tb-2556
DESCRIPTION
แนวทางวัณโรค 2556TRANSCRIPT
-
.. 2556
-
.. 2556
1 25563,000
2 ()2556
19,000
116()
.10120
ISBN 978-616-11-1866-2
-
.. 2556
2 ()
.. 2556
1-12
..25562()
()
.. 2556 2 ()
-
(Abbreviation)
1 1
1.1 3
1.2 4
1.3 5
2 11
2.1 14
2.2 TheStopTBStrategy 14
2.3 15
3 19
3.1 21
3.2 23
3.2.1 23
3.2.2 25
3.2.3 25
3.2.4 27
3.2.5 28
4 (DOT) 31
4.1 33
4.2 36
4.3 37
4.4 41
4.5 43
4.6 45
4.7 (refer&transfer) 49
4.8 49
4.9 50
4.10 51
4.11(DOT) 53
.. 2556 2 ()
-
5 57
5.1 59
5.2 60
5.3 61
5.4 62
5.5 64
5.5.1BCG 64
5.5.2 65
6 71
6.1 73
6.2 73
6.3 74
6.3.1 75
6.3.2 75
6.3.3 79
7 85
7.1 87
7.2 88
7.3 88
7.4 MDR-TB 95
7.5 97
7.6 MDR-TB 100
7.7 101
7.8 MDR-TB 102
7.9 XDR-TB 102
8 107
8.1 109
8.1.1 109
8.1.2 110
8.1.3 111
8.1.4 112
8.1.5 112
8.1.6 113
.. 2556 2 ()
-
8.2 113
8.2.1 115
8.2.2 115
8.2.3 115
9 119
9.1 121
9.2 122
9.2.1 122
9.2.2 124
9.2.3 126
9.3 127
9.4 127
10 131
10.1 134
10.2 135
10.3/ 136
11 141
11.1 143
11.2 145
11.3 145
11.4 147
153
1 155
2 / 175
3 / 178
1
4 / 180
2
5 (ISTC) 181
..2556 184
2()
..2555 186
.. 2556 2 ()
-
1 ZNstaining 24
2 Fluorescenceacid-faststaining 24
3 AFB 24
4 36
5 40
6 40
7 4FDC 41
8 2FDC 41
9
43
10 45
11 48
12 52
13 SLD 63
14 97
15 99
16 144
17 146
.. 2556 2 ()
-
1 4
2 50
3
(Contactinvestigationandmanagement)
67
4 MDR-TB
DirectsmearXpertMTB/RIF
90
5 MDR-TB
DirectsmearXpertMTB/RIF
91
6 MDR-TB
Directsmear
XpertMTB/RIFLPALPA
92
7 MDR-TB
XpertMTB/RIF
93
8 5 150
.. 2556 2 ()
-
(Abbreviation)AFB acid-fastbacilli
AFRIMS ArmedForcesResearchInstitute
ofMedicalSciences
AIDS acquiredimmunodeficiency
syndrome
ALT alaninetransaminase
Amk amikacin
Amx amoxycillin
ART anti-retroviraltherapy
AST aspartatetransaminase
BCG BacilleCalmette-Guerin
BSC biologicalsafetycabinet
CBC completebloodcount
CD4 CD4lymphocyte
CDC-US CentersforDiseaseControland
Prevention(USA)
Cfz clofazimine
Cln cinlastatin
Clr clarithromycin
Clv clavulanate
Cm capreomycin
CPT co-trimoxazolepreventive
therapy
CrCl creatinineclearance
Cs cycloserine
CSF cerebrospinalfluid
CXR chestx-ray
CYP450 cytochromep450
DOT directlyobservedtherapy
DOTS theinternationallyagreed
strategyforTBcontrol
DST drugsusceptibilitytesting
DTC districtTBcoordinator
E ethambutol
EFV efavirenz
ELISA enzyme-linkedimmunosorbent
assay
EPI expandedprogramon
immunization
EPTB extrapulmonarytuberculosis
Eto ethionamide
FDC fixeddosecombination
FLD firstlinedrug
FLDST first-linedrugsusceptibilitytesting
H,INH isoniazid
HAART highlyactiveantiretroviral
therapy
HEPA high-efficiencyparticulateairfilter
HIV humanimmunodeficiencyvirus
IC infectioncontrol
ICNurse infectiouscontrolnurse
ICF intensifiedcasefinding
IFN- interferongammaIGRA interferongammareleaseassay
IOM InternationalOrganizationfor
Migration
Ipm imipenem
IPT isoniazidpreventivetherapy
IRIS immunereconstitution
inflammatorysyndrome
ISTC internationalstandardsfor
tuberculosiscare
.. 2556 2 ()
-
IUATLD InternationalUnionAgainst
TuberculosisandLungDisease
K,Km kanamycin
LED light-emittingdiode
Lfx levofloxacin
L-J lowenstein-Jensen
LPA lineprobeassay
LTBI latenttuberculosisinfection
Lzd linezolid
MAC mycobacteriumaviumcomplex
MDGs millenniumdevelopmentgoals
MDR-TB multidrugresistanttuberculosis
Mfx moxifloxacin
MOTT mycobacteriumotherthan
tuberculosis
MTBC mycobacteriumtuberculosis
complex
NNRTIs non-nucleosidereverse
transcriptaseinhibitors
NTM nontuberculousmycobacterium
NTP Nationaltuberculosiscontrol
programme
