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1. FEASIBILITY RETURN TO WORK IN DRUG RESISTANT
TUBERCULOSIS PATIENTS
Maelanti Norma
Scientific resources : dr. Feni Fitriani Taufik, Sp.P (K), M.Pd.Ked
Dr. dr. Fathiyah Isbaniyah,Sp.P(K) M.Pd.Ked
Scientific coordinator : dr. Erlina Burhan, M.Sc. Sp.P (K)
3rd Literature Review
February 21th 2022
Departement of Pulmonology and Respiratory Medicine
Faculty of Medicine University of Indonesia 2022

2. OUTLINE
1. INTRODUCTION
2. ANTIBIOTIC RESISTANCE MECHANISMS IN MYCOBACTRIUM TUBERCULOSIS
3. TB TRANSMISSION
4. CHALLANGES IN DRTB TREATMENT
5. OCCUPATIONAL TB
6. PREVENT AND CONTROL DR TB
7. CONCLUSION

3. INTRODUCTION

4. INTRODUCTION
TB is an infectious disease caused by Mycobacterium tuberculosis
(M.Tb) that cureable and preventable.
One third of the world’s population gets infected with TB leading to nearly
1, 6 million deaths annually.
Global tuberculosis report 2020. Geneva: World Health Organization; 2020.

5. INTRODUCTION
Global tuberculosis report 2020. Geneva: World Health Organization; 2020.
Drug resistant TB (DRTB)
DRTB is M.Tb that are resistant to TB drugs as a result of non-adherence to
drugs TB treatment and ineffective TB therapy.
Only 333.304 people were treated for DRTB, 22% the 5-year target of 1.5 million.
Indonesia is one of the five countries with the highest number of people
receiving DR TB therapy between 2017 and 2019.

6. INTRODUCTION
Global tuberculosis report 2020. Geneva: World Health Organization; 2020
Bettex, AM. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases 21.2020
There is about three billion people working in the world but half are still in poverty,
low socioeconomic status as a factor in M.Tb transmission.
Long duration of work in the workplace can increase the risk TB transmission
TB mainly affects people in their most productive working years of life

7. ANTIBIOTIC RESISTANCE MECHANISMS IN
MYCOBACTRIUM TUBERCULOSIS

8. Drug resistance mechanisms in Mycobacterium TB
Zu˜niga J, et al. J Clinical and Developmental Immunology Volume 2012
Richa S, et alJournal of Applied Microbiology.2019
Pathogenesis of tuberculosis Resistance mechanisms of M.Tb

9. DR TB
Monoresistance
Polyresistance
Extensive drug
resistance
(XDR)
Multi-drug
resistance
(MDR)
Pre-extensive drug
resistance
(pre-XDR)
Rifampicin
resistance
WHO operational handbook on tuberculosis. Module 4.2020 Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.

10. Risk factors for DRTB
World Health Organization. Working together with businesses.WHO, ILO.2012;3
Simbwa et al. BMC Infect Dis (2021) 21:950
 High-burden country
 Previous exposure to antituberculosis drugs
 Patients with MDR tuberculosis tend to be
younger
 Socioeconomic or behavioural risk factors for
MDR
 Poor access to high-quality health care
 Abusers of alcohol
 Intravenous drug users

11. TB TRANSMISSION

12. Hypertransmitions:
prolonged hospitalization, delayed
diagnosis of drug resistance and
poor ventilation
- Cough strength and
frequency,
- Presence of lung cavities,
- Sputum viscosity
-Ventilation,
Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.

13. Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.
The number of
infectious doses was
340 m3 of air
leading to effective
transmission
Animal studi:
the time needed for
become infected in the
pre-antibiotic era (i.e.
have TST conversion) was
12–18 months, on
average
what are the minimum frequency
and duration of contact for infection to occur?

