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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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INTERVENTIONSINTERVENTIONS
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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INTERVENTIONSINTERVENTIONS
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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INTERVENTIONSINTERVENTIONS
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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INTERVENTIONSINTERVENTIONS
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 ?