Treatment and Programmatic Management

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Treatment and Programmatic Management

• ??.????? ????????
• ??.??.??????????????????????????? 5 ??????????
• ??????????????????????????? 5 ??????????

2
Treatment and Programmatic Management

• Drug or Regimens / Indication
• Follow up of Treatment
• Recording / Reporting form / Register
• DOTS, DOT
• Refer / Transfer system

Follow by International Standard for Tuberculosis
care (ISIC) ??? TBCTA (CUC, ATS, IUATLO, KNCV,
WHO)
3
TB CURE ONE PREVENT All !
??????
???????? 1 ??? ?????????????? 100
CONCEPT ??????????? ??? ??????????
4
?????????????????????????????
1. ??????????????? ???????????????
???????????????? ???????????????????
??????????????????????????? 2. ???????????????????
???????????????????????? 3. ??????????????????????
???? ???? ?????? 4. ?????????????????
?????????????????????????
5
?????????? ??????????????
?.?. 2425 2485 ??????????? ????????
Host Defence bed rest, good food,
fresh air, sunshine Surgery
artificial pneumothorax
6

• Modern concept of TB treatment
• More aggressive for cut off chain of
  transmission
• Maximum cure rate Minimum resist
• Most potency regimens / sterilizing effect
• Less success in second time of treatment

7
??????????????????

• ???????????????? 2 ???? ?????????????????
• ?????????????????????????????
• ?????????????????????????
• ???????????????
• ?????????????????? ??????????????????????

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?????????????? (Drug Regimens)

• ?????????????? 4 ?????? ???
• CAT1 2(3)HRZE(S)/4HR
• CAT2 2HRZES/1(2)HRZE/5HRE
• CAT3 2HRZE/4HR
• CAT4 Regimen ?????? Reserved drugs ????
  Second line
• ???????? CAT Category

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H Isoniazid R Rifampicin Z Pyrazinamide E
Etambutol S Streptomycin
Fixed DOSE Counbination ???? HR, CHR, HRZ, HRZE
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CAT1 ????????????????????

• 1. ???????????, ????????????????????????????????
  (New M)
• 2. ??????????? (Seriously ill) ???????????????????
  ???
• 2.1 Pulmonary Tuberculosis (M-)
• 2.2 Extrapulmonary Tuberculosis
• 2.3 ?????????????????????????????????
• 3. Meningitis, Disseminated ???? Spinal Disease
  with neurological complication ????? Continuation
  phase ??? 4 ????????? 7 ?????

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CAT2
1. Relapse 2. Treatment after failure ?????????
MDR-TB 3. Treatment after default (???????)
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CAT3 ????????????????????

• 1. ????????????????????????? 3 ???????????, CXR
  ????????????????, ????????????????????????????????
  ????????????????????????????????
• 2. Extrapulmonary Tuberculosis ???????????? ????
  TB ?????????????

13
CAT4 Reserved drugs

• 1. Failure case
• 2. Chronic ??????????????????????????????????????
  ??????????????????????????? CAT2

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DOSE ??? ?? TB
Dose (mg)
Drug
30 - 39 kgs
40 - 49 kgs
50 kgs
H R Z E S
300 300 1,000 800 500
300 450 1,500 1,000 750
300 600 2,000 1,200 1,000
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???????????????????????????
1. ?????????????????????????????????????????
???????????????????? ?????????????????????? 2.
??????????????????????????????????????
?????????????????? ????????????????????????
??????????????????????????????
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3. ????????????? ????????????????????
???????????????????????????????????? 4.
??????????????????????? ??????????????????????????
?????????????????????? ?????????????????????????
????????? ???????????????????????????????????????
?????? ????????????????? ??????????????????????
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???????????????????????????????????????????????? (
Side Effects and How to Manage It)
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Minor side Effect
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????????? ??? ????????
?? Enzyme ??????? ????????? INH 10
25 0.5 3 RFP No data 1.1
1.4 INHRFP 35 2.7
PZA 20 1.25
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??????????????????????????????????????????

• ???????
• ???????????
• MALNUTRITION
• PREGNANCY
• HEPATITIS B Carrier
• LIVER Enzyme ????????????????

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?????????????????????????????????(Follow up of
Treatment by Sputum Examination)

• 1. ?????? CAT1
• ????????????????????????? ?M For
  Diagnosis
• ??????????????????????????? 2(3) ? For
  Conversion rate
• ??????????????? 5 ? For failure
  evaluation
• ??????????????????????????? ? For
  success rate

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2. ?????? CAT2

• ????????????????????????? M
• ??????????????????????????? 3(4) ?
• ??????????????? 5 ?
• ??????????????????????????? ?

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3. ?????? CAT1 (M-), CAT3

• ????????????????????????? M-
• ??????????????????????????? 2 ?
• ???????????????????
• ???????????????????
• ?????????????????????????? ?