NVP nevirapine
O,Ofx ofloxacin
P,PAS para-aminosalicylicacid
PCP pneumocystiscariniipneumonia
PITC provider-initiatedHIVtestingand
counseling
PMDT programmaticmanagementof
drugresistantTB
PPD purifiedproteinderivative
PPM public-publicor
public-privatemix
PTB pulmonarytuberculosis
PTC provincialTBcoordinator
Pto prothionamide
R rifampicin
RTC regionalTBcoordinator
S,Sm streptomycin
SGOT serumglutamic-oxaloacetic
transaminase
SGPT serumglutamic-pyruvate
transaminase
SLD secondlinedrug
SLDST second-linedrugsusceptibility
testing
TAD treatmentafterdefault
TAF treatmentafterfailure
TB/HIV HIV-relatedTB
TLTI treatmentoflatenttuberculosis
infection
Trd terizidone
TST tuberculinskintest
UNAIDS JointUnitedNationsProgramme
onHIV/AIDS
UVGI ultravioletgermicidalirradiation
WHO WorldHealthOrganization
XDR-TB extensivelydrugresistant
tuberculosis
Z,PZA pyrazinamide
ZN ZiehlNeelsen
.. 2556 2 ()
-
1 .. 2556 2 ()
1
-
3 .. 2556 2 ()
1
(Tuberculosis TB) Mycobacterium
Mycobacterium Mycobacterium
tuberculosis ( 80)
Mycobacterium tuberculosis complex (MTBC)
Mycobacterium africanumMycobacterium bovis
MycobacteriumMycobacterium
AtypicalMycobacteriumMycobacteriumotherthantuberculosis(MOTT)
NontuberculousMycobacteria (NTM) 50
Mycobacterium aviumcomplex (MAC)
Mycobacterium
(droplets)
droplets
1.1
-
4 .. 2556 2 ()
droplets
(TBinfection)
90
10 (TB disease) 5%
2 5%
502
1
(TB infection and TB disease)1.2
(ExposuretoTB)
70% 30%(TBinfection)
*90%(LatentInfection)
50
10%(ActiveTB)25%25%
*
Source:StateGovernmentofVictoria,DepartmentofHealthServices,Australia.
-
5 .. 2556 2 ()
(primary tuberculosis)
primaryfocus
Ghonsfocus(mid-zone)
(lymphaticvessels)(hilarlymphnode)
primaryfocusprimarycomplex
(pleuraleffusion)
(atelectasis)
(bronchiectasis) (broncho-pneumonia)
(secondaryorpost-primarytuberculosis)
10
30-40150-705-7
..2536(..1993)(global
emergency)
1.3
-
6 .. 2556 2 ()
1 3
(prevalence)12
(infectious) (incidence) 8.6
1.3
22..2541
(..1998)80
1
.. 2555 (.. 2012)
80,000119
30
60,00050
..2537(..1994)9
..2543(..2000)15-40
62-7
..2542(..1999)
2.4..2544-2553
(..2001-2010)1-2
112
..2550-2552(..2007-2009)855,826862
93
3.4
-
7 .. 2556 2 ()
20-37
.. 2555
(..2012)8.61.112.8
1.3320,000(24.6)
..2554(
272555)91
15
9068
15
ThaiWorkingGroupA2*(TheAsianEpidemicModel(AEM)ProjectionforHIV/AIDSin
Thailand:2005-2025)..2553(..2010)
1,138,020
641,633 499,324
10,853
3
1..2540-
2541 (.. 1997-1998)
25.4 (multidrug resistant tuberculosis: MDR-TB)
2.012..25442545(..20001-2002)
14.8
(MDR-TB)0.933..2548-2549(..2005-2006)
15.7
1.65
-
8 .. 2556 2 ()
/
5-7
..2555(..2012)(MDR-TB)
1,760(800960)
..2553(..2010)400300
100
2(secondlinedrugs)
1. .:
.2:
,2546.
2. 2540-2549..
3. 2550-2555.
.
4. 2553..
5. 2550-2552 .
.
6.
2548-2552-..2554.
7. .2550-2552.
2554:32(2):92-100.
8. AkksilpS,WattanaamornkiatW,KittikraisakW,NateniyomS,etal.Multi-drugresistant
TBandHIVinThailand:overlapping,butnotindependentlyassociatedriskfactors.The
SoutheastAsianJournalofTropicalMedicineandPublicHealth2009:40(5):1264-78.
-
9 .. 2556 2 ()
9. HemhongsaP,TasaneeyapanT,SwaddiwudhipongW,etal.TB,HIV-associatedTBand
multi-drug resistant TB on Thailands borderwithMyanmar, 2006-2007. Journal of
TropicalMedicineandInternationalHealth2008:13(10):1288-96.
10. Tuberculosis:EpidemiologyandControl.WorldHealthOrganization,2002.
11. WHOreport2013.Globaltuberculosisreport2013:Geneva,WorldHealthorganization.
(WHO/HTM/TB/2013.11).
