Epidemiology Pakistan• Estimated incidence of TB is around 250,000 per year in Pakistan & existing patient population of around 1.8 million.• TB kills 64,000 people in Pakistan each year, accounting for 26% of the nations avoidable deaths• Most patients are ages 15 to 45; 52% are males; and 48% are females, according to government figures• Pakistan ranks 6th among the 22 high burden countries of TB in the world• It has declared TB as national emergency in 2001
The Stop TB Strategy at a glance, 2009VISION A world free of TBGOAL To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targetsOBJECTIVES 1. Achieve universal access to quality diagnosis and patient-centred treatment 2. Reduce the human suffering and socioeconomic burden associated with TB 3. Protect vulnerable populations from TB, TB/HIV and drug-resistant TB 4. Support development of new tools and enable their timely and effective useTARGETS 1. MDG 6, Target 8: Halt and begin to reverse the incidence of TB by 2015 2. Targets linked to the MDGs and endorsed by Stop TB Partnership: a. 2005: detect at least 70% of infectious TB cases and cure at least 85% of them b. 2015: reduce prevalence of and deaths due to TB by 50% c. 2050: eliminate TB as a public health problem
Important Definitions• Prevalence of Infection• Annual infection rate (incidence of infection)• Case Rate ( Prevalence of disease)• Incidence of new case• Prevalence of suspect cases• Prevalence of drug resistant case• Mortality rate
Important Definitions1. Sputum Smear 7. Failure Case2. Smear Positive TB 8. Return after default3. Smear Negative TB 9. Transfer in4. Adherence/Compliance 10.Transfer out5. New Case 11.Cured6. Relapse 12. Treatment Completed
Tuberculin testThe tuberculin skin test (TST) is not a test forimmunity to TB, but rather a measure of thedegree of tuberculin hypersensitivity asmeasured by a cell-mediated immuneresponse. The Mantoux test, the Heaf test andthe tuberculin tine test—all variants of thetuberculin skin test—can deliver tuberculinPPD into the skin.
Tuberculin test False Negative Tuberculin Skin Test• Out-of-date tuberculin is used.• Tuberculin leaks at the injection site.• Testing is undertaken too early in cases of primary exposure, before hypersensitivity has developed. (A hypersensitivity reaction generally takes six to eight weeks to develop.)• The injection is too deep.• The test reading is undertaken too early (before 48 hours) or too late (after one week).• The person has an inter current viral infection (such as measles) or has had a recent live viral immunisation.• The person is undergoing corticosteroid therapy (especially if long term) or immunosuppressive therapy.
Tuberculin test False Negative Tuberculin Skin Test• The person is suffering from malnutrition, perhaps from a period in a refugee or prison camp, or from significant cachexia.• The person is elderly.• The person has a medical condition that may result in partial immunosuppression, such as diabetes, sarcoidosis, advanced alcoholism, renal failure, massive trauma or burns.• The person is an injecting drug user.• The person has any malignancies, especially lymphoma.• The person has HIV/ AIDS.• The person is seriously ill, including when they have advanced or miliary TB.
Tuberculin testFalse Positive Tuberculin Skin TestA false positive TST can occur as a result of: • Recent BCG vaccination • A ruptured small venule at the time of injection • Faulty test interpretation, such as the measurement of erythema rather than of induration.
QuantiFERON-TB Assaya new blood test that is able to measurequantitatively the production of the cytokineInterferon-γ by lymphocytes sensitised tomycobacterial proteins using an ELISAtechnique.
DOTS• Directly observed administration of drugs• Short course (six month) treatment• A reliable, affordable supply of drugs• Case detection (laboratory confirmation, particularly smear-positive pulmonary TB)• Reliable surveillance, including recording and treatment include:• Government commitment to TB control.
DOTSDOTS has 5 elements:1. Political commitment with increased and sustained financing2. Case detection through quality-assured bacteriology3. Standardized treatment with supervision and patient support4. An effective drug supply and management system5. Monitoring and evaluation system, and impact measurement WHO Fact sheet 2008
DOTS• 184 countries have adopted DOTS, although services in• many countries need to be expanded and strengthened• Funding for TB control implementation has increased,• but for 2008 there is still a shortfall of US$ 1billion for the 90 countries with 91% of global TB cases• Nearly 32 million TB patients have been treated under DOTS since 1995 WHO Fact sheet 2008