INTRODUCTION & EPIDEMIOLOGY

by Dr. Jamalul Azizi Bin Abdul Rahaman

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LEARNING OBJECTIVES OF TOT

• To actively disseminate & train healthcare providers to practise what has been recommended in the main CPG • To assist the ‘trainers’ in delivering all of the components relating to the implementation of the CPG systematically & effectively 2

INTRODUCTION

• Tuberculosis (TB) remains an important disease both globally & in Malaysia • Number of TB cases in the country continues to increase unabated • High rates of morbidity & mortality due to: – Delayed presentation – Advanced HIV 3

RATIONALE FOR CPG

• TB issues in Malaysia – A common disease – Affects many organs in the body – Managed by doctors at all levels • Primary care • • General medicine Subspecialty – Lack of standardisation in TB management • Inaccurate diagnosis • Inappropriate empirical treatment

There is a need to standardise TB management to minimise the risk of multidrug-resistant (MDR) TB

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OBJECTIVES OF CPG

• To assist clinicians & other healthcare providers in making evidence-based decisions about appropriate specifically on: management of TB – screening – diagnosis – treatment – follow-up – prevention – referral 5

SCOPE OF CPG

• • • • • • • • • • • • • Epidemiology & High Risk Groups Investigations Treatment of TB in Adults LTBI in Adults TB in Children TB in Pregnancy, Lactation & Use of Oral Contraceptive Pills Liver & Renal Impairment HIV Infection Follow-up & Adverse Drug Events MDR-TB Prevention Referral Criteria Implementing the Guidelines 6

TARGET POPULATION

• Patients with TB – Adults – Paediatrics • Types of TB – Pulmonary (PTB) – Extrapulmonary (EPTB) • Co-morbidity e.g. HIV • Confirmed, suspected & latent TB 7

TARGET USERS

• Healthcare stakeholders including professionals in all & healthcare relevant settings – Doctors – Pharmacists – Allied health professionals – Medical students & trainees – Tuberculosis programme managers – Patients & carers/non-governmental organisations 8

DEVELOPMENT GROUP 1) Dr. Jamalul Azizi Abdul Rahaman Consultant Respiratory Physician, H.Serdang (Chairperson) 11) Assoc. Prof. Dr. Pang Yong Kek Respiratory Physician, PPUM

2) Dr. Anuradha P. Radhakrishnan Infectious Disease Physician, H. Sungai Buloh 12) Dr. Pushpagandy Ramanathan Consultant Radiologist, Hospital Ampang 3) Datin Dr. Ganeswrie Raj Consultant Clinical Microbiologist, HSA 4) Dr. Irfhan Ali Hyder Ali Respiratory Physician, Hospital Pulau Pinang 5) Dr. Jeyaseelan P. Nachiappan Sr. Consultant ID Paediatrician, H. Teluk Intan 6) Dr. Jumeah Shamsuddin Maternal-Fetal Specialist, DEMC Sp Hospital 7) Dr. Ker Hong Bee Consultant ID Physician, HRPB 8) Dr. Mat Zuki Mat Jaeb Consultant Respiratory Physician, H. RPZ II 9) Dr. Mohd. Aminuddin Mohd. Yusof Head, CPG Unit, HTA Section, MoH 10) Assoc. Prof. Dr. Nik Sherina Haidi Hanafi Primary Care Physician, Pusat Perubatan UM 13) Ms. Rahela Ambaras Khan Pharmacist, Hospital Sungai Buloh 14) Dr. Razul Md Nazri Md Kassim Respiratory Physician, H. Sultanah Bahiyah 15) Dr. Salmiah Md. Sharif Family Medicine Specialist, KK Batu 9 16) Dr. Suryati Adnan Consultant ID Paediatrician, HSAS 17) Assoc. Prof. Dr. Tengku Saifudin Tengku Ismail, Consultant Respiratory Physician , UiTM 18) Dr. Umadevi A. Muthukumaru Respiratory Physician, Hospital Taiping 19) Dr. Wong Jyi Lin Respiratory Physician, Hospital Umum Sarawak 20) Dr. Zubaidah Abdul Wahab 9 Consultant Clinical Microbiologist, H. Sg. Buloh

