TB cases, definition, register and treatment

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TB cases, definition, register and treatment
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Case classification and treatment

• Case definition is based on Int. policy
• Anatomical site of disease (PTB, Extra-P)
• Severity of diseaseparenchyma involved.
• Bacteriological status
• History of previous treatment

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Registration of cases on diagnosis. Categories.

• New (smear positive, smear neg. and
  extra-pulmonary)
• Relapse
• Failure
• Treatment after interruption or default
• Transfer in
• Other (e.g. chronic cases)

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Case definition by previous treatment (I)

• New case a patient who has never taken anti-TB
  drugs for more than 1 month.
• Relapse previously received treatment, cured,
  and has once again ss() PTB.
• Failure a TB patient who while on treatment
  remains ss(), or becomes ss() at 5th month or
  later, while on treatment, or was ss(-) at start
  and becomes ss() after 2nd month of treatment.

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Case definition by previous treatment (II)

• Return after interruption (default) a patient
  who completed at least 1 month of treatment, and
  returned after at least 2 months interruption of
  treatment.
• Transfer in registered for treatment in one
  district who transfers to another district where
  s/he continues treatment.
• Chronic remains ss() after 1 re-treatment

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Anti-TB drugs

• 1944. Streptomycin. Aminoglycosides (KM, 1957).
• 1946. PAS (1889). 1946. Thioacetazone.
• 1952. Isoniazid (synthesized 40 years before)
• 1952. Pyrazinamide(1971 short course
  chemotherapy)
• 1955. L-Cycloserine.1956. Ethionamide ( in
  TB,1959)
• 1961. Ethambutol ( in TB 1966)
• 1962. Capreomycin (peptide)
• 1966. Rifampicin
• 1985. Ofloxacin (Quinolones)

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Antituberculous Drugs, (WHO,1997)
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Categories of recommended treatment regimens
for different types of TB casesWHO/GTP
Treatment of TB Guidelines for National
Programmes, 1997.
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Sputum smear examinations of patients with
initial ss()PTB.
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DOTS and treatment cohorts

• Directly observed treatment a trained and
  supervised person observes the patient swallowing
  the tablets.
• Cohort a group of patients diagnosed and
  registered for treatment during an specific time
  period (usually one quarter of the year).
• New and previously treated patients form separate
  cohorts.

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COHORT. Evaluation of treatment

• Treatment efficacy of cured among patients who
  completed treatment.
• Treatment efficiency (success) of cured among
  patients who started treatment (cohort). The
  target (WHO/IUATLD) for success under DOTS is To
  cure at least 85 of the ss() PTB cases
  detected.

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COHORT STUDY

• On final evaluation of treatment, every patient
  who began treatment with ss() PTB will be
  registered - under Treatment Results - in one of
  the following categories
• cured a patient who is smear-negative at, or
  one month prior to, the completion of treatment
  and on at least one previous occasion.
• treatment completed a patient who completed
  treatment, but without bacteriological
  confirmation proof of cure.
• died a patient who dies, for whatever reason,
  during the course of treatment.
• treatment failure
• default (treatment interrupted)
• transfer out

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TREATMENT COHORT (An example)
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Treatment efficacy

• STANDARD SHORT COURSE REGIMENS CAN CURE OVER 90
  OF NEW,DRUG SUSCEPTIBLE TB CASES (even if
  resistant to H !).
• 2EHRZ (HRSZ)/ 6HE
• 2EHRZ (HRSZ)/ 4HR
• 2EHRZ (HRSZ)/ 4H3R3

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DOTS- MDR- HIV

• Cure rates are lower where MDR and HIV
  co-infection are relatively high.
• For countries (1) implement DOTS strategy in
  full, and on these bases more complex strategies
  like DOTS-plus where rates of DR and HIV
  infection are high.