mercoledì 4 luglio 2012

Standards of care in TB context


TB is a common and in many cases lethal, infectious disease caused by various strains of mycobacterium usually M. Tuberculosis.
Characteristics of M. Tuberculosis.
  • Aerobic - Resistance to cold/freezing.
  • Very sensitive to heat, sunlight and UV radiation.
  • Ability to mutate from one form to another.
NOTE:
Most people are infected with TB but development of TB disease depends on competence of immune system to resist multiplication of M.tuberculosis.
Mode of TB transmission
  • Sneezing (1,000,000: number of organisms released).
  • Coughing (500: number of org. liberated).
  • Talking (200: number of organisms liberated).
  • Via consumption unsterilized infected milk (M. bovis).
Type of turbecolosis.
N/B. TB can affect all parts of the body except – nails and hair.
  • Pulmonary TB (75%).
  • Extra pulmonary TB (25%)
Risk Factors for TB
  • All conditions leading to immunosuppression e.g. HIV, Diabetes Mellitus, Cancer, and Malnutrition.
  • Patient under long use of steroids.
  • Health workers dealing with PTB patient.
  • Health workers dealing with cough inducing procedures
  • People living in highly congested areas e.g. Prisoners, Slums, and Refugee camps.
  • All close contact people (living in same house, spending many hrs with TB patients).
Clinical Presentation
  • Adults and Children.
  • Cough for≥2 weeks (with or without haemoptysis).
  • History of close contact with confirmed TB patient.
  • Fever for ≥ 2 weeks.
  • Noticeable weight loss.
  • Chest pains or breathlessness.
  • Night sweats.
  • Swelling in neck, armpit, abdmen, joints, groin.
  • Failure to grow (in children).
  • Enlarged non-tender lymph node or lymph node abscess.
  • Progressive swelling or deformity in bone/joint.
Investigations
  • Sputum for AAFB (acid alcohol fast bacilli)
  • Sputum for culture and sensitivity.
  • Tissue biopsy for histology.
  • Fluid for Microscopy / cytology.
  • Use of chest x-ray (not conclusive).
  • Tuberculin skin test (Mantoux test)
  • NB – FHG and ESR are not diagnostic but suggestive.
Management
Health education on Important of good drug adherence and dangers of defaulting is of MUST.
Drugs should be given per kg body weight in both adult and children.
  • ALL CHILDREN ≤ 15 years should not get P4 ethambutol combinations.
  • All HIV/AIDS patient on ART should have NVP avoided in their regimen.
  • All patient started on Anti-TB should be tested for HIV and their partners/relatives Evaluated for TB/HIV.
  • Particulars should be taken for defaulter tracing purposes.
  • TB drugs are available and free in all Hospitals / Health facilities hence treat and register people within the locality. Refer people from far distances.
Newly DX TB patient (all forms of TB).
  • 2 RHZE 4 RH (Adults)
  • 2 RHZ 4 RH (children)
Defaulters and treatment.
  • 2 SRHZE/RHZE 5 RHE (8 months treatment)
Drug Resistance TB
  • 24 months of treatment with 6 months of injectable.
Drug Resistance TB.
The ability of mycobacterium to resist Anti TB.
Types of drug resistance
  • Mono-Resistant – Resistant to one first line drug e.g. RHZE.
  • Poly-resistant – Resistance to two or more drugs but not to both Rifampicin or Isoniazid.
  • Multi-drug – resistance (MDR) – Resistant to both Rifampicin and Isoniazid.
  • Extensively drug resistance (EDR) - Resistant to both Rifampicin and Isoniazid, and resistant to Fluorquinolone.
Who to suspect for DR TB.
  • Defaulters
  • Treatment failure
  • TB relapse patient.
  • Newly diagnosed TB client with positive history of contact with MDR patient.
  • Tb patient who has been put on under-dose.
Factors to Drug Resistance Emergency.
  • Poor drug adherence
  • Unreliable drug supply
  • Un controlled use of anti-TB
  • Weak TB programs.
Preventive measures
  • Intensified case finding
  • Early disease.
  • Stop spread.
  • Train patient on good coughing hygiene.
  • Separate young children from sick coughing patients.
  • HIV patients to be separated from TB patients.
  • Ensuring proper ventilation in the waiting bay, sputum preparation area, wards, chest/ special clinics.
  • Triaging of patients so that coughing patients wait as little as possible together with the others in the waiting bay.
Beppe (Medical Officer) and Martin (Registered Clinical Officer)
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Chaaria è un sogno da realizzare giorno per giorno.

Un luogo in cui vorrei che tutti i poveri e gli ammalati venissero accolti e curati.

Vorrei poter fare di più per questa gente, che non ha nulla e soffre per malattie facilmente curabili, se solo ci fossero i mezzi.

Vorrei smetterla di dire “vai altrove, perché non possiamo curarti”.

Anche perché andare altrove, qui, vuol dire aggiungere altra fatica, altro sudore, altro dolore, per uomini, donne e bambini che hanno già camminato per giorni interi.

E poi, andare dove?

Gli ospedali pubblici hanno poche medicine, quelli privati sono troppo costosi.

Ecco perché penso, ostinatamente, che il nostro ospedale sia un segno di speranza per questa gente. Non ci sarà tutto, ma facciamo il possibile. Anzi, l’impossibile.

Quello che mi muove, che ci muove, è la carità verso l’altro, verso tutti. Nessuno escluso.

Gesù ci ha detto di essere presenti nel più piccolo e nel più diseredato.

Questo è quello che facciamo, ogni giorno.


Fratel Beppe Gaido


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