-
11 .. 2556 2 ()
2
-
13 .. 2556 2 ()
2
(Theinternationally
agreedstrategyforTBcontrol:DOTSstrategy)..2539(..1996)
TheStopTBStrategy..2549(..2006)
(Millennium Development Goals: MDG)
8
6(combatHIV/AIDS,Malariaand
otherdiseases)223
24 (case detection)
(TheStopTBStrategy)..2554(..2011)
(TheGlobalPlantoStopTB2011-2015)..2554-2558
4 (1)
DOTS(2)(3)
(4)
-
14 .. 2556 2 ()
1. 80
(successrate)90..2558(..2015)
2. 50..2558(..2015)
..2533(..1990)
1
(DOTS)
(DOT)
2
/
3
4
The Stop TB Strategy 6
2.2
2.1
-
15 .. 2556 2 ()
(Internationalstandardsfortuberculosiscare:ISTC)
5
6
6
1)
national tuberculosis control
programme:NTP
NTP
2) (.)
NTP
2.3
-
16 .. 2556 2 ()
3) (.)
NTP
4) (.)
5) / /
1. (Intensifiedcasefinding:ICF)
2.
1. (ISTC)
2. .
BCG(BacilleCalmette-Guerin)
(ExpandedProgramonImmunization:EPI)
/
(.)
.
-
17 .. 2556 2 ()
.
1. firstlinedrugssecondlinedrugs
2./
3.electronic
1. .
2549.2549.
2. .
2558.2:
,2554.
3. .
..2550.1:,2550.
4. ..
http://www.undp.or.th/thai/focusareas/mdgprogramme.html.
5. AnexpandedDOTSframeworkforeffectivetuberculosiscontrol.WHO/CDS/TB/2002.27.
6. Frameworkforeffectivetuberculosiscontrol.WHO/TB/94.179.
7. http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm.
8. The global plan to STOP TB 20062015. Actions for life towards a world free of
tuberculosis.WHO/HTM/STB/2006.35.
9. TheglobalplantoSTOPTB20112015.Transformingthefighttowardseliminationof
tuberculosis.
10. The STOP TB strategy. Building on and enhancing DOTS tomeet the TB-related
MillenniumDevelopmentGoals.WHO/HTM/TB/2006.368.
11. UnitedNationsDevelopmentProgramme.TheMillenniumDevelopmentGoals.Fastfacts.
http://content.undp.org/go/cms-service/download/asset?asset_id=2883030.
-
18 .. 2556 2 ()
12. UnitedNationssitefortheMDGIndicators.UnitedNationsStatisticDivision.Officiallist
ofMDGindicators.
13. WhatisDOTS?AguidetounderstandingtheWHO-recommendedTBcontrolstrategy
knownasDOTS.WHO/CDS/CPC/TB/99.270.
14. WHOlaunchesnewstopTBstrategytofighttheglobaltuberculosisepidemic.http://
www.who.int/mediacentre/news/releases/2006/pr12/en/.
-
19 .. 2556 2 ()
3
-
21 .. 2556 2 ()
3.1.1 (patient-initiatedpathway)passivecasefinding
/
3
3.1
-
22 .. 2556 2 ()
3.1.2 (screening pathway)
(intensifiedcasefinding:ICF)
patient-initiated
1) (contacts of TB cases) (
5)
2) (clinical risk groups)
(silicosis)(chronicobstructive
lungdisease)(malnutrition)
3) (riskpopulations)
3
(6
8)
(activecasefinding)
(TBpreva-
lencesurvey)
2
( )
(hemoptysis)2
(TB suspect)
(specimen)
-
23 .. 2556 2 ()
3 2
50
2
1 (spot sputum)
2(collectedsputum)
EQA (external quality assurance) smear
microscopy
3.2.1
(..)
1,100(lightmicroscopy)
smear Ziehl Neelsen (ZN)
LED(fluorescentlight-emittingdiode)
3.2
-
24 .. 2556 2 ()
1 ZN staining
Grading
()
0AFB/100 Negative - 200
1-9AFB/100 actualcellcounts
(AFB)
actualcellcounts
(AFB)
100
10-99AFB/100 Positive 1+ 100
1-10AFB/ Positive 2+ 50
>10AFB/ Positive 3+ 20
:acid-fastbacilli:AFB
2 fluorescence acid-fast staining
AFB
0AFB/30 Negative
1-29AFB/30 AFB
>29AFB/30 1+
1-10AFB/ 2+
>10AFB/ 3+
3 AFB
SCALE
(1,000 x field = HPF)
MICROSCOPY SYSTEM USED
LIGHT MICROSCOPY
(ZN Stain)FLUORESCENCE MICROSCOPY (Fluorescent Stain)
1,000 x magnification: 1
length = 100 HPF
200-250 x magnification: 1
length = 30 fields
400 x magnification: 1 length
= 40 fields
Negative 0AFB/1lengthor100HPF 0AFB/1lengthor30fields 0AFB/1lengthor40fields
Scanty 1-9AFB/1lengthor100HPF 1-29AFB/1lengthor30fields 1-19AFB/1lengthor40fields
1+ 10-99AFB/1lengthor100HPF 30-229AFB/1lengthor30fields 20-199AFB/1lengthor40fields
2+ 1-10AFB/1HPFonaverage 10-100AFB/1lengthonaverage 5-50AFB/1lengthonaverage
3+ >10AFB/1HPFonaverage >100AFB/1fieldonaverage >50AFB/1fieldonaverage
:WHOIUATLD
-
25 .. 2556 2 ()
24
AFB
AFB
AFB10,000/1
smear
AFB
(laboratoryregisterbook)
treatmentcard primarydefault
(scantyactualnumber)
1
(sputumsmearpositivecase)
3.2.2 (chest x- ray: CXR)
3.2.3 (culture)
74
1
(drugsusceptibilitytestingforfirstlinedrug)33
2(drugsusceptibilitytestingforsecondlinedrug)4
-
26 .. 2556 2 ()
1. (sputumsmearnegativepulmonarytuberculosis)
2. MDR-TB
2
3.
culture
(decontamination)
2
1.
decontamination
2.
biologicalsafetycabinet(BSC)
BSCclassII
decontaminationprocedure
aseptictechniquecerebrospinalfluid(CSF)
LowensteinJensen(L-J)culture
L-J 2%Ogawamedium
BBLMGIT
BactecMGIT960Oxygenconsuming
-
27 .. 2556 2 ()
48
(Nogrowth)BactecMGIT960
26Nogrowth
(drugsusceptibilitytesting:DST)
1.
