DOTS MANAGEMENT DOTS MANAGEMENT IN TUBERCULOSISIN TUBERCULOSIS

Zul DahlanZul DahlanSubdivision PulmonologySubdivision PulmonologyDepDepartment of Internal Medicine artment of Internal Medicine Medical Faculty of Padjadjaran Medical Faculty of Padjadjaran University University Hasan Sadikin Hospital , BANDUNGHasan Sadikin Hospital , BANDUNG

MinilectureMinilecture

Female 40 yrsFemale 40 yrs Cough for >3 Cough for >3

monthsmonths 3 x to GP, only 3 x to GP, only

presciptionpresciption No sputum or No sputum or

CXRCXR She did CXR on She did CXR on

her initiativeher initiative Her sputum AFB Her sputum AFB

pospos

INTRODUCTIONINTRODUCTION Tuberculosis is an infectious disease that Tuberculosis is an infectious disease that

remain to be a major health problem in the remain to be a major health problem in the world including Indonesia. world including Indonesia.

Indonesia like other countries had adapted Indonesia like other countries had adapted WHO DOTS strategy for national TB control WHO DOTS strategy for national TB control and had succeed in variety of setting.and had succeed in variety of setting.

This presentation will disclose a few aspect This presentation will disclose a few aspect in the implementation of DOTS in the in the implementation of DOTS in the management tuberculosis, in pulmonary management tuberculosis, in pulmonary and extrapulmonary sites.and extrapulmonary sites.

DIAGNOSISDIAGNOSIS

SPUTUM EXAMINATION :SPUTUM EXAMINATION :

. 3 times, Ziehl Neelsen smear. 3 times, Ziehl Neelsen smear

POSITIVE RESULT :POSITIVE RESULT :

Positive In 2 of 3 AFB smears, orPositive In 2 of 3 AFB smears, or

Positive in 1 AFB smear and chest x- ray (+)Positive in 1 AFB smear and chest x- ray (+)

MICROSCOPIC EXAMINATIONMICROSCOPIC EXAMINATION

More objective and reliable than chest x ray More objective and reliable than chest x ray

0102030405060708090

100

AFB Exam Chest xray

98%

70%

Agreement of medical Practitioner

CHEST X-RAY EXAMINATIONCHEST X-RAY EXAMINATION Causing over- diagnosis of TBCausing over- diagnosis of TB

0102030405060708090

100

Suspect with positive Chest x-ray

True positive TB case

OVER DIAGNOSIS

FACTORS THAT PLAY ROLE IN THE FACTORS THAT PLAY ROLE IN THE MANAGEMENT OF TBMANAGEMENT OF TB

1. MYCOBACTERIUM: . SPECIES- . VIRULENCE

2. HOST : . IMMUNITY. ADHERENCE

3. MANAGEMENT & MEDICINE

CURED

INTERACTION

ASPECTASPECT OF OF TREATMENT TREATMENT FAILURE IN TUBERCULOSISFAILURE IN TUBERCULOSIS

1. ETIOLOGIC DIAGNOSIS :1. ETIOLOGIC DIAGNOSIS :

- TB MANIFESTATION - TB MANIFESTATION MICOBACTERIOSISMICOBACTERIOSIS

2. HOST :2. HOST :

- IMMUNITY DEFICIENCY- IMMUNITY DEFICIENCY

3. DRUG ASPECT :3. DRUG ASPECT :

- RESISTANT MYCOBACTERIUM - RESISTANT MYCOBACTERIUM

- ADHERENCE TO THERAPY - ADHERENCE TO THERAPY

4. SOURCE OF INFECTION :4. SOURCE OF INFECTION :

- EASIER TRANSPORTATION BETWEEN COUNTRIES- EASIER TRANSPORTATION BETWEEN COUNTRIES

AFB/ PA/ DNA

EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY – DOTS METHOD

. Pleura . Pleura : 16,2 %: 16,2 %

. Meningeal . Meningeal : 9,9 %: 9,9 %

. Peritonitis . Peritonitis : 8,3% : 8,3%

. Spondylitis . Spondylitis : 4,0 %: 4,0 %

. Limphadenitis: 2,2 %. Limphadenitis: 2,2 %

. Pericarditis . Pericarditis : 1,0%: 1,0%

. . Coxitis Coxitis : 1.0 %: 1.0 %

. Supracondylus. Supracondylus : 0.7 %: 0.7 %

. Skin. Skin : 0,4 % : 0,4 %

. Sinovitis : 0,3 %

. Hepar : 0,1 %. Renal : 0,1 %

• PULMONARY TB 55 %

TB MANIFESTATION AT HASAN SADIKIN HOSPITAL

• EXTRAPULMONARY TB 45 %

1. ETIOLOGY1. ETIOLOGYTABLE - GROUP OF MYCOBACTERIUM FOUND IN TABLE - GROUP OF MYCOBACTERIUM FOUND IN PATIENT DIAGNOSED TUBERPATIENT DIAGNOSED TUBERCCULOSISULOSIS

