Preventional interventions

8/7/2019 Preventional interventions

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Tuberculosis:Tuberculosis:

preventive interventionspreventive interventions

Lecturer: Ph.DLecturer: Ph.D

M.G.DolynskaM.G.Dolynska


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Chain of TransmissionChain of Transmission

IndexIndex casecase

contactcontact

BCGBCG

vaccinationvaccination

PreventivePreventive

ChemotherapyChemotherapy

Early

Diagnosis

AdequateTreatment

Environmental

Control

Jaap Veen, MD,Jaap Veen, MD,

PhDPhDKNCVKNCV


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Risk Groups Risk FactorsRisk Groups Risk Factors

Persons at risk for infectionsPersons at risk for infectionshigh risk environmenthigh risk environment riskgroupriskgroup

Prevalence of infectious casesPrevalence of infectious cases (household)(household)

contactscontacts

foreign bornforeign born

CrowdingCrowding homelesshomeless

drug addictsdrug addicts

alcoholicsalcoholics

prisonersprisoners

Patient care facilitiesPatient care facilities Health CareHealth CareWorkersWorkers


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Risk Groups Risk FactorsRisk Groups Risk Factors

Persons at risk once infection has occurredPersons at risk once infection has occurredIndividual risk factorsIndividual risk factors riskgroupriskgroupRecency of infectionRecency of infection contactscontacts

Medical risk factorsMedical risk factors

diabetes mellitusdiabetes mellitus

gastrectomygastrectomy

renal failurerenal failure

malnourishmentmalnourishment

malignancymalignancy

HIV infectionHIV infection HIV infectedHIV infectedAgeAge

childrenchildren

adolescentsadolescents

>= 65 years>= 65 years residentsresidents

nursing homesnursing homes


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RiskRisk

Risk FactorsRisk Factors

HIVHIV diabetesdiabetes

cancercancer

malnutritionmalnutrition

ageage etcetc

Risk GroupRisk Group

if incidence isif incidence is

IUATLD>IUATLD>100/100,00100/100,0000

Netherlands>Netherlands>50/100,00050/100,000

Veen: 5 xVeen: 5 xincidenceincidence


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INTERVENTIONSINTERVENTIONS

1.1. DiagnosisDiagnosis

passive case detectionpassive case detection(symptomatic)(symptomatic)

active screeningactive screening (risk groups)*(risk groups)*

** ONLY IF SYMPTOMATICS CAN BE CUREDONLY IF SYMPTOMATICS CAN BE CURED


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22. Treatment. Treatment

Early start of adequate treatment *Early start of adequate treatment *

* combination of drugs* combination of drugs

sufficient durationsufficient duration

direct observation of rifampicindirect observation of rifampicinintakeintake


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3. Environmental control3. Environmental control

Dilution of infectious particles fromDilution of infectious particles fromthe air *the air *

** ventilationventilation

filtrationfiltrationUV irradiationUV irradiation


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In the hotbed:In the hotbed:

DisinfectionDisinfection

Crowding avoidingCrowding avoiding

Sanitary standards enhansmentSanitary standards enhansment

Preventive chemotherapyPreventive chemotherapy

Bacteria excharger isolation andBacteria excharger isolation andtreatmenttreatment


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4. Preventive chemotherapy4. Preventive chemotherapy

Contact tracing *Contact tracing *

** only if good system is in placeonly if good system is in place

following the Stonefollowing the Stone--inin--thethe--PondPondPrinciplePrinciple


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Preventive chemotherapyPreventive chemotherapy

Primary (for nonPrimary (for non--infected persons exposedinfected persons exposedby close contact)by close contact)

Secondary (for infected persons exposedSecondary (for infected persons exposedby close contact or other risk factors)by close contact or other risk factors)


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How to avoid drug resistanceHow to avoid drug resistance??

Selection doesnt occur if bacteriaSelection doesnt occur if bacteria

amount is less than 10amount is less than 10

66

allallcases of latent tuberculosiscases of latent tuberculosis


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Drugs and dosagesDrugs and dosages

IsoniasidIsoniasid -- 55--1010 mgmg//kgkg ((0,30,3--0,450,45 g per day)g per day)

for exposed by MDRfor exposed by MDR--TBTB ethambutolethambutol 1515--2020mgmg//kgkg ((0,80,8--1,21,2 g per day) and pyrasinamideg per day) and pyrasinamide 2020--2525 mgmg//kgkg ((11--1,51,5 g per day)g per day)

for exposed by simple resistancefor exposed by simple resistance -- isoniasidisoniasid -- 55--1010mgmg//kgkg ((0,30,3--0,450,45 g per day) and rifampicing per day) and rifampicin 1010mgmg//kgkg ((0,450,45--0,60 g per day) g0,60 g per day) g

for exposed by XDRfor exposed by XDR--TBTB according the sensitivityaccording the sensitivityprofile, including fluoquinolons.profile, including fluoquinolons.


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5. BCG vaccination5. BCG vaccination

Newborns *Newborns *

** only in high incidence countriesonly in high incidence countries

High risk groups *High risk groups *

** only if no other means ofprotectiononly if no other means ofprotection


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BC

G vaccineBC

G vaccineAliveAlive

Artificial strain received by a series ofArtificial strain received by a series ofM.BovisM.Bovis passagespassages


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Immunity propertiesImmunity properties

ActiveActive

NonNon--sterilesterile

EExpressedxpressed within 3within 3--5 years5 years


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BCG vaccinationBCG vaccination

Newborns *Newborns *

** only in high incidence countriesonly in high incidence countries

High risk groups *High risk groups *

** only if no other means of protectiononly if no other means of protection

Jaap Veen, MD,Jaap Veen, MD,PhDPhD

KNCVKNCV


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Recombinant BCG vaccine


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Vaccination procedureVaccination procedure


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In 4In 4--6 weeks6 weeks

pustulepustule


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In 6In 6--8 weeks8 weeks

crustcrust


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In 2In 2--4 months4 months

cicatrixcicatrix


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BCGBCG--vaccinevaccine one of theone of the

safestsafest

Total complicationsTotal complications

prevalenceprevalence not more thannot more than0.06% of all vaccinated0.06% of all vaccinated


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Complications (BCGComplications (BCG--relatedrelateddiseases) classificationdiseases) classification

(WHO, 1984)(WHO, 1984)

Local (the most frequent) cold abscess,

ulcer, regional lymphadenitis. Disseminated BCG-infection (ostitis,

lupus).

Generalized BCG-infection with lethal

outcomes. Post-BCG syndrome (cheloid cicatrix,

nodular erythema, allergic rash).


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Complication: caseoticComplication: caseoticlymphadenitislymphadenitis


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Complication: ulcerComplication: ulcer


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Complication:Complication: cheloidcheloid cicatrixcicatrix


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Ethical and Legal aspects ofEthical and Legal aspects of

InterventionsInterventions Screening:Screening:

Mandatory or Voluntary ?Mandatory or Voluntary ?

If voluntary:If voluntary:

how much pressure may behow much pressure may beexercised ?exercised ?

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Preventional interventions

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