2.
3.
4.
5. 3
1
12-14
3.2.4 (molecular examination; nucleic acid amplification)
Rapid identification Mycobacterium tuberculosis
(M. tuberculosis)
AFB
Xpert MTB/RIF real-time
polymerasechainreaction(cartridge)
rifampicin
()
() rifampicin
10099
XpertMTB/RIF
XpertMTB/RIF
3
-
28 .. 2556 2 ()
1. relapse,TAF
2.
3.
GenotypeMTBDR (HAIN Test) line probe assay (LPA)
isoniazid rifampicin
2
98 3
XpertMTB/RIF
3.2.5
(tuberculinskintest:TST)
BCGBCG
TST
TST5
BCG
BCG
interferongammareleaseassay(IGRA)
(latent TB infection) Incubate purified protein
derivative (PPD) control antigen interferon gamma
(IFN-) lymphocyte sensitized enzyme-linkedimmunosorbentassay(ELISA)
(activetuberculosisdisease)
1. ....
5:2546:ISBN974-331-083-5.
2. . . :
,2529.
-
29 .. 2556 2 ()
3. .
.
,2552.
4. .
.4:2547:ISBN974-297-224-9.
5. KawaiM.,andFujikiA.Minimumessentialoflaboratoryprocedurefortuberculosiscontrol.
6. KubicaGP.,DyeWE.,CohnML.,andMiddlebrookG.Sputumdigestionanddecotamination
withN-acetyl-L-cystein-soduimhydroxideforcultureofmycobacteria.AmRevRespir
Dis1963:87:775-9.
7. KubicaGP.,KaufmanAJ.,andDyeWE.Commentsontheuseofthenewmucolicagent,
N-acetyl-L-cystein,asasputumdigestantfortheisolationofmycobacteria.AmRevRespir
Dis1964:89:284-6.
8. Petroff,SA.Anewandrapidmethodfortheisolationandcultivationoftuberclebacilli
directlyfromthesputumandfecae.JExpMed1915:21:38-42.
9. TheResearchInstituteofTuberculosis,JATA,1988:p.53-4.
10. VanDeunA.andF.Portaels.Limitationandrequirementforqualitycontrolofsputum
smearmicroscopyforacid-fastbacilli.IntJTubercLungDis1998:2(9):75676.
11. VestalA.L.Procedure for the isolationofmycobacteriaDHEWpublicationNo. (CDC)
79-8230U.S.DeptofHealthEducationandWelfarePublicHealthService.Atlanta,Georgia.
1978.P.129-30.
12. WorldHealthOrganization.Earlydetectionoftuberculosis:Anoverviewofapproaches,
guidelinesandtools.WHO/HTM/STB/PSI/2011.21.WorldHealthOrganization2011.
-
31 .. 2556 2 ()
4
(Directly observed therapy: DOT)
-
33 .. 2556 2 ()
4 (Directly observed therapy: DOT)
1)(TBsuspect)
2
( ) / (
)
2)(TBCase)(definitecase)
3) (Definite case) Mycobacterium
tuberculosis complexculturemolecularlineprobe
assayM. tuberculosis
AFBsmear1definitecase
1.
(pulmonarytuberculosis:PTB)
miliary TB
(mediastinal and/or hilar lymph node)
(Pleuraleffusion)
4.1
-
34 .. 2556 2 ()
(extrapulmonarytuberculosis:EPTB)
2.
M. tuberculosis
(PTB+)
smear1
(PTB-)
smear2
smear2culture
M. tuberculosis
65 50
/
(PTB sputum smear not done)
3.