83,1%

16,9%

MTC49,3%

MNTB50,7%

SLOW GROWING

FAST GROWING

Table – Frequency Species of Mycobacterium Found in Various Organs

Organ

Lung Pleura Gland Peritoneum Total I.M. NonTuberculosis -MNTB 1. M. gordonae 2. M. alvei 3. M. ratisbonen 4. M. concordense 5. M.mucogenicum 6. M. avium 7. M. fortuitum 8. Uncultured Mycob. 9. M.peregrinum 10. M.septicum 11. M.paratuberculosis Total  II. M. Tuberculosis Complex 1. M. africanum 2. M. tuberculosis 3. M. canetti Total

43121111000

14  

640

10

31311010110

12  

431

8

30000201001

7  

1250

17

11001000000

3  

000

0

115433322111

36 (50,7%)  

22121

35 (49,3%)

Mycobact’rium Species

22. HOST FACTOR. HOST FACTOR

. . GENETIC SENSITIVITY TO TB :GENETIC SENSITIVITY TO TB : - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN- MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN FUNCTION FUNCTION

.. INADEQUATE DRUGS DOSAGEINADEQUATE DRUGS DOSAGE

.. COMPLIANCECOMPLIANCE

EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY –> DOTS METHOD

COMPLIANCECOMPLIANCE

TB Patient frequently did not have their medicine TB Patient frequently did not have their medicine regularly and continuously because of :regularly and continuously because of :

Limited effort because of false understanding : Limited effort because of false understanding :

. Stopping medicine halfway because they are. Stopping medicine halfway because they are

feeling better feeling better TB relapse again TB relapse again

. “Taking the medicine too long “. “Taking the medicine too long “

. “Medicine too much”. “Medicine too much” High cost of therapy High cost of therapy Drug side effect/ untoward effect Drug side effect/ untoward effect

WITH TUBERCULOSIS :WITH TUBERCULOSIS :

- - Treatment is more than treatmentTreatment is more than treatment

- Treatment is prevention of :- Treatment is prevention of :

. further spreading of . further spreading of

infectioninfection

. further process of . further process of

diseasedisease

DOTSDOTS

Direct Observed Treatment Short-Direct Observed Treatment Short-CourseCourse

ACCURATE DIAGNOSIS,ADEQUATE PERIOD

FREE ANTI TB DRUGS

TAKING DRUGS UNDER SUPERVISING

MONITORING AND EVALUATION

POLITICAL

COMMITMENT

INCLUDING

FINANCIAL SUPPORT

TAKING COMBINATION DRUGS ON SUFFICIENT DOSAGE, REGULARLY, AND CONTINOUSLY

CURED

BASIC PRINCIPLES OF ANTI BASIC PRINCIPLES OF ANTI TUBERCULOSIS DRUGSTUBERCULOSIS DRUGS

Drug is effective during active multiplication phase Drug is effective during active multiplication phase

of mycobacterium, not in dormant phaseof mycobacterium, not in dormant phase

Use combination of 4 – 5 drugs, for 6 mo. or more Use combination of 4 – 5 drugs, for 6 mo. or more

Use of still effective drug for etiologic Use of still effective drug for etiologic

mycobacteriummycobacterium

Patient has to take the medicine regularly, Patient has to take the medicine regularly,

continuously in adequate dosage and periodcontinuously in adequate dosage and period

CLASSIFICATION TB :CLASSIFICATION TB :

Related to 4 aspects :Related to 4 aspects :

- Organ involved in TB process : lung/ extra-lung - Organ involved in TB process : lung/ extra-lung

- result of sputum examination : AFB (+)/ AFB (-)- result of sputum examination : AFB (+)/ AFB (-)

- Previous history of TB therapy :- Previous history of TB therapy :

