Inari
Enontekiö
Kittilä Sodankylä Muonio Savukoski
Kolari Pelkosen- niemi Pello Kemi- järvi Salla Rovaniemi
Posio
Ranua Tuula Toljamo MD, PhD, Docent Chief of the Pulmonary Department, Lapland Central Hospital Lapland Hospital District, Finland E-mail: [email protected] The Main Principles of Finnish Social and Health Care
• Everyone has the right to adequate social and health services regardless of place of domicile and wealth (constitution) • Services are predominantly public and funded through taxation • The state is responsible for providing direction and for monitoring • Municipalities/local governmental joint service areas are responsible for organization • Public-sector service providers • Private sector service providers • The non-governmental patient organizations supply patient education The Organisation for Respiratory Health in Finland, The Allergy, Skin and Asthma Federation etc. TB Control today in Finland
• Strong legislative support • The updated Communicable Diseases Law • Defines TB screening practices for workers in certain fields of work (food industry etc) • Allows for registration of TB contacts • Mandates the isolation of infectious TB patients • A national infectious diseases register with integrated laboratory data run by the National Institute for Health and Welfare (THL) • National advisory expert groups for TB control and TB care • The updated national TB programme • The National Tuberculosis Control Programme 2013. Ministry of Social Affairs and Health • Web-based training courses and information for health professionals and population www.filha.fi
Rajalahti,I. SLL. 2017
Responsibilities of Primary Health Care and Occupational Health Care in TB Control
Implementation of control actions of communicable diseases … In TB 1. Prevention • spread information on tuberculosis for the citizens, vaccinations, health counseling and check-ups • education of health care personnel • regional monitoring of tuberculosis control • acts addressed for the risk groups • fast diagnostics and referrals 2. Monitoring of treatment together with specialized health care • Provision of DOT 3. Prevention of spreading of tuberculosis • contact tracing and examinations of contacts • health counseling
4 Responsibilities of hospital districts in TB Control • Co-operation with primary health care is essential - Monitoring of TB infection regionally - Help communities to investigate local epidemias - Maintenance of regional register of TB - Education and information
• Treatment of patients as a whole - diagnostics - prevent hospital transmissions - start of treatment,end of treatment - written instructions for follow-up - consultations
5 What about TB history in Finland ?… Tuberculosis Act 1948
• The decree of the 1927 tuberculosis act was repealed • Strong administrative structure to prevention and treatment • Responsibility for the arranging of the care to municipilaties • Role of tuberculosis district • Every municipality must belong to some TB district • Sanatorium • Outpatient clinic has responsibility for TB prevention • The chief doctor has much power and responsibility • Contagious TB patients can be forced to the care • Vaccinating voluntary • Free-of-charge care to poor
1.11.2017 According to Keistinen T, 2017 7 Fighting TB during 1930 – 1960/1970 in Finland
• Improving socio-economic conditions (slow) • Sanatoria first to the privileged, then for all • Anti-TB non-governmental organizations • Diet and rest • Major role of surgery: pneumothorax and thoracoplastia • Vaccination • Drugs
According to Keistinen T,2017 New Tuberculosis Act 1960
• To municipalities strong duty to arrange the care • To municipalities be belonged to the tuberculosis district • Tuberculosis district must offer TB patients care • Compulsory group inspections • Contagious TB patients can be forced to the care • Rehabilitation is also part of care • Care and examinations are free-of-charge to patients
According to Keistinen T, 2017 9 Into and during the 1980´s
• Mass X-ray, vaccination • Standard anti TB regimens shorter duration (6 – 9 months) • Legislation changed starting 1987 • Communicable Diseases Act 1986 and Act on Specialized Medical Care 1989 • The special position for tb disappears • Doctor responsible into the Primary health centers for the infectious diseases • Notification still compulsory • Dipensaries/sanatoria converted into pulmonary departments at central hospitals • Tb treatment and prevention as an ordinary sector of somatic health care
• Clinical research
According to Keistinen T, 2017 What was the big change ?