14. Who is infectious?
Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.
which factors favour
disease
transmission?
- Patients
- Health staff and
- visitors.
The sources of
transmission in
hospitals
- Undetected,
- Untreated TB
- Patients with known TB, but
unknown drug resistance
(receiving ineffective therapy)
Hypertransmitions

15. Who is infectious?
Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.
Beccera MC. BMJ 2019;367
- The treatment is not effective
- Smear and culture do not convert
- Clinical and radiological indicators deteriorate Infectious
TB patients when
Smear sputum M.Tb positive more infectious
than smear sputum M.Tb negative whether
culture M.Tb positive or negative
Contacts of patients with multidrug
resistant tuberculosis were at higher risk of
tuberculosis infection than contacts exposed to
drug sensitive tuberculosis.

16. WHO operational handbook on tuberculosis. Module 4.2020
Simbwa et al. BMC Infect Dis (2021) 21:950
DRTB Therapy
Standar regimen :
A shorter DRTB regimen refers to a course
of treatment between 9-11 months.
Individualized :
Longer DRTB regimens are expected to be
about 18–24 months.
 Poor adherence to TB
medication, especially
when patients leave
hospital to return home.
 The long regimens and
associated side efects
make it very hard to fnish
the medication.

17. Migliori GB. Clinical Infectious Diseases. 2019
Treatment outcome definitions for DRTB
Cured
Died
Treatment failure
Relapse & Reinfection
Lost to follow-up

18. CHALLANGES IN DRTB TREATMENT

19. Thomas BE, et al. PLoS One 2016;
11
The long duration of
DRTB treatment
Psychological
distress
Poor adherence

20. Thomas BE, et al. PLoS One 2016;
11
The long duration of DRTB
treatment
Psychological
distress
Treatment
failure
Still
infectious

21. Monitoring therapy for DRTB patients
- Clinical,
- Laboratory
- Microbiology and
- Radiology.
 WHO guidelines suggest monthly sputum smear microscopy and
culture as an adjunct to clinical monitoring of patients to assess
treatment outcome.
 in DRTB patient Modest specificity and the best maximum
combined sensitivity and
specificity occurred between month 6 and month 10 of treatment
Dheda K, et al.Lancet Respir Med 2017;5

22. Treatment failure :
- Smear and culture do not convert, Initial response with
subsequent culture reversion,
- The need for a regimen change because of adverse events or
acquired drug resistance (the treatment is not effective).
- Clinical and radiological indicators deteriorate
Dheda K, et al.Lancet Respir Med 2017;5

23. HOSPITAL DISCHARGE CRITERIA
• No continuing clinical need for inpatient treatment
• Clinical improvement
• Effective treatment
• Continuity of care and DOT
Dheda K, et al.Lancet Respir Med 2017;5
Positive smear is not a contraindication for hospital discharge. The median time
to convert sputum culture to a negative result was 38.5 days

24. Prior to discharge from the hospital,
continuation of care and monitoring
during the outpatient phase of
treatment must be ensured.
HOSPITAL DISCHARGE CRITERIA
Dheda K, et al.Lancet Respir Med 2017;5
Confirmed TB
- Unable to produce sputum
- Overall symptoms have improved
Discharge decisions should be taken
by a multidisciplinary team
Confirmed MDR-TB
Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.

25. A proportion of cases still need to be admitted for
medical reasons, including
• Severe cases,
• Life threatening conditions,
• Comorbidities,
• Psychiatric problems,
• Adverse drug reactions and,
• For social reasons
Criteria for hospital admission
Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.

