> Íl 6ö 2016;yej d# -...
TRANSCRIPT
![Page 1: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/1.jpg)
2016
1
2
![Page 2: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/2.jpg)
3
960 150 120HIV
40
48
19
2035
4
(SDGs) WHO TB
2020 2025 2030 2035TB
201535% 75% 90% 95%
TB2015
20% 50% 80% 90%TB 0% 0% 0% 0%
![Page 3: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/3.jpg)
Projected acceleration of TB incidence decline to target levels
2025
10%
-5%/
2%/
17%
5
6
2015
![Page 4: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/4.jpg)
B2035
7
2005-2014
16,472
15,378
14,48014,265
13,336 13,237
12,63412,338
11,52811,326
72.5
67.4
63.2 62.0
57.8 57.2
54.5 53.0
49.4 48.4
30
40
50
60
70
11,000
12,000
13,000
14,000
15,000
16,000
17,000
18,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
(
1\
10
)
8
![Page 5: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/5.jpg)
9
Effect from Nationwide 9M INH in Children in TaiwanMOHW103-CDC-C-315-000302
Txstatus
<5Y 5-12Y 13-17Y
No. TB No. Incidence No. TB No. Incidence No. TB No. Incidence
Ever 2550 1 35 6703 8 75 2395 5 125
Never 804 5 600 1812 17 332 1257 14 1118
RR: 0.06 (<0.01 ~ 0.34)94% protection
RR: 0.22 (0.06 ~ 0.74)78% protection
RR: 0.11 (0.02 ~ 0.34)89% protection
10
![Page 6: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/6.jpg)
11
Txstatus
<13Y 13-29Y ≥30Y
No. TB Incidence No. TB Incidence No. TB Incidence
Ever 29169 7 63 14067 8 123 13597 15 113
Never 8307 17 420 10939 45 1130 25146 59 404
Effect from Nationwide 9M INH in Taiwan
≥30YRR: 0.27 (0.08 ~ 0.64)
73% protection
13-29YRR: 0.10 (0.03 ~
0.22)90% protection
12
Period: 2010-2012Contacts born before 1986: 5,145Contacts of highly infectious index: 3,810Complete TST: 2,217 (58.2%)Complete QFT: 2,259 (59.3%)TST/QFT both available: 2,202 (57.8%)
HR: 50.9 (5.88 - 439)
![Page 7: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/7.jpg)
LTBICLINICAL APPROACH OF LTBI DIAGNOSIS AND TREATMENT
IGRA vs. TST
13
1. identify Priority group
Tuberculosis Complex
ESAT-6 CFP-10 TB7.7 Environmental Strains
ESAT-6 CFP-10 TB7.7
M tuberculosis + + + M abcessus - - -M africanum + + + M avium - - -M bovis + + + M branderi - - -
M celatum - - -BCG substrain M chelonae - - -
gothenburg - - - M fortuitum - - -moreau - - - M gordonii - - -tice - - - M intracellulare - - -tokyo - - - M kansasii + + -danish - - - M malmoense - - -glaxo - - - M marinum + + -montreal - - - M oenavense - - -pasteur - - - M scrofulaceum - - -
M smegmatis - - -M szulgai + + -M terrae - - -M vaccae - - -M xenopi - - -
IGRA
IGRA BCG NTM 55 IGRA
14
![Page 8: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/8.jpg)
954 close contacts
142 QFT-positive/TST-positive
Chemoprophylaxis RIF and/or INH
No active TB
51 QFT-positive(49 TST-positive)
Mean follow-up >3.5 yr
Not treated
17 developed active TB
343 TST negative
5 QFT-positiveTST-negative
Not treated
2 developed active TB
413 TST positive
Not treated Not treated
No active TB No active TB
198 QFT-positive 756 QFT-negative
Diel R. AJRCCM 2011;183:88-95. 15
Negative and Positive Predictive Value of a Whole-Blood IFN-� Release Assay for Developing Active TB
Correlation between TST and QFTTST induration (mm) No. QFT-positive
10 – 14 55 4 (7.2%)
15 – 19 30 6 (20.0%)
20 – 24 7 2 (28.6%)
25 – 29 0
30 – 34 1 1 (100%)
-MOHW104-CDC-C-114-123201
0 34
MOHW
![Page 9: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/9.jpg)
48.9
31.4
14.1 14.118.8
34.1
27.3
0
10
20
30
40
50
60
70
<13 13-26 27-34 35-44 45-54 55-64 >=65
%
Contact Age
TST(+) QFT(+) Double(+)
Results of TST and IGRA
17
(681) (547) (485) (293) (209)(278) (1142)
18
• 15-61%
• 2015.10.05 3,975 TST+IGRA
LTBI
![Page 10: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/10.jpg)
19
• N = 3,975 up to 2015/10/5
1986.1.1
518
527
2008.4.1 2016.3.1
LTBI 1986.1.1
LTBI TST IGRA
TST IGRA
5 TSTIGRA LTBI 3
20
![Page 11: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/11.jpg)
�••
�
��
≥ ≥
≥
* TB Nil
22
![Page 12: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/12.jpg)
23
2. exclude Active TB
24
3. identify Supervised / Short-course preventive therapy
12 2703HP 9H
![Page 13: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/13.jpg)
25
Efficacy of INH Preventive Therapy (IPT)
ATS. AJRCCM 2000;161:S221-47.
