containment - lecture 11 - TB containment and control

importance of health services

• if the health services is not working then this means that certain health initiatives (TB, malaria HIV) will not work 

• clinical care, public health and the health services together is very important!!!

TB

• preventable, treatable, curable but still >10 million people ill and >1.3 million deaths annually

• why is it still a leading cause of death

  • social, economic and development disease

  • do not address the bacteria but focus on the drivers. human behaviour needs to change

    • no problem → money 92% has phone

    • TB treatment is too long (6 months) → people often take chronic drugs this also happens so is an excuse!

  • people can have the disease but no symptoms → need to detect disease early because 1 person can infect 10-15 people. want to stop before this happens.

TB IGRA/TST

• IGRA is een bloedtest die de immuunrespons op de tbc-bacterie meet,

• TST een huidtest is die een reactie op de injectie van tuberculine leest

• main point this should be the diagnosis way first! not microscopy! 

why TB disease rapid molecular test (x pert gene) can work

• gives insight into drug resistance

• diagnosis within 2 hours (prior to this it took 4-5 days)

• only need 1000 bacilles instead of 30 million to be able to diagnose

• BUT there are some problems → energy dependent, but they changed this not on battery, and only 4 samples can be tested per round (so patient build up).

treatment

• has been quite some advancement. treatment used to be 24 months with oral and injectables and 9 different medicines. people got a lot of side effects 

• now 6 months, all oral medication and mild side effects. 

• no point of care test → like rapid testing

what is TB - and how to have earlier detection 

• airborne bacteria

• infected people can infect 10-25 other people → this is why you want to detect early

  • education in communities very important! they need to know symptoms and where to go when they have these. 

  • screen people who have any other comorbidity (and are already seeking care) 

  • high risk people should be on preventative medicine 

risk factors for TB worldwide and specifically in Nl

• undernutrition

• alcohol use

• smoking 

• HIV infection 

• diabetes 

but these are not drivers in Nl 

• in Nl immunosuppressive diseased people 

• age (very young or old) 

where is the urgency in TB

• TIME

• everything being done on time is highly important (applicable for every infectious disease). 

basic TB prevention and care strategy

• early diagnosis

  • there is always contact (person got it from someone or has already given it to someone)

  • you need to do contact management. this is an indicator of quality of care.

• adequate and uninterrupted treatment

  • supply management → drug transport, temperature, system for drug transport needed to ensure safety 

  • systematic screening (screen household contact) 

TB infection and prevention control measures

• hierarchy with 3 levels

  • administrative controls (reduce risk of exposure)

    • triage of patients with TB signs and symptoms

  • environmental controls → reduce spread of infectious droplet

    • ventilation

    • UV light

    • health facility renovation

  • respiratory protection controls (PPE)

the basis principles to end TB

PICTURE

• cycle; search → treat → prevent 

• EARLY → anything that is not done early still sustains the disease!!!!! 

• cost also important. machine to diagnose 18000 dollar and each cartridge 9 dollars. 

magnitude of TB around the world

• low incidence 57 countries <10 cases / 100 000 population. 

• high incidence → 150-400 cases / 100 000 population

• few countries are super high incidence >500 cases / 100 000 population 

incidence by region

• south east asia 43% (very densely populated)

• africa 25%

• europe 2.3% (500 million people)  

• americans 3% 

• west pacific 18% 

also important to look at how many people are there and the location in the world.

• most TB cases lower half of the world → social economy is major factor defining the two

common drivers of TB epidemic

• population 

• development challenges 

• poverty 

• weak health system / access

• climate change

  • driver for TB → agricultural output is less

  • barrier for health systems → flooding results in infrastructure being down.

• undernutrition (one of biggest driver in Asia)

• HIV/AIDS (one of the biggest driver in Africa)

• alcohol abuse

• diabetes

• conflict

key areas for attention in TB program low incidence countries (Nl)

• drivers of TB epidemic l

  • aging population

  • population density 

• vulnerable populations l

  • migrant workers 

  • asylum seekers 

• challenges associated with low incidence l

  • stigma 

basic principles

1. care must be patient centred and right based

2. quality diagnoses including DST

3. quality medicines, appropriate regimen, and adequate duration (around the world the same drug)

4. adherence support

5. active TB drug safety. monitoring and management of the drug (aDSM)

6. overall monitoring, evaluation and reporting

drug resistant TB treatment

• only 6-9 months

• in the past very much longer

• bPaLM??

drug for TB

• rifampicin given in Africa but in the Netherlands (europe) this is not allowed

TB in children

• very hard to diagnose 

• need to use a cocktail to diagnose (everything you have in your mars on te testen) 

TB control strategies over time

• 1993 - DOTS

  • political commitment

  • case detection through bacteriology

  • DOT

  • effective and regular drug supply system → global drug delivery from 1 country so everyone got the same standard

  • M&E

• 2006 the STOP TB strategy

  • pursue high quality dots expansion and enhancement

  • address TB/HIV, MDR-TB and the needs of poor and vulnerable populations

  • contribute to health system strengthening based on primary health care

  • engage all care providers → into private sector

  • empower people with TB, and communities through partnership

  • enable and promote research

• end TB strategy

all programs in common; patients care, programs, and governance (search, treat, prevent) this should happen through financing and research!!!!