Tuberkulosis Anak, DOTS, ISTC Finny Fitry Yani Courtesy : UKK Respirologi Anak IDAI
World problems of Tuberculosis (TB) Global problem Neglected Childhood TB Low Case Detection Rate Lack of holistic approach of TB management Non-standardized management
Global burden of tuberculosis (TB) 1/3 of the population of the world have been infected Prevalence: 17.22 million (1990s ) 11.1 million (2008 ) New cases/year: 9.3 million (2007) 9.4 million (2008)
GOAL: TUBERCULOSIS PROGRAMS to break the chain of the transmission for eliminating the disease from society. Strategies: 1)case finding and treatment of active disease 2)treatment of LTBI 3)vaccination with BCG
National TB Programs (NTPs)= P2 TB Kemenkes Focus on adult cases Pediatric TB
DOTS (Directly Observe Treatment Short-course) A global strategy to combat world TB problems Developed by WHO and IUATLD Introduced in early 1990, implemented in Indonesia since 1994s DOTS coverage in 2006: 98%
5 KOMPONEN DOTS Komitmen Politis dan dukungan semua pihak Diagnosis mikroskopik Ketersediaan Obat 1 ANAK?? 4 WHO 1991 2 Pencatatan Pelaporan 5 3 Pengawas Menelan Obat
Cure rate tinggi (pemutusan rantai transmisi) Paling cost effective (Bank Dunia) Rekomendasi WHO
Tujuh Strategi Utama Program Nasional Penanggulangan TB Ekspansi Quality DOTS Equitable Quality DOTS Expansion Indonesia 1. Perluasan & Peningkatan pelayanan DOTS berkualitas 2. Menghadapi tantangan baru, TB-HIV, MDR-TB dll 3. Melibatkan Seluruh Penyedia Pelayanan 4. Melibatkan Penderita & Masyarakat Didukung dg Penguatan Sistem kesehatan 5. Penguatan Policy & Kepemilikan Daerah 6. Kontribusi thd Sistem Pelayanan Kesehatan 7. Penelitian Operasional
SEMBUH
TB management in Indonesia Healthcare providers Government Private PHCs Government hospitals Private hospitals Private practices BP4 RSP DOTS strategy GP Pulm
TB IN HOSPITALS Case finding : high (DIY: hospital 36%; PHCs 27%; BP4 37%) Have no working area Case holding: low high dropped out (>50%) Low cure rate (< 50%) HOSPITAL DOTS LINKAGE (HDL)
SITES OF DIAGNOSIS OF TB IN HOSPITAL
EXTERNAL NETWORKING CHC PRM / PPM Private Doctors PKK, PPTI NGO Hospitals District Health Service Community Leader Lung Clinics PPTI Clinics, WP,Lapas/Rutan
Option of TB management in HDL Option Suspect finding Diagnosis Treatment initiation Continuing treatment Consultation Recording and reporting 1. 2. 3. 4. Hospital/non PHC PHC
REFERAL SYSTEM IN HDL Alur Rujukan Penderita Tuberkulosis Koordinator HDL Kab/Kota Wasor TBC Kab/Kota informasi konfirmasi Rumah Sakit Penderita, OAT, TB.01, surat rujukan (TB.09) (TB.09) Puskesmas
World problems of Tuberculosis (TB) The second global cause of death from infectious agents Neglected Childhood TB Low Case Detection Rate Lack of holistic approach of TB management Non-standardized management
Non-standardized management Diagnosis over diagnosis underdiagnosis Treatment irrational treatment Public Health contact tracing Recording and reporting
ISTC (International Standard for TB care) Differ from existing guidelines standards what should be done guidelines how the action is to be accomplished Evidence-based, living document As a complementary of the existing guideline
Purpose of ISTC
ISTC Diagnosis Treatment Public Health 6 standards 9 standards 2 standards
Standards for Diagnosis Pediatric considerations
Standard 1 All persons with otherwise unexplained productive cough lasting two-three weeks or more should be evaluated for TB Pediatric consideration COUGH is NOT the main symptom of TB Other symptoms should be considered: weight loss or FTT in the last two months fever >2 weeks with unexplained causes Close contact with adult Pulmonary TB
Standard 4 All persons with chest radiographic findings suggestive of TB should have sputum specimens submitted for microbiological examination. Pediatric consideration Collecting sputum in children is challenging If possible, perform induced sputum or gastric lavage
Standard 6 The diagnosis of intra-thoracic TB in symptomatic children with negative sputum smears should be based on the finding of chest radiograph Pediatric consideration The appearance of lymphadenopathy is subtle and may be difficult to detect especially in malnourished children and when there is HIVrelated pulmonary disease.
Standards for Treatment pediatric considerations
Standard 8 All patients (incl those with HIV infection)... regimen using drugs of known bioavailability. The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol. Pediatric consideration Triple drugs: INH, Rif and PZA Four or five drugs for severe TB
Standards for Public Health
ISTC Standard 16 All providers of care for patients with TB should ensure that persons (especially children under 5 year of age and persons with HIV infection) who are in close contact with patients who have infectious TB are evaluated and managed in line with international recommendations.
Children under 5 years of age and persons with HIV infection who have been in contact with an infectious case should be evaluated for both latent infection with M. tb and for active TB. ISTC Standard 16
ISTC Standard 17 All providers must report both new and retreatment TB cases and their treatment outcomes to local public health authorities, in conformance with applicable legal requirements and policies.
Together in partnership we are more than the sum of our parts!