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(No Transcript)
25
(No Transcript)
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(No Transcript)
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?????????/?????????/???????(Recording/Reporting
form/Register)

• 1. ??????????????????? (Tuberculosis Treatment
  Card ???? TB Card ???? TB 01)
• 2. DOT Card (TB 02)
• 3. ???????????????????? (TB 03)
• 4. ?????????????????????????????? (Tuberculosis
  Laboratory Register ???? TB 04)
• 5. ??????????????????????????????? (TB 05)

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?????????/?????????/??????? (???)

• 7. ???????????? 3 ??????????????????????????????
  ????????????????????????????????? 0-3
  ?????????????? (TB 07/1)
• 8. ???????????? 3 ????????????????????????????????
  ??????????????????????????????????????????????????
  ??? 6-9 ?????????????? (TB 07/2)
• 9. ???????????? 3 ????????????????????????????????
  ????????????????????? 12-15 ?????????????? (TB
  08)
• 10. ?????????????????????????????? (TB 09)
• 11. ??????????????????????????????? (TB 10)
• 12. ???????????? 3 ????? ?????????????????????????
  ????????????????? 3-6 ????? ????????? (TB-HIV 01)

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???????????? (Cohort Analysis)
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????? Cohort Analysis
1. Case finding ??????? 1.1 ????????????????????
?? 1.2 ??????????????????? New M
????????????????? 2. Sputum conversion
????????????????????????????? -?????????????????
-??????????????????????????????????????? 3.
Treatment Outcome ?????????????????
???????????????????????? (Cure rate)
???????????????????????????????? (New M)
32
(No Transcript)
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(No Transcript)
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DOTS ??? DOT ??????????????
DOTS ?????????? 5 Elements DOT
?????????????????????????????????
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DOTS

• ??????????????????????????????????????????????????
  ?????
• ????????????????????
• ???????????????????
• ????????????????????????
• ???????? DOTS ??????????????????????????????
  100 ??????????
• ???????????????? ?????????????????????????????????
  ???????????????????
• ( ISTC ??? 9)

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5 Key Elements of DOTS

• Political commitment with increase and sustained
  financing
• Case detection through quality-assured
  bacteriology
• Standardize treatment with supervision and
  patient support
• Effective drug supply and management system
• Monitoring and evaluation system and impact
  measurement

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DOT Directly Observed Treatment

• ??? ?????????????????????????????
• ????? ??????????????????????????????????????
• ?????????????????????????????????????
  
• ??????????? ?????????????????????????
  

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??????????????????????????????? DOT

• ????????????? ?????????????? (???????????)
• ???????????????????? ???????????????????????????
• Relapse
• Default
• Failure

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??????????????????????????????????????????????????
??
?????????????????????? ???????? 1,2,3
???????? ???????? 2,3 ???????????? Supervise
???????????????????????
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?????????????????????????????? (?????????)

• ??????????????????????????????????????????????????
  ?????
• ???????????????????????????????????????????
• ?????????????????????????????????????????????
• ????????????????????????????? (???????????????????
  ??????????????????????)

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???????????????? DOT

• ?????????? check list DOT card
  ????????????????????????????? ??? ??????????
• ????????????????????????????????????????????
  ???????????????????????
• ???????? Cohort analysis ?????????????????????????
  ?????

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???????????????????? (Referral System) ?? 2 ???

• Refer

• Transfer

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??? Refer
Register
??? Register
????????? ?. ???????????????????
?????????????????????????????????? ?.
???????????????? ?. ????????????????????????????
????? Refer ????????????????????????? ?.
???????????????????????????????? ?. ???? New case
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??? Transfer
????????? ?. ???????????????????????????????????
Transfer in ????? District TB number
??????????????????????????????????????????????????
????????????? ?. (????????????????????????????????
????? ?.)
????????? ?. ?????????????????????????
??????????? District TB number ???????????????????
??? ????????? ?. Transfer out ????????????????????
????????? ?. ???????????? ?.?????????????????????
?????????????
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International Standard for TB Care ISTC

• Standard for Diagnosis 6 ???
• Standard for Treatment 9 ???
• Standard for Public Health
• Responsibilities 2 ???

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Standard for Treatment

• Standard 7 Any practitioner treating a
  patient for tuberculosis is assuming an important
  public health responsibility.
• Standard 8 All patients should receive an
  internationally accepted first-line treatment
  regimen drugs of known bioavailability,
  Fixed-dose combinations are highly recommended.
• Standard 9 To foster and assess adherence,
  Such measures may include direct observation of
  medication ingestion (directly observed
  therapy-DOT)
• Standard 10 All patients should be monitored
  for response to therapy, by follow-up sputum
  microscopy (two specimens) of completion of the
  initial phase of treatment (two months), at five
  months, and at end of treatment.