….Why was the new legislation needed? … reasons and consequences… The number of the new tuberculosis cases during years 1975 - 2012 in Finland
1.11.2017 12 The age groups of TB patients in Finland during 1998 - 2015 Major changes during 1990 ´s
• The majority of the tuberculosis sanatoriums were connected administratively as part of central hospitals • TB diminished - other pulmonary diseases asthma, COPD, Obstructive sleep apnea ,pulmonary cancer gave time to the change • The increase in the out-patient care reduced the need for the beds • The hospitals to be found new use. Some of the hospitals remained empty • Of the nursing staff and doctors there was a shortage and they were placed in other tasks of the care • More attention to the roles of primary health care and occupational health care in TB control
1.11.2017 14
What is TB patient´s chain of care today in Finland ? The chain of care of a tuberculosis patient
Patient Patient is Patient No discharged Indications of Home monitoring/ follow-up Patient Symptoms monitoring/ monitoring and Treatment follow-up :No further contact visits completed information examination tracing follow-up
Primary Health Suspicion of Basic Care Find out all risk tuberculosis examinations Center or factors DOT is organized –who is respnsible Occupational of treatment,what to do in case of Health Care problems,organization of follow-up A referral to the Central Hospital/ Pulmonary Clinic visits Following facts are written to the Outpatient follow-up patient chart visits Hospital admission and AIRBORNE INFECTION the safety ISOLATION ROOM in the Pulmonary ward Medication and length of stay in NO hospital Central Further The Hospital/ examinations and Diagnosis of Monitoring of Duration of pulmonary medication is Pulmonary differential Most important treatment the whole TBi Yes started Clinic diagnostics side-effects success treatment
DOT arrangements and written personal guidelines
The National Classification of treatment Institute for Notification of tb for the National Infectious success –follow-up Health and Diseases Register notification Welfare (THL)
More Information Isolation in airborne infection isolation room • single room, wc, shower • separate ventilation system, 12 ach/h • negative air pressure • (anteroom, window in interior door, basin)
- All TB patients and suspicions of TB are taken care in airborne isolation rooms - New sputum samples are collected when a patients arrives to the ward - If sputum smears positive, the patients are treated in isolation for at least 2 weeks - After 2 weeks new samples are collected and the isolation treatment will continue until the smears are negative Picture: Duodecim web TB-course 17
Patient monitoring and follow-up visits
Normal 6-months first line drug treatment (INH+RM+EMB+PZA) –drug susceptible TB Examination Before 2weeks 1month 2months 3months 4months 5months 6months (at the end)
Symptoms, clinical x x x x x x examination
Weight x x x x x x x
Blood tests Alat, Afos,Bil, Krea, x PVK,La CRP,HIV-ab
Alat,Bil PVK (CRP,La x x x x x x if needed)
sputum- x x x x x x x x
tbx3,(TbNho) THX X-RAY x x (x) x Test of vision (EMB) x x x x
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland 18
The first line TB drugs, drug susceptible TB : If side-effects to some TB drug :
TB -patient Intensive care Follow-up care Total treatment Drug not used Intesive care follow-up care Total time of used time drug Basic drug care PZA INH,RIF,EMB INH,RIF 7 months 9 months 2months New TB-case INH,RIF,PZA,EMB INH, RIF 4 months 6 months 2 months (in extensive RIF INH, INH,EMB,Mfx/Lfx, 12-18 months disease EMB,Mfx/Lfx,PZA 10-16 months INH,RIF,EMB ad 12 2-3months months) Intensive drug care INH RIF,EMB,PZA 2 RIF,EMB,PZA 10 12 months TB resistance INH,RIF,PZA,EMB,SM along with TB along with TB months months possible 2 months resistance resistance (foreign, earlier tb)
Relapsed TB INH,RIF,PZA,EMB,SM INH,RIF,EMB 5 8 months 2 months months and INH,RIF,PZA,EMB 1 month National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland When MDR-TB/ XDR –TB is suspected in Finland ?