6
-
35 .. 2556 2 ()
1. (new)
1
2. (relapse) recurrent
(true relapse) (re-infection)
smearculture
3. (treatmentafterfailure)
(new patient regimen)
5 (remained positive)
(becamepositive)
2
4. (treatmentafterdefault)
2
smearculture
5. (transferin)
6. (other)
1
(bacteriologicallynegative
relapse)(bacteriologicallynegativeextrapulmonaryTB)
-
36 .. 2556 2 ()
4
+ - -
+
+
+
+ -
+ -
100
1)
(initialphaseintensivephase)
(continuationphase)2
dormantform
2)
3) (6
89)
4)
(DOT)
4.2
-
37 .. 2556 2 ()
(Dailypackage)(FixedDoseCombination:FDC)
DOT
2
1. 1(Firstlinedrugs:FLD)
(Isoniazid:H,INH)
(Rifampicin:R,RMP)
(Pyrazinamide:Z,PZA)
(Ethambutol:E,EMB)
(Streptomycin:S,Sm)
FDCHRHRZHRZEFDC
30-70
2. 2(Secondlinedrugs:SLD)
(Kanamycin:K,Km)
(Levofloxacin:Lfx)
(Ethionamide:Eto)
(Para-aminosalicylicacid:P,PAS)
(Cycloserine:Cs)
(Ofloxacin:O,Ofx)
4.3
-
38 .. 2556 2 ()
2010
3
1. (new patient regimen)
2HRZE / 4HR
1
culture(DST)
24H,R,Z,E4
2H,R
1 (1HRZE)
(2)
relapsefailureH
(pre-treatmentisoniazidresistance)
(delay response)
9-12
6-9
9-12
2. 1 (re-treatment regimen with first-line drugs)
2HRZES / 1HRZE / 5HRE
(treatmentafterdefault)(relapse)
cultureDST
-
39 .. 2556 2 ()
3 2 5H,R,Z,ES 3
41 5
3H,R,E
:
1 3
DST
3. (Empirical MDR regimen)
> 6Km5LfxEtoCs + PAS / > 12 LfxEtoCs + PAS
MDR-TB
DSTMDR-TBmoleculartest
MDR-TBEmpiricalMDR-TBcultureDST
DST (individualized or
tailoredregimen)
(5)6
4(
4Fluoroquinolone1)
18
8
4 20
18
empiricalMDRregimenDOT
(7)
: K S
(14)
(5)(6)
-
40 .. 2556 2 ()
5
././ ././
(maximum dose)
H 4-6 5 300./
R 8-12 10 600./
Z 20-30 25 2000./
E 15-20 15 1600./
S 12-18 15 1000./
S
S15././
6
**(.)
(.)*
H
4-6 ./
R
8-12 ./
Z
20-30 ./
E
15-20 ./
***35-49 300 450 1,000 800
50-59 300 600 1,500 1,000
60-69 300 600 1,500 1,200
70 300 600 2,000 1,200
*
**
***35(5)
-
41 .. 2556 2 ()
7 4FDC
4FDC (H75 R150 Z400 E275)
H
(.)
R
(.)
Z
(.)
E
(.)
30-37. 2 150 300 800 550
38-54. 3 225 450 1200 825
55-70. 4 300 600 1600 1100
8 2FDC (H75R 150, H100 R150, H150 R300)
2FDC H
(.)
R
(.)
30-37. H75R150 2 150 300
38-54. H75R150 3 225 450
H100R150 3 300 450
55-70. H75R150 4 300 600
H150R300 2 300 600
(2 )
4.4.1 (2HRZE/4HR)
1) culture DST DST
MDR-TBtreatmentfailureMDR-TB
DST
2)
(2)
2HR
2*
4.4
-
42 .. 2556 2 ()
*
(drug-to-drug/drug-to-food
interaction)
(immuno-compromisedhost)
NTM
HRHRZE
1
3
3) 3
(2)
3HR4
3
Culture DST Liquid media Rapid test
HR
4) 5
HR
cultureDST
liquidmediarapidtest(Moleculartest)
treatmentfailureMDR-TBempiricalMDR
regimenDST
5)
4.4.2 (2HRZES/1HRZE/5HRE)
culture DST DST
MDR-TBtreatmentfailureMDR-TB
DST
-
43 .. 2556 2 ()
(Drug to drug Interaction) (Drug to food Interaction)4.4
1) ( 3
)
3HRE
3DST
cultureDST
HRE
2) 5
5HRE
5culture,DSTrapid(molecular)test
treatmentfailureMDR-TB
empirical MDR regimen
DST
3)
9
H -
-
-
-
-
- 12
-
R - -
- 12
-
-
44 .. 2556 2 ()
Z
E -
-
- 2
- - - - 4
-
Ofx
- 20%
2
Eto - -
- -
-
Cs - -
B12folicacid
9 ()
-
45 .. 2556 2 ()
9 ()
4.6
PAS - - - -
2
1. majorsideeffect
2. minorsideeffect
10
S
(vertigonystagmus) S
() H,R,Z
() E
purpura R
S
Z,R,H
Z,E AspirinNSAIDSParacetamol
H Pyridoxine50-75
H
IntermittentdosingR
-
46 .. 2556 2 ()
3
prednisolone
systemic steroid
prednisolone40-60.
HREZ
1/31/22-3
/
H,RZbilirubin
aspartatetransaminase(AST)serumglutamic-oxaloacetic
-
47 .. 2556 2 ()
transaminase(SGOT)/alaninetransaminase(ALT)serumglutamic-pyruvatetransaminase
(SGPT)R
> 60
AST/ALTtotalbilirubin
AST/ALT totalbilirubin 1-2
1
AST/ALT>3H,RZ
AST/ALT3
3
totalbilirubin>3./.AST/ALT3R
AST/ALT5H,RZ
re-challenge
fulminanthepatitis
AST/ALT10 . ()
BCGM. tuberculosis
(
> 5 .)
IGRA
3.
60-80%
30-40%
3
5.2.2
(definitediagnosis)
()
5.2
-
61 .. 2556 2 ()
5.3.1
1.
2-3
2.
3.
4. BCG
Mantoux test
2-30.1..4872
1)>5.
steroid
2) >10 .
4
3)>15.BCG
BCG5
80-9010.10-14.
BCG > 15 .
