toman's tuberculosis case detection, treatment and monitoring

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MONITORING Even the most effective regimens currently available, irrespective of the drug combination or duration of treatment, may fail if not administered regularly. Thus, today it is not the lack of knowledge about adequate treatment but its adequate administration (1) that is the crux of the matter (see “Why does treatment fail and what can be done to avoid poor treatment outcome?”, page 185). This is one of the problems that can be solved not by technical or medical means but mainly by organizational measures. Ensuring regular drug intake is a managerial task par excellence, and it has rightly been stated that the control of tuberculosis is basically a management problem. Nearly all attempts to ensure adherence through health education – for example, by thoroughly instructing patients about the importance of regularity and the poor prognosis in case of irregularity – have been insufficient to motivate patients to take their drugs regularly as prescribed (see “How frequently do patients stop taking treatment prematurely?”, page 181). Verbal motivation of patients is rarely successful unless applied in an adequate organizational framework satisfying certain operational requirements. Operational requirements Treatment services must be easily accessible. Patients who feel very ill may be willing to travel long distances in order to be seen by a reputed physician. However, they can rarely repeat such travel or stay at the place of treatment for a long time. Treatment services should therefore be within easy reach and be free of charge (2, 3). Treatment services should be acceptable to and utilized by the community. Health staff should be able to communicate with patients in their own language and should be sympathetic to their complaints and needs. Patients should be helped to handle the problems causing default. Services must be compatible with local beliefs, traditions, and habits, and should also be efficient. In short, they should inspire confidence (see “What is the significance of default (treatment interruption) in the treatment of tuberculosis?”, page 263). Drugs should always be available in sufficient quantities. When patients have to be turned away because drugs are out of stock, the effect on treatment regularity is bound to be detrimental. Treatment should be directly observed. This means that each dose should be administered under the direct observation of a trained, accountable individual. It is particularly important when rifampicin is included in the regimen, and especially in the intensive phase of treatment when the bacterial load is highest. However, it is not always easy to organize such treatment for every patient. In many instances, individual arrangements for treatment observation will have to be made. Sometimes the observation of treatment will have to be delegated to other institutions or individuals, e.g. to a hospital or health post located close to the patient’s workplace or home. In summary, treatment must be organized with a view to the patient’s convenience rather than to the convenience of the treatment service. At present, the key to cure is to be found in the organization of treatment delivery. The success rate of even the best available regimen will be low if treatment 261
TOMAN’S TUBERCULOSIS services are not focused on the cooperation of patients. On the other hand, even a second-best regimen may be highly successful if treatment is delivered with adequate organization. References 1. Fox W. General considerations on the choice and control of chemotherapy in pulmonary tuberculosis. Bulletin of the International Journal of Tuberculosis and Lung Disease, 1972, 47:51–71. 2. WHO Expert Committee on Tuberculosis. Eighth report. Geneva, World Health Organization, 1964 (WHO Technical Report Series, No. 290). 3. WHO Expert Committee on Tuberculosis. Ninth report. Geneva, World Health Organization, 1974 (WHO Technical Report Series, No. 552). 262
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The second edition of this practica
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WHO Library Cataloguing-in-Publicat
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11. What is the additional yield fr
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46. What are the causes of drug-res
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Preface to the First Edition One of
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plementation of effective control s
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TOMAN’S TUBERCULOSIS This second
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Acknowledgements for the Second Edi
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Contributors Rani Balasubramanian M
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TOMAN’S TUBERCULOSIS Margarita El
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1. What is the role of case detecti
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2. What is a case of tuberculosis?
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3. What is the role of sputum micro
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CASE DETECTION Case detection in ou
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4. How many bacilli are present in
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CASE DETECTION 4. David HL. Bacteri
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CASE DETECTION Table 2 Number of ac
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CASE DETECTION Table 4 Frequency of
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CASE DETECTION (spot sample). The s
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CASE DETECTION the peripheral healt
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6. What are the main causes of fals
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CASE DETECTION with a swab may prov
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CASE DETECTION 2. Smithwick RW. Lab
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CASE DETECTION actually have tuberc
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8. What are the advantages and disa
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Culture Fluorescence Total microsco
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9. What is the role of mycobacteria
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CASE DETECTION Figure 1 Percentage
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CASE DETECTION In a carefully condu
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CASE DETECTION diagnosis. If availa
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CASE DETECTION 8. Rao KP et al. Som
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CASE DETECTION Table 12 Results of
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CASE DETECTION Table 13 Results of
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CASE DETECTION Among patients in wh
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12. How reliable is chest radiograp
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CASE DETECTION Table 16 Observer er
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CASE DETECTION patients with previo
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CASE DETECTION Figure 4 Examples of
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chest radiograph as the diagnostic
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13. What are the relative merits of
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CASE DETECTION Table 21 Correlation
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CASE DETECTION tries, this delay le
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CASE DETECTION Table 22 Interval be
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CASE DETECTION However, even in the
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CASE DETECTION 7. Douglas BH, Pinne
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CASE DETECTION Figure 5 Risk of inf
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CASE DETECTION Table 23 Mode of det
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CASE DETECTION Figure 8 Cumulative
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CASE DETECTION Czechoslovakia. Seco
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CASE DETECTION Figure 9 Radiographi
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CASE DETECTION 4. Harries AD. Tuber
