Management ofTuberculosis Patient

in Hong Kong

(10 December 2000)

TB notification rate (per 100,000) (1952-1999)

0

100

200

300

400

500

600

700

800

Year

Rat

e (p

er 1

00,0

00)

Percentage of elderly among TB patients (1961-1999)

0

5

10

15

20

25

30

35

40

Year

Perc

enta

ge

65+(TB)75+(TB)

75+(population)

65+(population)

Medical conditions of patients at the time ofdeveloping TB (notified in August 1999) (Total no.= 594)

One or more medical conditions 155 (26.09%)

[Two medical conditions 16 (2.69%)]

[Three medical conditions 2 (0.34%)]

Total number of cases analysed = 594(Apart from this: no reply received for 28 cases)

Medical conditions of patients at the time ofdeveloping TB (notified in August 1999) (Total no.= 594)

Medical conditions Number %

Diabetes mellitus 72 12.12

On steroid 8 1.35

Chronic renal failure 18 3

On cytotoxic drug 1 0.17

Leukaemia/ lymphoma 4 0.67

Malignancy 27 4.55

Alcoholism 10 1.68

Drug addiction 6 1.01

Pneumoconiosis 9 1.52

Others 20 3.37

Drug resistance rate among cases seen at chest clinics during the period January to April 1999

% resistant to % resistant toCategoryE R H S 1 drug 2 drugs 3 drugs

MDR-TB Total %resista

nce

Totalno. ofcases

analysed

New cases

Retreatmentcases

Overall

1.03

2.59

1.23

0.77

7.76

1.68

6.96

18.10

8.41

8.76

14.66

9.53

9.41

12.07

9.75

2.45

4.31

2.69

0.90

6.90

1.68

0.77

6.90

1.57

12.76

23.28

14.13

776

116

892* *

SOURCES OF CARE FOR PATIENTS SOURCES OF CARE FOR PATIENTS WITH TUBERCULOSIS IN HONG KONGWITH TUBERCULOSIS IN HONG KONG

PATIENT WITH TUBERCULOSIS

Private Practitioner

Private Practitioner

Department of HealthTB & Chest Service

18 chest clinics~7,000 new patients

each year

Department of HealthTB & Chest Service

18 chest clinics~7,000 new patients

each year

Department of Health

General out-patientclinics

Department of Health

General out-patientclinics

Hospital AuthorityAccident

andEmergency

Departments

Hospital AuthorityAccident

andEmergency

Departments

Private Hospitals

Private Hospitals

Hospital AuthorityChest Hospitals

5 hospitals800 beds

7,000 in-patient episodes

Hospital AuthorityChest Hospitals

5 hospitals800 beds

7,000 in-patient episodes

HospitalAuthorityGeneralHospital

HospitalAuthorityGeneralHospital

Hospital AuthoritySpecialist

Out-patientClinics

Hospital AuthoritySpecialist

Out-patientClinics

PRIMARY LEVEL

SECONDARY LEVEL

Classical symptoms suspicious of TB

• persistent cough for over 3 to 4 weeks• blood in sputum• weight loss• persistent fever• night sweating

Particular points to note in the history

• previous history of TB - previous ST pattern• coexisting medical illnesses• occupational history - e.g., health care worker,

silicosis• contact history - e.g., ST of source case• smoking status• previous BCG (especially for child)

Physical examination

• often yields negative findings• general condition• cervical LN• pleural effusion• unilateral wheeze (endobronchial involvemen

t)• help in differential diagnosis: e.g., finger club

bing favour CA lung

Diagnosis• Chest X-ray: relatively simple, sensitive, but less sp

ecific– apical lesion: high positive predictive value

– If sputum smear negative, usually needs serial film to assess activity of pneumonic shadow trial of antibiotics (ddx from other community acquired pneumonia)

• Sputum examination for AFB (smear and culture)– on 2 to 3 consecutive mornings

– identification and sensitivity tests should be done for positive culture isolates

• Further tests may be required for difficult cases:– CT scan, bronchoscopy, needle lung biopsy

– tuberculin test (usually limited use)

Before starting anti-TB drugs

• Note contraindication to use of anti-TB drugs– liver disease, renal disease, visual problem, hearing pro

blem, drug allergy, concomitant medication

• Young females: counselled on pregnancy-related issues– interaction with oral contraceptives– avoidance of pregnancy during anti-TB treatment

• Pretreatment: LFT, RFT, HIV antibody (with consent), screening test for vision

Before starting anti-TB drugs (Cont’d)

• Health education: nature of disease, healthy lifestyle, drug-adherence, possible side effects of drugs (discoloration of body fluid)– supplemented with educational materials

– self-reporting of side effects

• Good rapport with patient

Public Health Functions

• Notification of TB• Contacts:

– examination of close contacts

– “stone-in-the-pond” principle

– health education: maintenance of good bodily health and early awareness of suspicious symptoms

• Health education on patient’s personal hygiene

TB Notification System in Hong Kong

(1) Prevention of the Spread of Infectious

Diseases Regulations (under Quarantine and

Prevention of Disease Ordinance)(Cap.141)

(TB is a statutory notifiable disease since 1939)

(Report to Department of Health)

(2) Occupational Safety and Health Ordinance

(E.g., health-care workers)

(Prescribed period = 6 months)

(Report to Labour Department)

Notification formavailable from:- any chest clinics- DH homepage

Completed form sent back to:- Wanchai Chest Clinic- Fax: 28346627- Tel: 25726024

TB Notification

Aims:

• Surveillance

• Contact tracing and examination

• Identification of clusters

Under-notification

• A common problem

• The importance of the need to notify TB cases should be recognised.