5.3.2 Interferon gamma
BCG
M.tuberculosisInterferongamma
5.3
-
62 .. 2556 2 ()
ELISPOT(T-spotTB)96100
BCG
ELISPOT
Quanti FERON-TB Gold (QTF-G) 90
95LatentTuberculosisInfectionActiveTB
QTF-G
QTF-G
5.3.3
PCR
1-290PrimerPCR
PCR
(PCR)
intermittentregimen
E 25 ././
(DOT)
5.4.1
Rapid Advice WHO/HTM/
TB/2010.13Guidelinefortheprogrammaticmanagementofdrug-resistanttuberculosis
WHO/HTM/TB/2011.6
5.4
-
63 .. 2556 2 ()
1. FLD
*isoniazid
H*:10./.(10-15./.)max300./ 1
R:15./.(10-20./.)max600./ 1
Z:35./.(30-40./.) 1
E:20./.(15-25./.) 1
2.
(newpatientregimen)HR,ZE2
H R 4 (2HRZE/4HR)
2HRZE/10HREtoE
(retreatment regimen) H
R,Z,ES2HR,ZE1
HRE5(2HRZES/1HRZE/5HRE)
default 2
(gastricaspirate)
(MDR regimen)
(MDR-TB)
4fluoroquinolone1
> 6Km5LfxEtoCs+PAS / > 12 LfxEtoCs+PAS
13 SLD
././ ()
(.50 .)
Eto 15-20 2 500. 1
PAS 150 2-3 8 12
Cs 10-20 1 500. 1
Km 15-30 1 750. 1
Lfx 7.5-10 2 800. 800.
-
64 .. 2556 2 ()
5.4.2
1-2803
90410-12
6
2-3
2-3
95relapse1
BCG
5
5.5.1 BCG
BCG
1,200 BCG
5064
78
primary, reactivation exogenous cell
wallantigenrecombinanttechnologyBCG
BCG..2496-2499
(..1953-1956)2..2497-2509(..1954-1966)6..2510
(..1967)5-10
1-2..2520(..1977)EPI10.>15.
2..2538-2540(..1995-1997)..2542-2543(..1999-2000)
5 BCG
9.1 8.2
>15.22.618.72
(retrospective)(prospective)..2547-2549(..2004-2006)
1.64 61.4
120-30
(:LTBI)
9019
recentinfection
1. (infectious index case)
(contactinvestigation)
-
67 .. 2556 2 ()
5 >15 . H 10 ././
6-910-14.
H10.6.
(recentconverter)H6-9
3 (Contact investigation and management)
DOTS
Isoniazid
6-9TST > 15 Isoniazid 6-9
TST 10-14
Isoniazid 9
< 5 > 5 HIV+
DOTS
:
-
68 .. 2556 2 ()
H5.(corticosteroid
>10.)
old fibrotic lesion
>10.
recentconverter2
(MDR-TB) 2
-
69 .. 2556 2 ()
1. . .. 2551.
5:2552:ISBN974-297-547-7.
2.
. .. 2555.
1 : 2555: ISBN978-616-
11-1839-6.
3. , .
..2553.
4. ...
.5:
2546:ISBN974-331-083-5.
5. ,.
.2550:28:185-9.
6. ..
2551:29:115-3.
7. ..
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-
71 .. 2556 2 ()
6
-
73 .. 2556 2 ()
1.
10
2.(recurrenttuberculosis)
(endogenousreactivationortruerelapse)
(exogenous re-infection)
/
1. (susceptibility)
6
6.1
6.2
-
74 .. 2556 2 ()
2.
3.
4.
5.
6.
7.
1. /
2. /
3. /
4. /
5. /
..2543(..2000)
12
..2547(..2004)
72..2548
(..2005)
6.3
-
75 .. 2556 2 ()
UNAIDS
1
53
6.3.1
1.
2.
3.
4.
6.3.2
3I/
1. (ICF)
/
/
/
..
-
76 .. 2556 2 ()
(Counselor)
(..)
clusterofdifferentiate
4(CD4)>200cells/mm3CD4
CD45)
H
-
79 .. 2556 2 ()
3.
(infectioncontrol:IC)
/ (
9)
6.3.3
1.
1-2
provider-initiatedHIVtesting
andcounseling(PITC)
PITC
3C
1) informedconsent
2) counseling
3) confidentiality
-
80 .. 2556 2 ()
CD4count
2.
-
81 .. 2556 2 ()
3. (co-trimoxazole
preventive therapy: CPT)
AIDS-definingillness
co-trimoxazole CD4 lymphocyte
4. (anti-retro viral therapy: ART)
CD4
CD4
2CD42DST
MDR-TB
4. MDR-TB:treatmentafterfailure(TAF)ofnewpatientregimen
FLD(5)
DSTMDR-TB
5. MDR-TB:treatmentafterfailure(TAF)ofretreatmentregimen
FLD5DSTMDR-TB
6.MDR-TB:transferin(SLD)
(transferout)
7.MDR-TB:others1-6
.()
.
.
-
96 .. 2556 2 ()
2
1.
2.
3.
4.(DOT)
(firstlinedrugs:FLD)
5.
