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Monica Avendano, MD, FRCPC Associate Professor of Medicine University of Toronto Medical Director, TB Service West Park Healthcare Centre, Toronto
is still one of the leading causes of death in low-income and middleincome countries. TB remains a threat to public health in industrialized countries. The worldwide burden is still growing.
Exposure to TB
Increasing
Poverty: -Lack of or poor housing -Poor nutrition -Over crowding -No access or erratic access to healthcare
Wars
and Natural Disasters Mass Migrations usually from poor resources settings to industrialized settings
Management of TB
Medical Management
Diagnosis Treatment Follow-up
Psychosocial Management
Stigma Multicultural issues Financial implications Impact on family life
Management of TB
Obtain adequate clinical specimen Drug susceptibility in first isolate At least 3 bactericidal drugs Adequate duration of treatment: beyond the time of sputum conversion and amelioration of symptoms
Adequate follow-up: prescribing the drugs is just the beginning Attention to psychosocial factors
Treatment of TB
Goals 1. Sterilize the lesion 2. Avoid development of resistance Clinical Principles 1. Treat with multiple drugs 2. Adequate dosages 3. Sufficient duration 4. Expert monitoring
Drug Susceptibility in TB
Fully susceptible to all first line drugs
Anti-TB Drugs
Group 1 - Isoniazid, Rifampin, Pyrazinamide,Ethambutol Group 2 - Amikacin, Kanamycin, Capreomycin Group 3 - F-Quinolones Group 4 - Ethionamide, Cycloserine. PAS,Prothionamide Group 5 - Clofazimine,Imipenem, Thioacetazone, Clavulin, Macrolides, Linezolid
Duration of TB Treatment
Drugs INH/RMP/PZA + EMB x 2 months INH/RMP x 4 months INH/RMP + EMB No INH or No RMP Duration 6 months 9 months 18 24 months
MDR TB
> 450,000 cases identified every year 150,000 deaths/year from a disease that could and should be curable MDR TB is MAN MADE -Mismanagement of Fully susceptibleTB or INH resistant TB -Poor quality of drugs -Drugs shortages erratic supply - Patients not taking drugs correctly XDR TB results from failure to properly manage MDR TB
Presented in July with productive cough, weight loss, night sweats and fatigue of 3 months duration
Referred by community physician to the TB Clinic at WPHC. Abnormal Chest Radiography Admitted to WPHC from the clinic with presumptive diagnosis of MDR TB
Completed 32 months of treatment in January 2011 (24 months after bacteriologic conversion)
Follow-up every 3 months for the first year after treatment completion: CXR, bacteriologic update (induced sputum) and Chest CT Scan if CXR shows even minimal changes Last clinic visit April 2011. Remains well.
MDR TB Management
Treatment should be individualized and based on drug susceptibility studies Patient to receive all the drugs to which the infecting M.TB is susceptible. When available drugs need to be given iv If there is past history of TB and drugs previously received are known, give at least 3 drugs (bactericidal) never used before If drug susceptibility still unknown give at least 3 bactericidal drugs, but no Rifampin or Isoniazid Treatment for 2 years following bacteriologic conversion DOT mandatory Well structured and strict follow-up
Management of MDR TB
Prolonged Hospitalization Significant psycho-social issues Requires increased number of drugs Poor tolerance to the drugs Increased drug- associated toxicity Long term Follow-Up is necessary Increased health care costs
MDR TB in Ontario
Affects mainly foreign born individuals in Canada for less than 5 years Significant number of patients have previous history of TB People from countries with high burden of TB and Drug Resistant TB will continue to migrate to Canada
MDR TB Control
Extraordinary measures are needed in countries with the highest rates of TB and MDR TB: rapid detection, access to drugs and steady drugs supply and effective and expert care. The only reasonable approach is strengthening TB Control worldwide to prevent MDR TB and XDR TB
Tuberculosis anywhere
is
Tuberculosis everywhere