Guidance Notes for notification of TB

• Leung CC, Tam CM. Guidance notes for notification of tuberculosis. Public Health & Epidemiology Bulletin 1999;8(4):36-9.

Source of TB Notification

0

1000

2000

3000

4000

5000

6000

7000

8000

Not

ific

atio

ns

1994 1995 1996 1997 1998 1999

Year

Private Sector

Public Hospital

Chest Hospital

Chest Clinic

Infectiousness of the TB patient• Sputum smear: a general guide to the infectiouness

– also: severe cough, cavitatory disease

• To reduce risk of infection to others:– prompt initiation of treatment (infectivity reduced signific

antly after 2 weeks of treatment in which rifampicin is included)

– health education

– personal hygiene measures

– good indoor ventilation

– screening of close contacts

– sick leave assessed on a case-to-case basis (teachers, staff of elderly homes, etc.)

TUBERCULOSIS

CHEMOTHERAPY

DIRECTLY OBSERVED TREATMENT,

SHORT COURSE

to stop it at the source

TBT

B

do s

s op

DOT (directly observed treatment)

• Strongly recommended by WHO, crucial for treatment success

Short course service programme (6 months)2H3R3Z3E3 / 4H3R3

H = isoniazid R = rifampicin

Z = pyrazinamide E = ethambutol

S = streptomycin

• Drugs: preferably taken in a single dose each time and not in split doses

• Combined drug preparations: e.g., rifater, rifinah– useful alternatives, but have to be given daily

– can avoid monotherapy

– but do not allow flexible dosage adjustment

Treatment of tuberculosis

The Tuberculosis Control Coordinating Committee of the Hong Kong Department of Health and the Tuberculosis Subcommittee of the Coordinating Committee in Internal Medicine of the Hospital Authority, Hong Kong. Chemotherapy of tuberculosis in Hong Kong: a consensus statement.

Hong Kong Med J 1998;4:315-20

During anti-TB treatment• Initial phase: follow up at least monthly (in chest

clinic, while under DOT)– to reinforce patient education

– watch out for adverse drug reactions

– routine blood tests usually not necessary unless: clinical features suspicious of hepatitis, underlying liver disease, etc.

• CXR: at 2nd or 3rd month to assess progress• Sputum

– If pretreatment sputum positive, recheck at 2nd month to assess conversion to negativity

– If still positive at 2nd month, recheck at 3rd month

During anti-TB treatment (Cont’d)• Treatment defaulters: being traced by

health nurses– Identify the underlying reasons for default, and

try to solve the problem as far as possible

– Incentives/ enablers

• Tracing back of treatment defaulters: IMPORTANT for treatment success and public health control of TB.

• Defaulters are a potential persistent source of infection in the community.

At the end of six month’s treatment

• Assessment:– Repeat chest radiograph

– Sputum examination

• Health education:– Maintenance of a healthy lifestyle, awareness of

suspicious symptoms

Complicating issues

• Examples of complicating issues:– Extensive disease– Poor general condition– Diagnostic dilemma– Treatment failure due to non-adherence– Drug resistance– Concurrent medical diseases– Drug reactions

• Consult when necessary, hospitalisation may be required

Tuberculosis- Indications for hospital admission

1. Complications of pulmonary tuberculosis, e.g., pleural effusion, pneumothorax, etc.

2. Complications of treatment, e.g., severe reactions like drug intolerance, hypersensitivity reactions, hepatitis, etc.

3. Concomitant diseases, e.g., uncontrolled DM.

4. Psychosocial problems, e.g., alcoholics, drug addicts, previous defaulters.

5. Difficulty in attending clinics for DOT, e.g., elderly, hemiplegic, living in remote areas, etc.

6. Extrapulmonary TB for special investigation

Some points for caution

• ‘Addition phenomenon’ to be avoided– Not to add a single drug to a failing regimen

• Desensitisation– May be required for drug-induced hypersensitivity,

but be careful not to induce drug-resistance

• Ethambutol to be avoided under age 6 unless necessary

• Higher incidence of side effects of drugs in elderly

IMPORTANT

• Drug adherence is most important and is vulnerable because:– Long duration of treatment required

– Disappearance of symptoms before treatment completion

– Bulk of tablets: mistake, GI upset and other side effects

– Stigma of TB: cannot accept the fact of being diagnosed as having TB

– Health belief: e.g., use of herbal or alternative medicine

• DOT is strongly recommended– Prevent failure, relapse, drug-resistance, spread of the di

sease, long-term sequelae of destroyed lung

TUBERCULOSIS

Reasons for failure of chemotherapy:• Non-compliance• Drug resistant tuberculosis• Drug toxicity• Failure of drug to reach site of action• Immunosuppressed

Conclusion

• Management of TB can be simple, but can go wrongly easily, which can result in serious consequences

• Complicating issues may arise from time to time– Caution required, consult when necessary

• Management:Clinical + Public Health measures + Good

communication

Components of DOTS

1. Government commitment to sustained TB control.2. Sputum smear microscopy to detect infectious cases.3. A standardized, short-course anti-TB treatment regimen

of six to eight months, with direct observation of treatment for at least the initial two months.

4. A regular, uninterrupted supply of quality anti-TB drugs.

5. A MONITORING AND REPORTING SYSTEM to evaluate treatment outcomes for each patient diagnosed and the performance of the TB control programme as a whole.

Future activities

• Programme Forms (to be filled in for all TB patients starting from January 2001):– Baseline characteristics of TB patient

– Clinical features and results of investigations

– Treatment outcomes at various time points up to 2 year from DOS (date of starting treatment)

• The collaboration of both the PUBLIC AND PRIVATE SECTOR in the evaluation process is very important and very much appreciated.

The collaboration of public and private sector in the control of tuberculosis is very important.

THANK YOU!