6. SLD
-
97 .. 2556 2 ()
7.5
14
Group 1: First-line oral anti-tuberculosis agents
Pyrazinamide(Z)
(500.)1
20-30
././
2,000./
Ethambutol(E)
(400,500.)1
15-20
././
1,600./
Group 2: Injectable anti-tuberculosis agents
Streptomycin(S)
1
15././ 1,000./
Amikacin(Amk)
1
15././ 1,000./
Kanamycin(Km)
1
15././ 1,000./
Capreomycin(Cm)
1
15././ 1,000./
Group 3: Fluoroquinolones
Levofloxacin(Lfx)
(250,500.)1
7.5-10././ 1,000./
Moxifloxacin(Mfx)
(400.)1
7.5-10././ 400./
-
98 .. 2556 2 ()
14 ()
Group 4: Oral bacteriostatic second-line anti-tuberculosis agents
Ethionamide(Eto)
(250.)2
15-20././ 1,000./
Prothionamide(Pto)
(250.)2
15-20././ 1,000./
Cycloserine(Cs)
(250.)2(12.)
10-20././ 1,000./
Para-AminoSalicylicacid(PAS)
(1)3-4
150-200././ 12,000./
Group 5: Anti-tuberculosis agents with unclear efficacy
Clofazimine(Cfz)
(50,100.)
100./ 100./
Linezolid(Lzd)
(600.)
600./ 1,200./
Amoxycillin(Amx)/Clavulanate(Clv)
875/125.2
4.Amx/
250-400.Clv
Clarithromycin(Clr)(500.) 500.2 1,000.
Imipenem/Cinlastatin(Ipm/Cln)
500-1,000.6.
4.50././
()
High-doseIsoniazid(High-doseH) 10-15././ NA
-
99 .. 2556 2 ()
mono-drug resistance poly-drug resistance
culture DST
MDR-TB
15
()
H(S) R,ZE 69
fluoroquinolone
HZ R,Efluoroquinolone 9-12
HE R,Zfluoroquinolone 9-12
R H,E,fluoroquinolone
Z2
12-18
RE(S) H,Zfluoroquinolone
2-3
18
(6)
RZ(S) H,Efluoroquinolone
2-3
18
(6)
H,E,Z(S) R,fluoroquinolone
1
2-3
18
(6)
MDR-TB
MDR-TB
DSTMDR-TBmoleculartest
MDR-TBEmpiricalMDR-TBcultureDST
DST (individualized or
tailoredregimen)
> 6Km5LfxEtoCs+PAS / > 12 LfxEtoCs+PAS
-
100 .. 2556 2 ()
(5)6
4
18
8
4 20
18
(MDR-TB regimen) DOT
MDR-TB
(central
nervoussystem)
H,Z,Pto,Eto100%Cs
80-100%
R10-20%
EPAS
Km, Am, S aminoglycoside
smearculture
2
DST
6
cultureconversionculture2
30 (culture conversion)
MDR-TB7.6
-
101 .. 2556 2 ()
7.7.1 (Interim outcome)
6
culture6culture2
30
(died)>2(defaulted)
(transferout)
7.7.2 (final outcome)
1. (cured) culture 5
1230
2.(completed)culture12
3.(failed)
culture2512
culture13
4.(died)
5.>2(defaulted)2
6.(notevaluated)
smearculture
2366
2
7.7
-
102 .. 2556 2 ()
MDR-TB7.8
(closecontact)MDR-TB
(indoorlivingspace)
4
MDR-TBMDR-TB
TST(tuberculinskintest)
IGRATestsmear,cultureDST
MDR-TB2
XDR-TB
1. 1(Z,ERifabutin)
2. (12 )
3. FluoroquinolonegenerationMoxifloxacin
4. 4(Eto/Pto,Cs,PAS)
5. 5 (Clofazimine, Linezolid, Thioacetazone, high-dose H, Clarithomycin)
2
6. HDST
7. (localizeddisease)
8. (Infectioncontrol)
9.
10.
XDR-TB
(11)
XDR-TB7.9
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2. 2546:24:
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109 .. 2556 2 ()
8
182551(..
2008)
..2539(..1996)
(144)2544(..2001)
(Tuberculosis Coalition for Technical Assistance and International
CommitteeoftheRedCross,2009(..2552))
8.1.1
(screening pathway)
(1)1
8.1
-
110 .. 2556 2 ()
(screening method)
.) (symptomscreening)
21
1
1
1
6
2
.)
2
()
2
(patient initiative pathway)
(screeningmethod)
8.1.2
2550(..2007)70
-
111 .. 2556 2 ()
13
(DOT)
8.1.3 (collaborative TB/HIV activities)
41
2551 (.. 2008)
71
.
(pre-test counseling) (post-test
counseling)
.
pre-testpost-testcounseling
.
co-trimoxazole
-
112 .. 2556 2 ()
CD4
CD4
CD4
1-2
3-8
6
8.1.4 (TB recording reporting)
(TB03)
4TB07,TB07/1,TB08TB/HIV01M/XDR-TB
PMDT03,PMDT07PMDT07/1
5
8.1.5 (referral system)
10-16
(dischargeplanner)
(dischargeplanner)
-
113 .. 2556 2 ()
8.1.6 (supervision, monitoring and evaluation)
(on the job training)
2
(mentor)
3 5
(TB prevalence survey)
(TBdrugresistantsurveillance)
(migrantworker)
(cross - border population)
carrier
8.2
-
114 .. 2556 2 ()
..2539431,451372,242
390100,0005-6
1.
2.
3. (referralsystem)
4.
1. (registeredmigrant worker)
()
-
115 .. 2556 2 ()
2. ()
3. (illegalmigrantworker)
4. crossborderpopulation
8.2.1
1.
2.
3.
4. (screening pathway)
8.2.2
(NTP)
()
8.2.3 (monitoring and evaluation)
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116 .. 2556 2 ()
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9-11
2547.
