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National TB control program Flashcards

1
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- vision?

A

Vision:
Msia free of TB by year 2035
- Aim to reduce TB death (compared to 2015) by 95% & reduced TB incidence by 90% [<10 per 100 000 population] (compared to 2015)

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2
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- goal?

A

Goal: Decrease the burden of TB by
1) Ensuring universal access to timely and quality Dx & Rx of all forms of TB
2) Prevent development of DRTB in the country

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3
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- target?

A

Target:
Target by 2020:
1) TB mortality reduced by 25%
2) TB notification rate increase to 100 per 100 000 population
3) Universal access to Dx & Rx of all forms of TB inc MDR & XDRTB (at least 90% of MDRTB are successfully treated)

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4
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- 11 strategies?

A

Strategy 1: Enhance case detection of TB

Strategy 2: Improve control of TB among children

Strategy 3: Decrease the burden of TB/HIV in ppl at risk of or affected by both disease

Strategy 4: Strengthen Programmatic Mx of DR-TB

Strategy 5: Strengthen laboratory network to find all TB cases

Strategy 6: Strengthen Programmatic Mx of LTBI activities

Strategy 7: Enhance BCG vax program

Strategy 8: Ensure uninterrupted supply of quality-assured TB drugs

Strategy 9: Enable supportive environment & systems for effective TB control

Strategy 10: Ensure no households that experience catastrophic cost due to TB

Strategy 11: Intensify research & innovation as priority issues in TB control program

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5
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 1: Enhance case detection of TB?

A

Strategy 1: Enhance case detection of TB

Key indicators:
1) Increase case notification from 75 (in 2015) to 100 per 100 000 population by 2020
2) Symptomatic screening: 2000 per 100 000 population by 2020
3) Contact screening coverage at 1st visit >90% and at 4th visit >50%
4) Treatment success rate >90%

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6
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 2: Improve control of TB among children

A

Strategy 2: Improve control of TB among children

Key indicators:
1) Increase case detection from 3.1% to 5% in 2020
2) Achieve Rx success to 95% for peads cases

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7
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 3: Decrease the burden of TB/HIV in ppl at risk of or affected by both disease

A

Strategy 3: Decrease the burden of TB/HIV in ppl at risk of or affected by both disease

Key indicators:
1) # new or relapse TB in documented HIV/ # of new or relapse TB = 100%
2) # HIV on LTBI Rx/ # of eligible cases = 90%

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8
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 4: Strengthen Programmatic Mx of DR-TB

A

Strategy 4: Strengthen Programmatic Mx of DR-TB

Key indicators:
1) MDRTB cases notification <3% of all TB cases
2) Rx success rate of DR-TB >90%

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9
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 5:
Strengthen laboratory network to find all TB cases

A

Strategy 5:
Strengthen laboratory network to find all TB cases

Key indicators:
1) Drug susceptibility test coverage 100%

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10
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 6: Strengthen Programmatic Mx of LTBI activities

A

children <5yo of household treated for LTBI started on LTBI Rx/ # eligible ppl for Rx >50%

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11
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 7: Enhance BCG vax program

A

Strategy 7: Enhance BCG vax program

Key indicators:
BCG coverage for newborns >98%

Re: BCG vax
- 70-80% effective against most severe form of TB e.g. TB meningitis in children, which lasted 10-15y

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12
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 8: Ensure uninterrupted supply of quality-assured TB drugs

A

Strategy 8: Ensure uninterrupted supply of quality-assured TB drugs

Key indicators:
Ensure uninterrupted supply of quality-assured TB drugs

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13
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 9: Enable supportive environment & systems for effective TB control

A

Strategy 9: Enable supportive environment & systems for effective TB control

Key indicators:
1) # of TB pt referred by community volunteers/NGOs for TB Dx & Rx
2) #of TB pt under f/up or DOT with community volunteers/NGOs
3) # TB pt cured/ completed TB Rx under supervision of community volunteers/ NGOs

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14
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 10: Ensure no households that experience catastrophic cost due to TB

A

Strategy 10: Ensure no households that experience catastrophic cost due to TB

Key indicator: not specified in guideline

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15
Q

What is the National Strategic Plan (NSP) for TB control 2016-2020
- key indicators for Strategy 11: Intensify research & innovation as priority issues in TB control program

A

Strategy 11: Intensify research & innovation as priority issues in TB control program

Key indicator:
Establishment of TB research network

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16
Q

What are the three elements of the National Strategic Plan (NSP) for TB control 2016-2020?