. New/ exacerbation, relapse, migration/ drop out, . New/ exacerbation, relapse, migration/ drop out,

failurefailure

- Degree of severity of disease: mild or severe - Degree of severity of disease: mild or severe

DECISION ON CATEGORY OF THERAPY

IMPLEMENTATION OF TB THERAPYIMPLEMENTATION OF TB THERAPY

Aspect–aspect :

Decision on the category of TB therapy

Therapy supervising :

. Healthcare officer, family, friend, etc

Monitoring of sputum ACB, during :

- intensive period

- the end of therapy/ 1 month before the

- follow up of sputum conversion

Monitoring of therapy :

- cured, drop out, not cure

THE CHOICE OF ANTITUBERCULOSIS DRUG THE CHOICE OF ANTITUBERCULOSIS DRUG BASED ON CATEGORIESBASED ON CATEGORIES

Alternative of Combined Drug

CategoryOf therapy

Classification and Type of TB Patient TB

Intensive phase (daily or 3x /

week)

Late Phase

I New case AFB (+)New case AFB (-)Chest x-ray (+) with advanced lung

damage/ severe disease New case of TB Severe extra pulmonary TB case

2 HRZE*2 HRZE

2 HRZE

4 HRZE*4 HR

6 HE

II Patients : relapse failure drop out (after default)

2 HRZES / 1 HRZE*2 HRZES / 1 HRZE

5 H3R3E3*5 HRE

New case TB AFB (-) , Chest x-ray (+), mild disease

2 HRZ*2 HRZ

4 H3R3*6 HE

III Mild new ekstrapulmonary case 2 HRZ 4 HR

IV Chronic case Consultation to specialist for secondary medicine

MULTI DRUG RESISTANCE MULTI DRUG RESISTANCE TBTB

(MDR TB)(MDR TB)

DEFINITION OF RESISTANCE

Mono Resistant:Resistant to 1 drug:: OAT:H/ R/ S/ E

Multi Drug Resistance (MDR) :Minimally resistant to INH and Rifampisin: H+R/ H+R+S/ H+R+E.

Poly Resistant :Resistant to a few OAT exept INH & Rifampisin: H+S+E/ S+E/ H+E.

Extensive Drug Resistance (XDR):MDR resistant also to fluoroquinolon and kanamicin/ amikacin/ capreomicyn:MDR+Cipro+kana/ MDR+cipro+ami.

Causes of Drug resistant TBCauses of Drug resistant TB

Due to physicianDue to physician– inappropriate drug, dosage – inappropriate drug, dosage

and durationand duration Due to patientDue to patient – compliance, malabsorption, – compliance, malabsorption,

financial, financial, Due to drugDue to drug – substandard formulation, poor – substandard formulation, poor

bioavailabilitybioavailability Due to health careDue to health care – non availability source was – non availability source was

MDR TB MDR TB

Treatment of Poli/ MDR : More difficult, costly, and more

side effect Individualized :

- “tailor made” - Package

MANAGEMENT OF MDRMANAGEMENT OF MDR

DOTS Plus Strategy Base on :DOTS Plus Strategy Base on : Anamnesis.Anamnesis. Diagnosis berdasarkan Diagnosis berdasarkan laboratorium.laboratorium. Pengobatan berdasarkan Pengobatan berdasarkan laboratorium.laboratorium. Evaluasi pengobatan berdasarkan Evaluasi pengobatan berdasarkan

laboratorium.laboratorium. Evaluasi efek samping, faal hati, faal ginjal, Evaluasi efek samping, faal hati, faal ginjal,

dll berdasarkan dll berdasarkan laboratorium.laboratorium. Lama pengobatan min. 18 bln, dg tahap Lama pengobatan min. 18 bln, dg tahap

intensif 6 bln paduan mengandung OAT intensif 6 bln paduan mengandung OAT suntik.suntik.