2. ..:
.2546.
2-42546
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:
9-112547
.
4. .
1.:
9-112547
.
5. .
..2545.
:
9 - 11 2547
.
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119 .. 2556 2 ()
9
-
121 .. 2556 2 ()
10
particle droplet nuclei
1-5
(alveoli)
alveolarmacrophages
(dormantbacilli)(latentTBinfection)
(5-10)
9
9.1
-
122 .. 2556 2 ()
(recentinfection)
10
silicosis
3
1.
2.
3.
9.2.1
(expose)
9.2
-
123 .. 2556 2 ()
1)
2)
3)
7
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4)
(TB suspect)
2
5)
-
124 .. 2556 2 ()
6)
2-3
7)
8)
MDR-TB
surgicalmask
2
9)
9.2.2
-
125 .. 2556 2 ()
1)
(naturalventilation)
()
(mechanicalventilation)
)
)
)
high-efficiency particulate air (HEPA) filter
(ultravioletgermicidalirradiationUVGI)
)
2)
(directultravioletgermicidalirradiation
fixture)
-
126 .. 2556 2 ()
(upperroomorshielded
ultravioletgermicidalirradiationfixture)
3)HEPA
9.2.3
MDR-TBbronchoscopy
1.surgicalmask
mask
surgical mask (
)
-
127 .. 2556 2 ()
2.
1HEPAmask,N95bronchoscopy
1.
2.
(tuberculinskintest)
2.1
61
2.21-3(two-steptest)2
boosted reaction 2.1 2
tuberculin1-2
(tuberculin conversion) 1-2
1
6
(riskassessment,developmentoftheTBinfection-controlplanandperiodicreassessment)
9.3
9.4
-
128 .. 2556 2 ()
-
129 .. 2556 2 ()
(drug
susceptibilitytesting)
1. .
.,2529:17:131-6.
2. 2540-2549..
3. ..
.:
2550.
-
130 .. 2556 2 ()
4. . .
..2554.:
.
5. .
...2553,:
.
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proneacuterespiratorydiseaseinhealthcare.June2007,WorldHealthOrganization.
-
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10
-
133 .. 2556 2 ()
TheStopTBStrategy
6
(Engage all care providers)
(Public-PrivateMix:PPM)
(ISTC)
()
/
DOTS
10
-
134 .. 2556 2 ()
()
10.1.1
(3)
10.1.2
(11)
10.1.3
(NTP)
10.1
-
135 .. 2556 2 ()
10.1.4
10.1.5
DOT
(Multidrug-Resistant Tuberculosis: MDR-TB)
DOT
10.1.6
6- 8
2(refer)(transfer)
1.
/
13
2. (hospital TB coordinator)
(infectious
controlnurse:ICnurse)
10.2
-
136 .. 2556 2 ()
/ (public private mix: PPM)10.3
3. /
3.1/
/
/
/
3.2
./
3.3/
4. /
5.
/
6.
/
-
137 .. 2556 2 ()
1.
/
2.
3.
4. (TB
networkmeeting/DOTSmeeting)
34/
5.
6.
3
-
138 .. 2556 2 ()
1. DOTS (Public-Private
PartnershipforTBcontrol):
.9-11
2547.
2. :
.
2546.2-42546
.
3. DOTS
:
. 9-11 2547
.
4.
:
.9-11
2547.
5.
..2545
:
9-112547
.
6. .2553.:
.
7. .
2551.5:2552:ISBN974-297-547-7.
8. .
2558.2:
2554.
-
139 .. 2556 2 ()
9. .
..2550.1:.2550.
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Society,CDC,andInfectiousDiseasesSocietyofAmerica.MMWR2003:52(No.RR-11):177.
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edition.AmericanPharmacistAssociation.SeniorEditor:CharlesFLacy,LoraLArmstrong,
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HTM/TB/2009.420
-
141 .. 2556 2 ()
11
-
143 .. 2556 2 ()
(supervision)(monitoring)(evaluation)
(supervision)
3
(evaluation)
1
interimevaluation
11.1.1
1
(quality)(reliability)
(verification)
11
11.1
-
144 .. 2556 2 ()
11.1.2 (.)
.13
.
(on the job training)
1.
2.
3. ()
16
RTC 4
PTC+RTC 4
.. DTC/TBclinic 4
:
1. RTC(RegionalTBCoordinator:)
PTC(ProvincialTBCoordinator:)
DTC(DistrictTBCoordinator:)
TBClinic:
2. RTC PTC ()
..
3. ..DTCTBclinic
DTCTBclinic..
-
145 .. 2556 2 ()
3
)
)
11.2
11.3
-
146 .. 2556 2 ()
17
1.
(casedetection
rateforallformofTB)
2.
(sputum
conversionrate)
(
)
(
)
3.
(treatmentsuc-
cessrate)
(
)
(
)
4.
(defaultedrate)
(
)
2
(
)
5.
(failurerate)
(
)
(
)
6. (deathrate) (
)
(
)
died
7.
(transferredoutrate)
(
)
(
)
8.
(HIVtesting
rate)
()
(
)
()
-
147 .. 2556 2 ()
17 ()
9.
(HIVposi-
tiverate)
10.
(ARTrate)
()
(
)
()
(
)
11.
co-trimoxazole
(CPTrate)
()
co-tri-
moxazole
(
)
CD4