A

1) Integrated, pt-centred care & prevention (Strategies 1-7)
- early Dx inc drug-susceptibility test & screening of contacts & high-risk groups
- Rx all Tb inc DRTB
- collaborative TB/HIV activities & Mx of comorbidities
- preventive Rx of persons at high risk & vax against TB

2) Bold policies and supportive systems (Strategies 8-10)
- Political commitment with adequate resources for TB care & prevention
- engagement with communities, public/ private care providers
- universal health cover age policy, and regulatory frame work for case notification, vital registration, quality and rational use of meds & infection control
- Social protection, poverty alleviation & actions on other determinants of TB

3) Intensified research & innovation (Strategy 11)
- discovery, development and rapid uptake of new tools, interventions & strategies
- research to optimise implementation & impact, and promote innovations

17
Q

What is the available TB screening program?

A

1) Contact tracing of index case
- 4 visits in total: (0,3,6,12-m interval)
1st visit at 0 month
2nd visit at 3m after 1st visit
3rd visit at 6m after 2nd visit
4th visit at 12m after 3rd visit

2) Screening of high risk group
- High risk group:
i) contact of index TB case
ii) TB/HIV comorbid
iii) inmate for prisons/ cure & care rehab centre
iv) DM
v) smokers
vi) ESRF on HD
vii) pt taking TNFi
viii) COPD
ix) elderly
x) on methadone therapy/ under substance abuse clinic

3) Screening of TB in prison (at entry & regular screening)

18
Q

What are the challenges in TB Mx in Malaysia?

A

1) Low case detection of TB & MDR-TB
2) Resources available not parallel with disease burden
3) Low TB case detection among children
4) Insufficient TB-HIV collaborative activities
5) Inadequate policy for LTBI Rx
6) Inadequate knowledge & awareness re BCG vax
7) Poor TB Rx outcomes
8) Lack of adequate engagement of communities in active TB finding & Rx adherence
9) Lack of TB support groups & policy to address social determinants of pts
10) Inadequate research & innovations in TB program

19
Q

Case definition

A

1) Bacteriologically confirmed TB
- one from whom a biological specimen is positive by smear microscopy, culture or WHO-recommend rapid diagnostic tests (e.g. GeneXpert)
- all such cases should be notified, regradless whether TB Rx has started

2) Clinically diagnosed TB
- one who does not fulfil the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the pt a full course of TB Rx.
- includes cases diagnosed on basis of abnorm X-ray, or suggestive of HPE and extrapulmonary cases w/out lab confirmation.
- Clinically diagnosed cases subsequently found to be bacteriologically positive (before or after starting Rx) should be reclassified as bacteriologically confirmed.

TB cases are also classified according to:
a) anatomical site of disease
b) Hx of previous Rx
c) drug resistance
d) HIV status

20
Q

Bacteriologically confirmed TB cases are classified according to:
a) anatomical site of disease
b) Hx of previous Rx
c) drug resistance
d) HIV status

A

Anatomical site of disease:
1) Pulmonary TB (PTB):
- involving lung parenchyma or tracheobronchial tree
- miliary TB
- both PTB and EPTB should be classified as PTB
###TB intrathoracic lymphadenopathy or pleural TB without radiographic abnorm in the lungs is considered EPTB##

2) Extrapulmonary TB (EPTB)
- involving organs other than lungs e.g. pleural, lymph nodes, abdo, GUT, skin, joints and bones, meninges.

21
Q

Bacteriologically confirmed TB cases are classified according to:
a) anatomical site of disease
b) Hx of previous Rx
c) drug resistance
d) HIV status

A

Hx of previous Rx:

this classification is independent of bacteriologically confirmed or site of disease

1) New pt:
- never been treated for TB or have taken ATT for <1m

2) Previously treated pt:
- have received ≥1m ATT in the past
- this group is further classified by the outcome of their most recent course of Rx:

a) Relapse pt:
- previously treated for TB were decleared cured or Rx completed at the end of their most recent course of Rx
- and are now diagnosed with recurrent episode of TB
- (either true relapse or a new episode of TB caused by reinfection)

b) Rx after failure pt:
- previously treated for TB, and whose Rx failed at the end of their most recent course of Rx

c) Rx after loss to follow-up pt:
- Previously treated for TB and were declared loss to f/up at the end of their most recent course of Rx

d) Other previously treated pt:
- Those who have previously been treated for TB but whose outcome after their most recent course of Rx is unknown or undocumented