REVIEW COMMITTEE 1) Dato’ Dr. Abdul Razak Muttalif, Director & Sen. Cons. Resp. Physician, IPR (Chairperson) 10) Dato’ Dr. K. Aris Chandran Senior Consultant Physician, HRPB

2) Mdm. Abida Haq Syed M. Haq Dep. Director, Pharm. Services Division, MoH 11) Dr. Naemah Sharifuddin Family Medicine Specialist, KK Bandar Sri Putra 3) Datuk Dr. Aziah Ahmad Mahayiddin Senior Consultant Respiratory Physician, IPR 4) Dr. Fairuz Amran Consultant Microbiologist, IMR 5) Dato’ Dr. George Kutty Simon Sen. Cons. Resp. Physician, AIMST University 6) Dr. Japaraj Robert Peter Cons. Maternal-Fetal Med. Specialist, HRPB 7) Dr. Jiloris F. Dony Head, TB/Lepr. Sect., Dis. Control Div., MoH 8) Dr. Hooi Lai Ngoh Consultant Resp. Physician, Public Sp.Centre

9) Dr. Kuppusamy Iyawoo Consultant Respiratory Physician, H. Assunta 12) Dr. Ng Kien Keat Family Medicine Specialist, UiTM 13) Assoc. Prof. Dr. Roslina Abdul Manap President, Malaysian Thoracic Society 14) Datin Dr. Rugayah Bakri Dep.Director, Health Tech. Assessment Sect., MoH 15) Dr. Subramani Venugopal Senior Consultant Radiologist, H. Tunku Ja’afar 16) Dr. Suresh Kumar Consultant ID Physician, Hospital Sungai Buloh 17) Dr. Tan Kah Kee Senior Consultant ID Paediatrician, HTJ 10

EXTERNAL REVIEWERS 1) Associate Professor Dr. Ben J Marais Cons. ID Paediatrician, University of Sydney

2) Dr. Fong Siew Moy Cons. ID Paediatrician HWKS, Likas 3) Dr. Iskandar Firzada Osman Family Medicine Specialist, KK Jaya Gading 4) Professor Dr. Khoo Ee Ming Sen. Cons. Primary Care Physician, PPUM

8) Dr. Petrick Periyasamy Lecturer & ID Physician, PPUKM

9) Dr. Puvaneswari a/p Subramaniam Public Health Physician, JKN, Perak 10) Dr. Revathy Nallusamy Sen. Cons. ID Paediatrician, H. Pulau Pinang 11) Ms. Sameerah Shaikh Abd. Rahman Dep. Director, Nat. Phar. Control Bureau, MoH 5) Dr. Mahiran Mustafa Sen. Cons. ID Physician HRPZ II 7) Dr. Norhaya Mohd. Razali Cons. Respiratory Physician, HSNZ 12) Dr. Sathyamoorthy Ponnusamy Cons. Radiologist, Damai Service Hospital, KL 6) Professor Dr. Ngeow Yun Fong Sen. Res. Fellow & Cons. Microbiologist, PPUM 13) Dr. Tie Siew Teck Respiratory Physician,, Hospital Umum Kuching 14) Professor Dr Wang Yee Tang, Dir., TB Control Unit, & Sen. Cons., Tan Tock Seng H., Singapore 11

EPIDEMIOLOGY

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TB AS A GLOBAL HEALTH ISSUE

• Top 3 causes of death for women aged 15 to 44 years • One quarter of all deaths in people living with HIV • Multi-drug resistant TB (MDR-TB) • TB death rate dropped 41% between 1990 & 2011 13

FIG. 1: TEN LEADING CAUSES OF DEATH

(WHO Factsheet, 2008) World

Ischaemic heart disease Stroke & other cerebrovascular disease Lower respiratory infections Chronic obstructive pulmonary disease Diarrhoeal diseases