26. OCCUPATIONAL TB

27. Dheda K, et al.Lancet Respir Med 2017;5
 Healthcares
 Mining
 Oil and gas industries
 Migrant
 Commercial sex workers
 Construction
Occupational risk for
TB infection

28. Drug-resistant TB (DR-TB) also affects
HCWs
Occupational TB
WHO:
1) Health professionals
2) Health associate professionals
3) Personal care workers in health services
4) Health management and support personnel
5) Other health service providers not
elsewhere classified.
Greater frequency than the
communities they serve.
World Health Organization. A people-centred model of
tuberculosis care. 1st ed. 2019: 4-38

29. Occupational TB
Hospital staff sharing air with contagious patients
with MDR/XDR-TB
TB among HCWs leads to :
- Worker absenteism,
- Disruption of health services, -
Loss of productivity.
World Health Organization. A people-centred model of
tuberculosis care. 1st ed. 2019: 4-38

30. Return to work Criteria
for DR TB patients

31. Return to
work Criteria
for DR TB
patients
1. Have had three negative AFB sputum smear results
collected 8–24 hours apart (at least one of which should
be an early morning specimen)
2. Have responded to anti-TB treatment that should be
effective based on drug susceptibility testing results
Nathavitharana RR, et al. La Presse Médicale. 2021;46
The assessment of TB patient can return to work should be made by a physician who
has expertise in the management of TB.
Return to work will be linked to medical certification.

32. TB patient is no longer infectious and can return
to work
Patients with pulmonary DR TB can be
considered non-infectious when:
1. They have received adequate chemotherapy for
two to three weeks;
2. They show clinical improvement; and
3. There is a negligible chance of MDR-TB
Migliori GB, et al. World Health Organization Regional Office for Europe. Eur Respir J 2019
World Health Organization. Working together with businesses: 2012
Dheda K, et al.Lancet Respir Med 2017;5
Dharmadhikari et al:
reported rapid effect of treatment for
MDR-TB on transmission become less
infectious.
Fennelly et al:
found that aerosol cultures in patients
with MDR tuberculosis who were on
effective treatment declined faster than
sputum smears or cultures

33. Loudon and colleagues: Aerosolization and drug concentration as
the key for limiting the spread of disease from patients on effective
treatment
Evaporation of the droplet nuclei could increase the drug
concentration around bacilli
Inactivate the bacilli or hamper their
capacity to successfully infect human hosts
Migliori GB, et al.World Health Organization Regional Office for Europe. Eur Respir J 2019.

34. Treatment failure :
- No culture conversion from the outset,
- Initial response with subsequent culture reversion,
- The need for a regimen change because of adverse
events or acquired drug resistance.
Dheda K, et al.Lancet Respir Med 2017;5

35. PREVENT AND CONTROL DRTB

36. Precautions against airborne infection transmission are necessary
because biohazards, such as the Mycobacterium tuberculosis that
causes TB, are transmitted by airborne droplets.
WHO suggests that people deemed to be at a low risk of RR-TB and
/MDR-TB should be placed in single rooms and that those at a high
risk should ideally be accommodated in a negative-pressure room
while rapid diagnostic tests are urgently performed until effective
treatment starts
International Labour Office Health WISE Action Manual. 2014;1
R.R. Nathavitharana, et al.Presse Med. (2017)
Mycobacterium tuberculosis as Biohazards

37. Administrative controls
International Labour Office Health WISE Action Manual. 2014;1
• Control the spread of pathogens by using cough etiquette
• Reduce the time a person stays in a health facility and treat promptly those
infected
• Identify promptly and early people with TB symptoms, quarantinee infectious
patients.
• Train health workers TB signs, symptoms, prevention, treatment, and
infection control.

38. International Labour Office Health WISE Action Manual. 2014;1
Environmental
controls

39. CONCLUSION

40. CONCLUSION
1. Contacts of patients with DRTB were at higher risk of
tuberculosis infection than contacts exposed to drug
sensitive tuberculosis. The risk of developing tuberculosis
disease did not differ among contacts in both groups
(DRTB/DSTB)
2. Long duration of work in the workplace can increase the
risk TB transmission
3. There are side effects of DRTB therapy and significant
psychosocial that affect DRTB patients.

41. CONCLUSION
4. DRTB patients can return to work if they are not
infectious
5. The risk of DRTB in health workers is higher than
community, because of frequent contact
6. Prevention of DRTB transmission with management
control and environmental control.

42. THANK YOU