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Management of
Tuberculosis Patient
in Hong Kong
(10 December 2000)
Year
97
19
94
19
91
19
88
19
85
19
82
19
79
19
76
19
73
19
70
19
67
19
64
19
61
19
58
19
55
19
52
19
Rate (per 100,000)
TB notification rate (per 100,000) (1952-1999)
800
700
600
500
400
300
200
100
0
Percentage of elderly among TB patients (1961-1999)
40
35
25
20
65+(TB)
75+(TB)
15
10
65+(population)
5
75+(population)
Year
97
19
94
19
91
19
88
19
85
19
82
19
79
19
76
19
73
19
70
19
67
19
64
19
61
0
19
Percentage
30
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
155
16
2
Total number of cases analysed = 594
(Apart from this: no reply received for 28 cases)
(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
% resistant to
E
R
H
S
% resistant to
MDR-TB Total % Total
resista no. of
1 drug 2 drugs  3 drugs
nce cases
analyse
d
New cases
1.03 0.77 6.96 8.76
9.41
2.45
0.90
0.77
12.76
776
Retreatment
cases
2.59 7.76 18.10 14.66
12.07
4.31
6.90
6.90
23.28
116
Overall
1.23 1.68 8.41 9.53
9.75
2.69
1.68 * 1.57 * 14.13
892
SOURCES OF CARE FOR PATIENTS
WITH TUBERCULOSIS IN HONG KONG
PATIENT WITH TUBERCULOSIS
PRIMARY
LEVEL
SECONDARY
LEVEL
Private
Practitioner
Private
Hospitals
Department of Health
TB & Chest Service
18 chest clinics
~7,000 new patients
each year
Hospital Authority
Chest Hospitals
5 hospitals
800 beds
7,000 in-patient episodes
Department
of Health
General outpatient
clinics
Hospital
Authority
Accident
and
Emergency
Departments
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
Notifications
7000
6000
Private Sector
5000
Public Hospital
4000
Chest Hospital
3000
Chest Clinic
2000
1000
0
1994
1995
1996
1997
Year
1998
1999
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
DIRECTLY OBSERVED TREATMENT,
SHORT COURSE
to stop it at the source
TB
TB
do s
s op
DOT (directly observed treatment)
• Strongly recommended by WHO,
crucial for treatment success
Short course service programme (6 months)
2H3R3Z3E3 / 4H3R3
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.
The collaboration of public and
private sector in the control of
tuberculosis is very important.
THANK YOU!