New & relapse cases of TB are incident TB cases

22
Q

Bacteriologically confirmed TB cases are classified according to:
a) anatomical site of disease
b) Hx of previous Rx
c) drug resistance
d) HIV status

A

Drug resistance:

1) Monoresistance: resistant to one 1st line ATT
2) Polydrug resistance: resistant to >1 1st line ATT (apart from both H & R)
3) Multidrug resistance: resistant to at least both H & R
4) Extensive drug resistance:
Previously: resistant to fluoroquinolone + injectable drugs + H + R
Currently: resistant to H+R+ fluoroquinolones + Bedaquiline or Linezolid
5) Rifampicin resistance: resistant to R

23
Q

Bacteriologically confirmed TB cases are classified according to:
a) anatomical site of disease
b) Hx of previous Rx
c) drug resistance
d) HIV status

A

HIV status

24
Q

What are ‘incident TB cases’?

A

New & relapse cases of TB are incident TB cases

25
Q

TB treatment outcome definitions
- for drug-susceptable TB
- for drug-resistant TB

Mnemonic: CCF-DuLu-NaS

A

Only applicable in drug-susceptable TB:
1) Cured:
- a PTB case with bacteriologically confirmed TB at the beginning of Rx
- who was smear or culture negative in the **last month of Rx ** and on at least one previous occasion

2) Rx completed:
- TB pt who completed Rx without evidence of failure,
- but with no record to show that sputum smear or culture results in the last month of Rx and on at least one previous occasion were negative,
- either because tests were not done or because results are unavailable

3) Rx failed:
- TB pt whose sputum smear or culture is positive at month 5 or later during Rx

4) Died:
- TB pt who dies for any reason before starting or during the course of Rx

5) Lost to f/up:
- TB pt who did not start Rx, or
- Rx was interrupted for two consecutive months or more

6) Not evaluated:
- No Rx outcome is assigned.
- Includes cases ‘transferred out’ to another Rx unit
- as well as cases for whom Rx outcome is unknown to the reporting unit

7) Treatment success:
- the sum of cured and treatment completed

CCF-DuLu-NaS

26
Q

TB treatment outcome definitions
- for drug-susceptable TB
- for drug-resistant TB

Mnemonic: CCF-DuLu-NaS

A

Only applicable in drug-resistant TB:
1) Cured:
- Rx completed as recommended by national policy
- without evidence of failure
- AND ≥3 consecutive cultures taken at least 30d apart are negative after the intensive phase

2) Treatment completed:
- Rx completed as recommended by the national policy
- without evidence of failure
- BUT no record that ≥3 consecutive cultures taken at least 30d apart are negative after the intensive phase

3) Treatment failed:
- Rx terminated or need for permanent regimen change of at least two ATT drugs because of:
i) lack of conversion by the end of the intensive phase, or
ii) bacteriological reversion in the continuation phase after conversion to negative, or
iii) evidence of additional acquired resistance to fluoroquinolones or second-line injectable drugs, or
adverse drug reaction

4) Died:
- pt who died for any reason during the course of Rx

5) Lost to follow-up:
- treatment was interrupted for 2 consecutive months or more

6) Not evaluated:
- No Rx outcome was assigned
- incl cases transferred-out to another treatment unit and whose Rx outcome is unknown

7) Treatment success:
- the sum cured and treatment completed

CCF-DuLu-NaS
Cure
Completed
Failed
Died
Loss to

27
Q

TB forms (TBIS-10)

A

TBIS-10(place the letter here)

A: Awal - To be filled up upon Dx

B: Buku - The book documenting pt’s personal info, Rx & progress. When pt move to different Rx unit, fill up TBIS-10K and send this TBIS-10B together to the new PR1

C: Contact - List of close contacts & doc’s Ax of contacts

D: Default
- To report pt & close contact who defaulted
- fill up this TBIS-10D form for pt who failed to attend treatment on 3rd day consecutively
- fill up this form weekly for at least 8 times , for pt who failed to attent Rx for ≥2 months consecutively

E: Electronic - the DOT book

F: Follow-up
- To inform PR2 about DOT, when is PR1 next TCA and completion of Rx

G: Gagal
- to find out factors for Rx failure

H: Harian
- put in front of folder
- Appointment dates for PR1
- ATT regimen
- sputum conversion date
- PR2 location