Directly Observed Preventive Therapy (DOPT)
2016 3 1
2016 4 1(3HP)
26
once weekly x 3 months = only 12 doses900mg Isoniazid (INH) +900mg Rifapentine (RPT)
![Page 14: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/14.jpg)
2008.4.1 2016.3.1
LTBI 1986.1.1
LTBI TST IGRA
TST IGRA
9H 9H 3HP
- ( 500 )
5 TSTIGRA LTBI 3
27
DOPT
28
![Page 15: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/15.jpg)
29
4. monitor Side effects
2473
3227
4175
3263
700Risk of INH-
induced hepatitis
Kopanoff DE, et al. Am Rev Respir Dis 1978;117:991-1001.
• USPHS• 13838 cases• 1971/07 ~ 1972/11
![Page 16: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/16.jpg)
31
2008 2009 2010 2011 2012 2013 2014
Case No. 1402 2628 3902 4948 5906 5485 4082
Interruption 515 944 1376 1829 1509 1196 857
Due to AE (%) 16(1.1%)
27(1.0%)
57(1.5%)
117(2.4%)
153(2.6%)
106(1.9%)
85(2.1%)
MOHW104-CDC-C-315-000203
<10 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥80
Case No. 11809 9486 2874 1073 1169 1015 462 253 212
Follow (p-m) 79713 72140 22839 7524 8291 7274 3312 1774 1516
AE (%) 102(0.86)
125(1.32)
100(3.48)
54(5.03)
72(6.16)
66(6.50)
32(6.93)
11(4.35)
3(1.42)
Hepatitis 13(0.11)
25(0.26)
42(1.46)
27(2.52)
29(2.48)
28(2.76)
20(4.33)
3(1.19)
0(0.00)
Admission 3 3 0 3 3 2 2 0 0
32
32
19.3%
10.0%
18.6%
24.8%
33.3%
10.7%
37.1%
43.3%
15.5%
37.9%
9.6%
7.1%5.5%
14.3%
3.6%2.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
All age <13 13-29 >=30
HEPATITIS HEPATITIS SEVERE SKIN RASH SKIN RASH SEVERE
MOHW103-CDC-C-315-000302
![Page 17: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/17.jpg)
Follow-up Liver Function Tests
0
5
10
15
20
25
30
35
40
AST(U/L)
ALT(U/L)
Totalbilirubin(mg/dL)
AST(U/L)
ALT(U/L)
Totalbilirubin(mg/dL)
AST(U/L)
ALT(U/L)
Totalbilirubin(mg/dL)
AST(U/L)
ALT(U/L)
Totalbilirubin(mg/dL)
3HP 9H*
* *
* * *
-
MOHW104-CDC-C-114-123201
34
yes no
•
••
>=35
HBsAg, anti-HCV AbHIV ELISA/Combo Ag+Ab
<35
*
���
![Page 18: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/18.jpg)
TB
• ICD-10– Z201–
R76.1
•CXR
• LTBI
35
•IGRA LTBI
•
•
36
*
E4003C 100
E4004C IGRA ( ) 300
E4005C 100
• 1 1• 5 IGRA
![Page 19: > ÍL 6ö 2016;yEJ D# - homepage.ntu.edu.twhomepage.ntu.edu.tw/~ntuidrec/file/20160304/2016_03_09... · 2016-235 Æ14£\5 &f 2fW ... once weekly x 3 months = only 12 doses 900mg Isoniazid](https://reader030.vdocuments.net/reader030/viewer/2022011723/5a82131d7f8b9a682c8db427/html5/thumbnails/19.jpg)
– Z201R76.1
–E4003CE4004C IGRA ( )E4005C
– TB –
37
38
Latent TB Infection - PASS
1. identify Priority group
2. exclude Active TB
3. provide Supervised / Short-course preventive therapy
4. monitor Side effect