Tuberculosis (TB) is an ancient disease that has affected humans for thousands of years. It has been documented in Egyptian mummies from 4000 years ago and was a common fatal disease in the time of Hippocrates. Throughout history, TB has been given many names as its symptoms and transmission were gradually understood. Modern policies for controlling TB began with the World Health Organization in the mid-20th century. The document then discusses TB control strategies and targets in the state of Perak, Malaysia, including increasing detection and cure rates while reducing incidence and mortality. It also presents two case studies of TB patients to demonstrate challenges with detection and treatment.

1. TB (PART 1) 04/18/11

2. HISTORICALLY: Challenge of Tuberculosis Through the Ages IUATLD 1st Asia-Pacific Region Conference Kuala Lumpur August 2, 2007 Contents 􀂄 Tuberculosis through the ages 􀂄 Evolution of WHO policies for TB control 􀂄 From DOTS to the New Stop TB Strategy • Phthisis • Wasting • Scrofula • Pott’sdisease • Lupus vulgaris • Consumption • The Captain of the Men of Death • The White Plague Tuberculosis: What’s in a Name ? The disease was named Tuberculosis in 1839 by J. L. Schönlein Tuberculosis: An Ancient Killer 􀂄 Tubercular decay in skull and spinal bones found in 4000 year old Egyptian mummies 􀂄 Hippocrates around 400 BC: “ Phthisis is the most common disease of humans and it is nearly always fatal” Tuberculosis as Killer in Arts 􀂄 Violetta in Verdi’s opera La Traviata (1853) dies of TB 􀂄 Edvar Munch’s painting “Sick Child” (1885) depicts his sister dying of tuberculosis 04/18/11

3. 04/18/11

4. 04/18/11

5. 04/18/11

6. 04/18/11

7. MDG 6 Target 6C To Halt And To Reverse The Incidence Of TB 04/18/11

8. SITUATION IN PERAK Kadar kejadian TB negeri Perak 2009 52.19 per 100,000 penduduk Kadar kematian TB negeri Perak 2009 2.09 per 100,000 penduduk Target Kebangsaan untuk Kadar kematian, < 3 per 100,000 04/18/11

9. By 2005, to detect at least 70% of new sputum smear positive TB cases Case Detection Rate Smear +ve detection has not reached 70% in 5 districts in Perak. All health facilities have been asked to screen all patients with cough more than 1 week and work towards a target of 3% AFB screening in all new outpatients.

10. Case Detection Rate (CDR) Target 58.3 % ( Jan - Okt 2010 ) 48/100,000

11. Cure Rate Target 85 % ( Jan - Jun 2009 )

12. TB Mortality Perak – (Jan- Okt 2010) Bil District Total TB Death Non TB Death Deaths Audited Deaths NOT Audited 1 Kerian 2 0 2 2 0 2 LMS 41 4 13 17 24 3 Hulu Perak 5 4 0 4 1 4 K Kangsar 7 2 1 3 4 5 Pk Tengah 7 3 4 7 0 6 Btg Padang 8 3 0 3 5 7 Hilir Perak 10 3 7 10 0 8 Manjung 20 10 10 20 0 9 Kinta 36 15 21 36 0 Total 136 44 58 102 34

13. Mengurangkan kes TB baru sehingga 50% dari jumlah kes tahun 2000 (1014 kes) sebelum tahun 2015. Jumlah Kes pada tahun 2010 adalah sebanyak 1389 kes Mengurangkan 50% kematian disebabkan TB dari Jumlah kematian pada tahun 2000 iaitu 149. Jumlah kematian TB pada tahun 2010 adalah sebanyak 151 kes

14. Objektif Khusus Meningkatkan pengesanan Kes TB Berkahak Positif dari 72% ke 80% melalui saringan aktif & pasif. Pengesanan kes TB diperingkat awal iaitu mengurangkan bilangan kes baru dengan keputusan “X-Ray Sangat Teruk” dari 8% ke 5% pada 2015 Meningkatkan hasil rawatan dari 76% kepada 85% melalui pengendalian rawatan secara DOTS untuk semua pesakit TB dan mengurangkan kes keciciran tidak melebihi 2.5%

15. Objektif Khusus Meningkatkan pengetahuan Pengamal Perubatan berkaitan penyakit TB melalui “Pendidikan Kesihatan Berterusan” dan mengadakan Kursus Sehari untuk TB setiap bulan bagi setiap daerah Meningkatkan kesedaran masyarakat mengenai penyakit TB melalui Pendidikan Kesihatan dan kerjasama dengan agensi-agensi bukan kerajaan.

16. 04/18/11

17. Case Study 1 11year old school boy Admitted to Hosp.A on 20/6/2008 Presented with 4 months history of On off fever especially at night with chill and rigors Productive cough LOA ,LOW , Lethargic, malaise Hist Of Present Illness: 17.02.08 - fever, URTI 18.02.08 - URTI with sputum 18.03.08 - right sided chest pain, syr. Bena given 26.03.08 - cough with greenish sputum, syr bena and ampicillin given 21.04.08 - cough, fever, vomiting. Syr phenergen, amoxicillin 19.06.08 - X-ray ordered, sputum AFB, **** TCA 1 WEEK

18. Case Study 1 Multiple clinics and OPD visits with same complaints, mostly treated as URTI CXR:showed Multiple cavities and consolidations at right and left upper lobes, and right middle lobe. Fibrotic changes at the left upper lobe. Pleural Effusion-right lung. Sputum AFB: >50/3L for 3/7 Diagnosis : Advance PTB

19. Contact defaulted 2 nd screening. Was contacted and advised to come, but still did not turn up. Visited a GP in February with complain of cough, and was referred to a private hospital for X-ray. X-ray: shows consolidation at Rt.upper lobe with fibrosis. Cavitating lesion seen at the rt. upper lobe. Pulmonary TB Contact Tracing Is Very Important CASE STUDY 2

20. Be Aware Of TB And Think Of TB

21. 04/18/11

22. 04/18/11

24. Inhomogenous opacities with cavitation seen in both upper zones, more on the right side. Impression: Active pulmonary tuberculosis (MODERATELY ADVANCED)

26. Inhomogenous opacities seen at the left mid zone. There is a cavitating lesion within the opacities Impression: Active Pulmonary Tuberculosis (MILD)

28. 22 & 23 There are multiple diffuse tiny nodular opacities 1-2 mm throughout both lung fields Impression: Miliary Tuberculosis (FAR ADVANCED)

29. 04/18/11

30. 04/18/11

31. 04/18/11 RECOMMENDATIONS Active case detection : Sputum AFB for symptomatic patients in OPD ~ spot speciment & 2 nd sp ~ target 3% of all new outpt attendance CXR ~ To use CXR findings as one of the key performance indicators To increase index of suspicion on outpatients with Cough > 5 days

32. 04/18/11

33. 04/18/11

34. 04/18/11 Risk of progression of TB infection to disease Life-time risk of 10% in immunocompetent adults; 5% risk in first 2 years after infection Risk especially high in early childhood Risk increased in certain medical conditions

35. 04/18/11

36. 04/18/11

37. 04/18/11

38. 04/18/11