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CASE DETECTION BCG is given in infa
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18. What is the current and potenti
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CASE DETECTION currently performed
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CASE DETECTION 13. Holden M, Dubin
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Exclusion CASE DETECTION Another ap
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CASE DETECTION 6. Khatri GR, Friede
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20. What were the main landmarks in
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TREATMENT 2. WHO Expert Committee o
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TREATMENT present even before treat
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TREATMENT 2. Furesz S et al. Rifamp
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TREATMENT Table 25 Incidence of tub
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TREATMENT 3. Holmes CB, Hausler H,
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TREATMENT The time during which an
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TREATMENT The “flu” syndrome, w
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Streptomycin TREATMENT Isolated by
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Capreomycin TREATMENT Capreomycin i
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valuable in preventing resistance t
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TREATMENT 13. Skolnick JL et al. Ri
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TREATMENT Thus the emergence of new
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TREATMENT Table 27 Recommended trea
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TREATMENT toxicity, particularly in
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TREATMENT drug-resistant organisms
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TREATMENT Table 28 Lag in growth of
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TREATMENT Table 30 Comparison of re
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TREATMENT Table 32 Studies using pa
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TREATMENT tuberculosis in the forme
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28. What is the dosage of drugs in
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29. What is the evidence for tuberc
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TREATMENT 4. Acocella G. Clinical p
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TREATMENT Table 35 Duration of trea
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TREATMENT concluded that smear-nega
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TREATMENT Table 41 Response to trea
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TREATMENT National Tuberculosis Ins
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Rare adverse effects ● Osteomalac
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Management ● For minor adverse ef
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TREATMENT Management of jaundice an
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32. What are the merits of thioacet
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always receive at least two drugs (
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TREATMENT culosis, and brain tuberc
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References TREATMENT 1. Ramanathan
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TREATMENT If a tuberculin skin test
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35. How does treatment of tuberculo
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TREATMENT being part of the immune
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36. What were the main findings of
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TREATMENT decoded by the Centre’s
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TREATMENT Table 45 Quiescence of di
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TREATMENT Summary In a controlled c
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37. How frequently do patients stop
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38. What are the advantages of dire
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39. Why does treatment fail and wha
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TREATMENT duration of treatment, es
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40. What are the advantages and dis
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TREATMENT ● There is a theoretica
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41. How does drug resistance develo
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42. Why are special precautions nee
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TREATMENT 2. Espinal MA et al. Stan
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TREATMENT past. This type of drug r
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Figure 16 The “fall and rise” p
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45. How many drug-resistant tubercl
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TREATMENT Table 50 Estimated number
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46. What are the causes of drug-res
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47. How can the emergence of drug r
Page 230 and 231: 48. How reliable are drug susceptib
Page 232 and 233: 49. What are the possible consequen
Page 234 and 235: 50. What reserve regimens are avail
Page 236 and 237: TREATMENT countries, using reserve
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Page 240 and 241: TREATMENT Before a decision is made
Page 242 and 243: TREATMENT Table 53 Management of ch
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Page 252 and 253: 53. What is the health, social, and
Page 254 and 255: MONITORING Table 55 Estimated house
Page 256 and 257: MONITORING 14. Saunderson PR. An ec
Page 258 and 259: MONITORING tion in prevalence over
Page 260 and 261: 55. What is DOTS? I. Smith 1 DOTS i
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Page 266 and 267: MONITORING Figure 19 Theoretical fr
Page 268 and 269: MONITORING tributed US$ 229 in dire
Page 270 and 271: MONITORING Table 58 Interpretation
Page 272 and 273: 58. How effective is tuberculosis t
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Page 276 and 277: MONITORING Figure 20 Countries/area
Page 278 and 279: MONITORING ing a greater danger to
Page 282 and 283: 61. What is the significance of def
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Page 286 and 287: 62. How important is follow-up and
Page 288 and 289: References MONITORING 1. Revised in
Page 290 and 291: MONITORING proportion of patients e
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Page 298 and 299: MONITORING Administrative controls
Page 300 and 301: MONITORING 5. Frieden TR et al. A m
Page 302 and 303: MONITORING M. tuberculosis is thus
Page 304 and 305: 67. What are the principles and req
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Page 310 and 311: MONITORING A satisfactory randomiza
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Page 318 and 319: MONITORING 4. García-García M et
Page 320 and 321: 69. Can tuberculosis be controlled?
Page 322 and 323: Prevalence of disease Prevalence of
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Page 326 and 327: MONITORING blunt the impact of this
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MONITORING tively) and have achieve
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MONITORING and shelters for the hom
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71. What are the indicators of an e
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MONITORING only after several years
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MONITORING More importantly, there
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MONITORING 10. Results of directly
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MONITORING ● Expansion of the lab
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Monitoring (including research) ●
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MONITORING personnel; there is an i
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MONITORING 5. Global tuberculosis c
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MONITORING who fund and support the
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