Indonesia : Indonesia : 22 High Burden Countries22 High Burden Countries

Indonesia : Indonesia : 22 High Burden Countries22 High Burden Countries1. India

2. China

3. Indonesia4. Bangladesh5. Nigeria6. Pakistan7. South Africa8. Philippines9. Russia10. Ethiopia11. Kenya12. DR Congo13. Viet Nam14. UR Tanzania15. Brazil16. Thailand17. Zimbabwe18. Cambodia19. Myanmar20. Uganda21. Afghanistan22. Mozambique

Indonesia 10%Indonesia 10%Indonesia 10%Indonesia 10%

Bangladesh 4%

China15%

China15%

India30%India30%

Other28%

Philippines 3%

Pakistan 4%

Nigeria 3%

South Africa 2%

Russia 1%

Penyebab kematian terbanyak penyakit infeksi (SKRT 1995)

583.000 kasus baru/tahun, 140.000 kematian /tahun (WHO)

BACKGROUND OF TB PROBLEM IN BACKGROUND OF TB PROBLEM IN DEVELOPING COUNTRIESDEVELOPING COUNTRIES

-Annually there are 1 millions new TB patients

- And TB is responsible for an annual 3 millions death

- 97 % patients located in developing c’ tries 25% can be

avoided

- In Indonesia : TB is third major cause of mortality ( SKRT ‘95)

MANAGEMENT OF TB IS BASED ON :-Species of causal mycobacterium - Infected organs- Advanced and progression of diseases

THE STRATEGY IS TO MORBIDITY & MORTALITY

* HIGH MORBIDITY AND MORTALITY RATE

World Health Organization

Country

1. India

2. China

3. Indonesia

7. Philippines

8. Pakistan

10. Russia

13. Viet Nam

22. Afghanistan

1,008,937

1,275,133

212,092

75,653

141,256

145,491

78,137

21,765

184

107

280

330

175

132

189

321

1,856

1,365

595

249

247

193

148

70

Population (thousands)

Cases (thousands)

Rate x105

Estimated Annual Incidence of TB in Estimated Annual Incidence of TB in Selected High Burden Countries, 2000Selected High Burden Countries, 2000

BackgroundBackground Indonesian situation :Indonesian situation :

- population : 222,781,000- population : 222,781,000- global rank : 3- global rank : 3- incidence : 239 (239/100,000/year)- incidence : 239 (239/100,000/year)- incidence of new cases : 108 - incidence of new cases : 108

(108/100,000/year)(108/100,000/year)- prevalence : 262 (262/100,000/year)- prevalence : 262 (262/100,000/year)

- mortality : 41 (41/100,000/year)- mortality : 41 (41/100,000/year)- co-infection TB/HIV : 0,8%- co-infection TB/HIV : 0,8%- MDR-TB : 1,6%- MDR-TB : 1,6%

The Global The Global PlanPlan

The Regional The Regional PlanPlan

Country PlansCountry Plans

A pessimist sees the difficulty in every opportunity:

an optimist sees the opportunity in every difficulty.

Sir Winston Churchill

Global Strategy to Stop TB 2006-Global Strategy to Stop TB 2006-20152015

1. Pursuing quality DOTS expansion and enhancement1. Pursuing quality DOTS expansion and enhancement• Government commitment with long-term planning and adequate resources Government commitment with long-term planning and adequate resources

to reach targetsto reach targets• Case detection : bacteriology and strengthening of laboratory networkCase detection : bacteriology and strengthening of laboratory network• Standardised treatment, under proper case management conditions Standardised treatment, under proper case management conditions

including DOT and patient supportincluding DOT and patient support• Effective and regular drug supply systemEffective and regular drug supply system• Monitoring system for supervision and evaluation, including impact Monitoring system for supervision and evaluation, including impact

measurementmeasurement2. Additional components2. Additional components

11 Addressing TB/HIV and MDR-TBAddressing TB/HIV and MDR-TB2. 2. Contributing to health system strengtheningContributing to health system strengthening3. 3. Engaging all care providersEngaging all care providers

4. 4. Empowering patients and communitiesEmpowering patients and communities 5. 5. Enabling and promoting researchEnabling and promoting research

Stop TB DepartmentStop TB Department

The new Stop TB Strategy and the The new Stop TB Strategy and the Regional Strategic Plan, 2006-Regional Strategic Plan, 2006-

20152015 Sustaining and enhancing Sustaining and enhancing

DOTS to reach all TB DOTS to reach all TB patients, improve case patients, improve case detection and treatment detection and treatment successsuccess

Establishing interventions Establishing interventions to address TB/HIV and to address TB/HIV and MDR-TBMDR-TB

Forging partnerships, Forging partnerships, including with communities, including with communities, to ensure equitable access to ensure equitable access to international standards of to international standards of TB care for all TB care for all

Contributing to Contributing to strengthening health strengthening health systemssystems