HIV/AIDS

Trachea, bronchus, lung cancers

Tuberculosis

Diabetes mellitus Road traffic accidents

Deaths in millions

7.25

6.15

3.46

3.28

2.46

1.78

1.39

1.34

1.26

1.21

% of deaths

12.8% 10.8% 6.1% 5.8% 4.3% 3.1% 2.4% 2.4% 2.2% 2.1% 14

FIG. 2: ESTIMATED TB INCIDENCE RATE, 2011

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FIG. 3: NUMBER & NOTIFICATION RATE OF TB CASES IN MALAYSIA, 1960 - 2010

No. of Cases

35000 30000

estimated

25000 20000 15000 10000 5000 0

Notif. Rate

400 350 300 250 200 150 100 50 0 Number of cases Notification Rate/100,000 16

4000 3500 3000 2500 2000 1500 1000 500 0

FIG. 4: NUMBER OF TB CASES IN MALAYSIA, 2011

Number of TB cases

State

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FIG. 5: NOTIFICATION OF NEW TB CASES IN MALAYSIA, 2005 - 2011

14000 12000 10000 8000 6000 4000 2000 0 Smear Positive Smear Negative Smear status unknown ExtraPulmonary 2005 8446 4313 549 1702 2006 9414 3977 359 1920 2007 9578 3828 258 2107 2008 10441 3643 180 2197 2009 9981 4143 453 2344 2010 11135 4122 216 2545 2011 11862 4446 55

%

FIG. 6: PERCENTAGE OF TB CASES AMONG CHILDREN (0 - 4 YRS & 5 - 14 YRS) IN MALAYSIA, 2000 - 2010

2,50

2,08 2,01 2,05 2,07 1,91 1,94 1,88 1,91

2,00

1,82 1,87 1,85

1,50 1,00 0,50 0,88 0,79 1,02 0,71 0,77 0,77 0,74 0,84 0,73 0,75 0,82 0,00 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

2010 0 - 4 yrs 5 - 14 yrs 19

FIG. 7: SCREENING RATE OF TB-HIV CO-MORBIDITY IN MALAYSIA, 1990 - 2010

Rate (Thousands)/100,000

12,0 10,0 Screening HIV in TB : average – 88% Screening TB in HIV : 100% 8,0 6,0 4,0 2,0

10,4 9,1 8,4 1,9 1,6 2,1 1,9 1,8

0,0 199019911992199319941995199619971998199920002001200220032004200520062007200820092010 TBHIV in HIV TBHIV in TB

TB AMONG NON-MALAYSIANS

Fig 8: Number & Proportion of TB Cases Among Non-Citizen, 1993 - 2010 Fig 9: Foreign Worker Screening & Proportion Unfit due to “TB”, 2001 - 2010 (millions)

1,6 1,4 1,2 1,0 0,8 0,6 0,4 0,2 0,0

No.

0,3 0,3 0,3 0,4 0,5 1,0 1,6 0,8

% unfit

1,8 1,6 1,4 1,2 1,0 1,0 1,0 0,8 0,6 0,4 0,2 0,0 Numbers % Unfit 21

Year 2004 2005 2006 2007 2008 2009 2010

TABLE 1: MULTI-DRUG RESISTANT TB (MDR-TB) IN MALAYSIA

Notified TB Cases (All Forms) 15429 15875 16665 16918 17506 18102 19337 Isolates tested for DST 5083 6309 6386 6687 6264 7137 6963 MDR Cases 13 17 42 41 56 55 51 % MDR (By number of culture positive tested for DST)

0.3

0.3

0.7

0.6

0.9

0.8

0.7

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FIG. 10: TB IN HEALTHCARE WORKER (MOH)

No of Cases

200 180 160 140 120 100 80 60 40 20 0 31,49 31 59,68 68 75,88 91 69,71 88 75,44 100 65,71 92 80,59 119 71,42 124 97,86 182

NR/100,000HCW

120,00 100,00 80,00 60,00 40,00 20,00 No TB cases HCW NR/100,000 HCW 23

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 24

TAKE HOME MESSAGES

• TB is prevalent in Malaysia • High risk groups* should be considered to be screened for active TB 25

THANK YOU

 [email protected]

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