I: Information
- overview of pt’s Rx, smear conversion, DOTs & Rx outcome

J: Jalan
- pt’s death and reason

K: Keluar
- For TB cases transferred out to other PR1

28
Q

TB treatment centres
- PR1
- PR2

A

PR1: Treatment unit that
- diagnose the pt with TB
- started pt on TB Rx
- Do on-going appointments and reviews of the pt,
- Stop the TB Rx

PR2: Treatment unit that
- continue the TB Rx (DOTs),
- BUT does not started the TB Rx or do on-going appointments and reviews
- this facility may diagnose the TB

29
Q

Case detection
- definition
- aim

A

Definition:
= The number of TB cases detected in a given year.
- the TB case reported within the national surveillance system, then to WHO

Aim:
1) Ensure high quality pt care
2) Aid staff providing adequate services
3) Allows managers in national TB program to monitor program performance
4) Basis for program and policy development

30
Q

Case screening
- def
- types

A

Def of Systematic screening for TB disease:
- systematic identification of ppl at risk for TB disease,
- in a predetermined target group
- by assessing Sx and
- using tests, examination, or other procedures
- that can be applied rapidly.

Types:
1) Active case finding
- provider-initiated screening
- systematic screening
- systematically target ppl high risk of exposure or developing TB
- Screens them by assessing Sx, test, examination/ other procedures
- high risk exposures: contacts of TB, PLHIV, high TB burden population (e.g. prisons, miners with silica exposure)

2) Passive case finding
- Pt-initiated pathway
- person with TB who experienced Sx
- person having access and seeking care, and present spontaneously at a health facility
- Health worker correctly assessing criteria of TB

31
Q

What are the WHO END TB strategy pillars and principles

A

3 pillars underpinned by 4 key principles:

Pillars:
1) Integrated, pt-centred TB care and prevention
2) Bold policies and supportive system
3) Intensified research & innovation

Key principles:
1) Government stewardship and accountability, with monitoring and evaluation
2) Building a strong coalition with civil society and communities
3) Protecting and promoting human rights, ethics & equity
4) Adaptation of the strategy and targets at country level, with global collaboration

Pillars:
- bring together critical interventions
- to ensure all ppl with TB have equitable access to high-quality Dx, Rx care and prevention,
- without facing catastrophic expenditure or social repercussion

Principles:
- The success of the strategy in driving down TB deaths and illness will depend on
- countries respecting the key principles
- as they implement the interventions outlined in each pillar

32
Q

WHO indicators and targets for monitoring the implementation of End TB strategy

A

All countries should aim to reach these targets by 2025:
1) Rx coverage ≥90%
2) Rx success rate ≥90%
3) Preventive Rx coverage ≥90%
- PLHIV & children who are contact of cases started on LTBI Rx
4) TB affected households facing catastrophic costs 0%
5) Uptake of new diagnostics and new drugs ≥90%

33
Q

When should contact screening be done?

A

TB pts with the following characteristics:
1) bacteriologically confirmed PTB
2) Proven or presumed MDR TB or XDR TB
3) PLHIV
4) Child <5y

34
Q

What are the risk factors that increase the risk of TB infection in close contacts

A

1) Contact with DM
2) Index case with cavitation
3) Index case with >100AFB/field
4) Being household contact at night
5) Being a contact who is actively smoking

35
Q

What is the definition of close contact?

A

No uniform definition, so depends on local context.
- Some definitions:
i) Family members living in the same room with index case for >30d
ii) family members or other ppl living with index case for >6m

36
Q

Algorithm of contact tracing based on CPG Msia

A
37
Q

Process in reporting TB defaulter

A

1) Pt failed to attend TCA –>
2) Call pt on Day 1 & advise to attend TCA –>
3) If pt uncontactable, issue the first TBIS-10D on Day 3 –>
4) PR needs to issue TBIS-10D every week until 8 weeks, to allow further legal action to be taken

38
Q

Legal acts involved in TB issues

A

1) Prevention and Control of Infectious Diseases Act 1988 (Act 342)
2) Mental Health Act (Act 615)
3) Child Act 2001, amended 2016 (Act 611)

39
Q

WHO End TB strategy
- vision
- goal
- targets

A

Vision:
A world free of TB
Zero deaths, disease and suffering due to TB

Goal:
End the global TB epidemic

Targets:
1) Reduction in number of TB deaths by 90% (2030) and 95% (2035), compared with 2015
2) Reduction in TB incidence rate by 80% (2030) and 90% (2035), compared with 2015
3) TB-affected families facing catastrophic costs due to TB 0% (2030 and 2035)

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