DOTS Success StoryDOTS Success Story DOTS the internationally recommended control DOTS the internationally recommended control

strategy was launched in 1994 strategy was launched in 1994 The DOTS framework has subsequently been The DOTS framework has subsequently been

expanded and implemented in 182 countries. expanded and implemented in 182 countries. DOTS implementation has helped countries to DOTS implementation has helped countries to

improve national TB control programmes (NTPs) improve national TB control programmes (NTPs) and make major progress in TB controland make major progress in TB control

By 2004, more than 20 million patientsBy 2004, more than 20 million patientshad been treated in DOTS programmeshad been treated in DOTS programmesworldwide and more than 16 million of themworldwide and more than 16 million of themhad been cured.had been cured.

HEALTH CENTER INVOLVED IN DOTS< 60 %60 - 80 %81 - 100 %

020406080

100120140160180200

Hospital distributionHospital distribution(absolute numbers)(absolute numbers)

Coverage of DOTS Services in Coverage of DOTS Services in

National TB ProgramNational TB Program

PUSKESMAS (N 7489)

98.5%

HOSPITAL,

LUNG CLINICS (N 1316)

37%

GPs etc ??Source of Thy

failure, MDR-TB, TB-HIV, XDR

The practices of TB care among The practices of TB care among doctors in private sectordoctors in private sector

Over diagnosis and under diagnosisOver diagnosis and under diagnosis Over treatment and under treatmentOver treatment and under treatment Chest X-ray regarded as the most important Chest X-ray regarded as the most important

diagnostic tool diagnostic tool Sputum smear is mostly neglected Sputum smear is mostly neglected Non standard tests gaining popularity (serology, Non standard tests gaining popularity (serology,

PCR etc) PCR etc) Incorrect use of anti TB drugs (regimen, doses, Incorrect use of anti TB drugs (regimen, doses,

duration, compliance)duration, compliance)

Eur Respir J 2006; 28: 687–690

Lead to substandard Lead to substandard care and failurecare and failure

Extension of DOTS Service in Hospital through Hospital DOTS

Extension of PPM (Public Private Mix) (DPS, Jail, Army/ Police Dept.)

Extended of working cooperation with LSM with Health Service

DOTS in Work Place Extension of working

cooperation with Medical Proffesion to facilitate DOTS

ISTC & PCTC (Patients’ charter for TB Care)

Involvement of All Health Personnel & health centers

ISTC TB Training Modules 2009

Audience:Audience: all health care practitioners, all health care practitioners, public and privatepublic and private

Scope:Scope: diagnosis, treatment, and public diagnosis, treatment, and public health responsibilities; intended to health responsibilities; intended to complement local and national guidelinescomplement local and national guidelines

Rationale:Rationale: sound sound tuberculosis control requires the effective engagement of all requires the effective engagement of all providers in providing providers in providing high quality care and in and in collaborating with TB control programscollaborating with TB control programs

ISTC: Key PointsISTC: Key Points

ISTC ObjectivesISTC Objectives

The The Standards Standards are intended that all care are intended that all care provider delivered high quality care: provider delivered high quality care:

for patients of all ages, those with sputum for patients of all ages, those with sputum smear (+), sputum smear (-), and extra smear (+), sputum smear (-), and extra pulmonary TBpulmonary TB

TB caused by drug-resistant TB caused by drug-resistant M M tuberculosis tuberculosis complexcomplex

TB + HIVTB + HIV

ISTC TB Training Modules 2009

ISTC: Key Points (Edition 1)ISTC: Key Points (Edition 1) 17 Standards17 Standards Differ from existing guidelines:Differ from existing guidelines: standards standards

present what should be donepresent what should be done, whereas, , whereas, guidelines describe how the action is to be guidelines describe how the action is to be accomplishedaccomplished

Evidence-based, living documentEvidence-based, living document Developed in tandem withDeveloped in tandem with Patients’ Charter Patients’ Charter

for Tuberculosis Carefor Tuberculosis Care Handbook for Using the International Handbook for Using the International

Standards for Tuberculosis CareStandards for Tuberculosis Care

ISTC TB Training Modules 2009

ISTC: Key Points (Edit. 2- 2009)ISTC: Key Points (Edit. 2- 2009)

21 Standards Original Standards were renumbered and

new Standards were written Evidence-based, living document, will require

future revisions as well ISTC Tuberculosis Training Modules and

Facilitator’s Guide were updated and developed to be in agreement with Edition 2 of the ISTC

