of tuberculosis disease
• Treat all cases of active tuberculosis disease
• Complete treatment of all cases of active
disease and their infected contacts
TB Control: Physician Roles
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Efficient case detection
Appropriate and adequate treatment
Communication with health authorities
TB prevention
Advocacy
Active Tuberculosis Disease
Bacteriologically-Defined
Clinically-Defined
• M. tuberculosis present
in any bodily fluid, or
tissue.
• Confirmed by:
• Clinical evidence
– Culture
– Nucleic acid detection
– Acid Fast Smear
– Symptoms
– Radiography
– TST result
• Response to therapy
VAC §32.1-49.1
Management of Tuberculosis
• Early diagnosis and treatment based on clinical
features, radiography, bacteriology
• Baseline and monthly clinical assessment:
– Treatment response
– Adherence
– Drug intolerance
• Maintain and update written treatment plan and
record of adherence (VAC §32.1-50.1)
• Submission of initial and subsequent reports to LHD
Statement of Responsibility
“Because in the treatment of tuberculosis the
benefits accrue to society as well as to the
patient, any provider undertaking to treat a
patient with tuberculosis is taking on a public
health function in which she/he is assuming
responsibility for successful completion of
therapy.”
ATS/CDC/IDSA Guidelines for Treatment of Tuberculosis, 2002
Disease Reporting
Every physician practicing in this Commonwealth who
shall diagnose or reasonably suspect that any patient
of his has any disease required by the Board to be
reported and every director of any laboratory doing
business in this Commonwealth which performs any
test whose results indicate the presence of any such
disease shall make a report within such time and in
such manner as may be prescribed by regulations of
the Board.
VAC § 32.1-36
Reporting of Tuberculosis
Disease
Who:
Physician
Health Care Facility
Laboratory
What:
Patient characteristics
Diagnostic information
Treatment/follow-up information
When:
Within 24 hours (initial report)
Within 1-2 weeks (secondary report)
How:
Telephone/fax/(internet)
VAC § 32.1-50 B, C
TB Disease: Required
Subsequent Reports
• Treatment ceases
– Fails to keep treatment appointment
– Relocates with transfer of care
– Discontinues treatment on or against medical
advice
• Regimen changes
• Clinical status changes
• As updates become available
VAC §32.1-50 D
TB Treatment Plans
• Required for all patients receiving treatment
for TB disease
• Local health director approval mandatory for
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All inpatients prior to discharge
HIV co-infected
Confirmed or suspected rifampin resistance
History of prior TB treated or untreated
Demonstrated history of nonadherence
VAC §32.1-50.1
TB Treatment Plan Elements
• Tailored to patient’s medical and social needs
• Updated at least monthly
• Must include at minimum:
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Verified patient address
Name of MD responsible for care
Drug regimen and estimated completion date
Written record of adherence
VAC §32.1-50.1
Tuberculosis 2002: Global
Emergency
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1/3 of the world’s population infected
8 million new cases of active disease per year
2-3 million deaths per year
80% of global morbidity found in just 22 countries
One person is newly infected every second and one
person dies every 10 seconds
Rising incidence of drug-resistant disease
Billions of dollars in lost productivity
“A fundamental human right”
“We are now at a critical
juncture…”
“On the one hand, control of tuberculosis in the United
States has been regained and we are at an all-time low
in the number of new cases. On the other hand, we are
particularly vulnerable again to the complacency and
neglect that comes with declining numbers of cases.
Now is the time to commit to the abolition of the
recurrent cycles of neglect followed by resurgence that
have been the history of tuberculosis. ... But to meet this
goal, aggressive and decisive action beyond what is
now in effect will be required."
p. viii
Institute of Medicine. Ending Neglect. 2000