Before TB medicine During TB –care Patient has had known contact with MDR TB- Sputum smear or culture positive after taken over patient 3months TB drugs
Patient has lived >6month as a tourist or has TB progression during therapy clinically or visited own country > 3months period (Baltic radiologically and/or sputum smear become countries, East- Europe, Middle-Asia, China, India, positive again Somalia, conflict areas: Syria, Irak)
Patient has been at hospital care or in prison in Treatment unsuccessful, drugs taken irregularly some over-mentioned country or has in Finnish prison contacted a citizen from those countries
Earlier interrupted TB treatment
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland Classification of TB treatment success
• Healed • full treatment and sputum culture conversion • Treatment completed • full treatment but bacterial confirmation missing • Unsuccessful treatment • cultures stay positive or become positive after 5 month treatment • Dead • Interrupted treatment • at least for 2 mo or patient has moved, no treatment reports available • Continued treatment • Not available
National Tuberculosis Control programme,2013 Ministry of Social Affairs and Health, Finland
21 Screening and treatment of LTBI in case of using TNF-alfa-inhibitors in case of having other drugs adalimumab, etanersept, golimumab, abatasept, tosilitsumab,ustekinumab,chemotherapy, glucocorticoids sertolitsumabipegol ja infliksimab
Exclude active TB – symptoms, contact Exclude active tb- symptoms, TB exposure-questionnaires, THX X-ray, blood exposure -questionnaires, THX X- tests, induced sputumx3 RAY,other examinations
No active TB No active TB
High risk to have High or very high All other cases No riskfactors of TB active TB probability of TB -anamnesis or Anamnesis, THX X RAY THX X-RAY B-LyTbIFNg or B-TbIFNg IGRA
Positive Negative Positive Negative
Cure of LTBI No cure of LTBI Cure of LTBI No cure of LTBI
ADULT: INH 300mgx1 + B6 20mgx1 for 6(-9)months or RIF 600mg x1 (weight>50kg) + INH 300mgx1 +B620mgx1 3months Blood tests(TVK, ALAT,Afos, Bil, Krea) at baseline, 2weeks, then x1/month Follow-up afterwards: THX 2months + 6months http://reumatologinenyhdistys.fi/files/LTBI-reumatologinen-yhdistys-lopullinen.pdf Rapidly changing challenges in TB work in Finland … a forgotten rare disease ? • Cases becoming rare • Problem to maintain the knowledge and • Continuous effort and action needed • Cost-effective use of resources • To determine the most important subgroups within the main risk groups • Foreign- born persons • Mean age of TB patients has declined – increasing proportion of immigrant cases • Alcohol and subtance abusers • The homeless • Children • Adolescents- students • Close contacts
Rajalahti,I. SLL. 2017
The Russian collegues visited Lapland Central Hospital 1.5 – 5.5. 06 COPD co-work
Panychev Dmitry, Pääterapeutti, Sosiaali -ja terveydenhuoltokomitea, Murmanskin aluehallinto Mechkovskaya Olga, Keuhkosairauksien ylilääkäri, Murmanskin aluesairaala Lyalyushkin Sergey, Lääkäri , Montsegorskin kaupunginsairaala Rocheva Irina, Ylilääkäri, Kirovskin kaupunginsairaala Rushechnikova Liudmila Ylihoitaja, Murmanskin aluesairaala
Environmental exposure as an independent risk factor of chronic bronchitis in northwest Russia
Pentti Nieminen1*, Dmitry Panychev2, Sergei Lyalyushkin3, German Komarov4, Alexander Nikanov5, Mark Borisenko2, Vuokko L. Kinnula6 and Tuula Toljamo7 1Medical Informatics and Statistics Research Group, University of Oulu, Oulu, Finland; 2Ministry of Health and Social Development, Murmansk Region, Murmansk, Russia; 3Monchegorsk City Hospital, Murmansk, Russia; 4Department of Pulmonary, Murmansk Regional Hospital, Murmansk, Russia; 5NordWest Science Centre of Public Health Care, Murmansk, Russia; 6Department of Medicine, Pulmonary Division, University of Helsinki, Helsinki, Finland; 7Department of Pulmonary Medicine, Lapland Central Hospital, Rovaniemi, Finland
Background. In some parts of the northwest Russia, Murmansk region, high exposures to heavy mining and refining industrial air pollution, especially sulphur dioxide, have been documented. Objective. Our aim was to evaluate whether living in the mining area would be an independent risk factor of the respiratory symptoms. Design. A cross-sectional survey of 200 Murmansk region adult citizens was performed. The main outcome variable was prolonged cough with sputum production that fulfilled the criteria of chronic bronchitis. Results. Of the 200 participants, 53 (26.5%) stated that they had experienced chronic cough with phlegm during the last 2 years. The prevalence was higher among those subjects living in the mining area with its high pollution compared to those living outside this region (35% vs. 18%). Multivariable regression model confirmed that the risk for the chronic cough with sputum production was elevated in a statistical significant manner in the mining and refining area (adjusted OR 2.16, 95% CI 1.074.35) after adjustment for smoking status, age and sex. Conclusions. The increased level of sulphur dioxide emitted during nickel mining and refining may explain these adverse health effects. This information is important for medical authorities when they make recommendations and issue guidelines regarding the relationship between environmental pollution and health outcomes. Keywords: sulphur dioxide; pollution; respiratory symptoms; Murmansk; mining
Int J Circumpolar Health. 2013;72. doi: 10.3402/ijch.v72i0.19742. Epub 2013 Feb 22.