ISTC TB Training Modules 2009

ISTC Standard 1

All persons with All persons with otherwise otherwise unexplained unexplained productive productive cough lasting two-three weeks or more should should be evaluated for be evaluated for tuberculosistuberculosis

The Indonesian Version of The Indonesian Version of ISTCISTC

ISTC in IndonesiaISTC in IndonesiaIndonesian Standard for Tuberculosis Indonesian Standard for Tuberculosis

ControlControl

Is accepted and being endorsed by Is accepted and being endorsed by several profession organizationseveral profession organization

In socialization phaseIn socialization phase Has been disseminated and implemented Has been disseminated and implemented

in Jakarta, West Java, East Java, and in Jakarta, West Java, East Java, and Central Java as pilot projectCentral Java as pilot project

GoalsGoals

Equitable quality DOTS for all- To standardize the care of TB patients in

variety of different providers - To provide high quality of care- Improve CDR, cure rate- Prevention of MDR- Reduce mortality- Cover co-infection TB/HIV

The first priority is to endorse and implement ISTC among private physicians and hospitals

WORKING TEAM ON PULMONARY & EXTRAPULMONARY TB ERADICATION

PROGRAM

TRAINING DOKTER/PERAWAT/

PARAMEDIS

PULMONARY & EXTRAPULMONARY

TUBERCULOSIS CENTRAL CLINIC

RESPIROLOGY TEAM

DOTS PROGRAM AT HASAN SADIKIN HOSPITAL BANDUNG

TB PATIENTS

OTHER CLINICS

NEURO

CLINIC

ORTHOPAEDI

C CLINIC

INTERNAL

MEDICINE CLINIC

PEDIATRIC CLINIC

TBE (+)

THERAPY (+)

TBP +/- TBE

THERAPY

TBP +/- TBE

THERAPY

DOTS CORNE

R

SOCIAL WORKER

LABORATORYOFFICER

MEDICALPRACTITIONER

DATA COLLECTINGREPORTING

OFFICER

FARMACY-OFFICER

Conclusion 1Conclusion 11.1. TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM IN TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM IN

INDONESIA WITH A HIGH MORBIDITY AND MORTALITY RATE .INDONESIA WITH A HIGH MORBIDITY AND MORTALITY RATE .

2.2. STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN EFFECTIVE STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT MUST BE DONE METHOD TO ERADICATE UBERCULOSIS. IT MUST BE DONE NATIONALLY AND SUPPORTED BY WHOLE COMMUNITY WITH NATIONALLY AND SUPPORTED BY WHOLE COMMUNITY WITH ADEQUATE PERSONNEL, MEDICINE, AND FINANCIAL.ADEQUATE PERSONNEL, MEDICINE, AND FINANCIAL.

3.3. RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHER RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHER SPECIES MAY HAMPER THE ERADICATION OF TUBERCULOSIS SPECIES MAY HAMPER THE ERADICATION OF TUBERCULOSIS AND MYCOBACTERIOSIS. AND MYCOBACTERIOSIS.

ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC AGENT MUST ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC AGENT MUST BE DONE WHICH WILL BE HELPFUL IN TREATING THE RESISTANT BE DONE WHICH WILL BE HELPFUL IN TREATING THE RESISTANT SPECIES.SPECIES.

Conclusion 2Conclusion 2 The result of Indonesian National TB The result of Indonesian National TB

Program was encouragingProgram was encouraging However, Puskesmas gave the biggest However, Puskesmas gave the biggest

contribution to successful outcomecontribution to successful outcome The problems lie on Hospitals and Private The problems lie on Hospitals and Private

providersproviders The Implementation of ISTC expected to The Implementation of ISTC expected to

be complimentary to existing DOTS be complimentary to existing DOTS program program

TB EpidemicTB Epidemic

DOTSDOTS

HIV EpidemicHIV Epidemic

Working groups of the Working groups of the Stop TB PartnershipStop TB Partnership

1. DOTS Expansion2. DOTS-Plus3. TB/HIV

4. Drugs5. Diagnostics6. Vaccines

7. Advocacy, Communication & Social Mobilization

GP2Analysis of costs and benefits

Stop TB DepartmentStop TB Department

THANK YOU THANK YOU

WIPE OUT MYCOBACTERIUM

……….. THE VICIOUS ENEMY