Course on Multidrug-Resistant Tuberculosis MDR-TB COURSE on MULTIDRUG-RESISTANT TUBERCULOSIS MDR-TB
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Course on Multidrug-Resistant Tuberculosis MDR-TB COURSE ON MULTIDRUG-RESISTANT TUBERCULOSIS MDR-TB © World Medical Association The World Medical Association (WMA) is an international organization representing approximately 7 million physicians of all specialties and sectors. It was founded on 18 September 1947, when physicians from 27 different countries met at the First General Assembly of the WMA in Paris. The organization was created to ensure the independence of physicians, and to work for the highest possible standards of medical care, ethics, education and health-related human rights for all people, at all times. The WMA has Medical Association from all over the world as its constituent members. The WMA offers Associate Membership to individual physicians. The WMA provides a forum for its member associations to communicate freely and cooperate actively in order to achieve consensus on high standards of medical ethics and professional competence, to promote the professional freedom of physicians worldwide and to uphold the endur- ing traditions of the profession: Caring, Ethics and Science. This unique partnership facilitates high-calibre, humane care to patients in healthy environments, enhancing the quality of life for all people in the world. World Medical Association 13, Chemin du Levant - 01212 Ferney-Voltaire, France Tel.: + 33 450 40 75 75 • Fax: + 33 450 40 59 37 e-mail: [email protected] www.wma.net Disclaimer All reasonable precautions have been taken by the World Medical Association, the Foundation for Professional Development and the Norwegian Medical Association to verify the information contained in this publication. However this course is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Medi- cal Association, the Foundation for Professional Development and the Norwegian Medical Association be liable for damages arising from its use. As research and experience with MDR-TB progress we do expect that WHO will update it’s guidelines. We do our best to incorporate changes into the course, however please visit the WHO web page to check for the latest versions of the guidelines. Acknowledgement: The World Medical Association gratefully acknowledges: The partnership of Eli Lilly by a generous unrestricted educational grant and a tireless coordination of the humanitarian efforts in the NGO community to fight TB. The support by its constituent members: Foundation for Professional Development (FPD) the educational division of the South African Medical Association (SAMA) The Norwegian Medical Association and its learning platform for transforming the course into the online format and making the course online available The German Medical Association for coordinating this WMA project The volunteer support by our advisory committee Dr Oumou Bah-Sow, Tuberculosis Area of Work Division for AIDS, TB and Malaria (ATM) World Health Organization/Regional Office for Africa (WHO/AFRO), Zimbabwe Dr. Liu Jianjun, National Center for Tuberculosis Control and Prevention, China Dr. Yao Hongyan, National Center for Tuberculosis Control and Prevention, China Dr. John Sbarbaro, University of Colorado, USA Prof. Mohammad Reza Masjedi, National Research Institute of Tuberculosis and Lung Disease, Iran Mr. Bjorn Hoftvedt, Norwegian Medical Association, Norway Dr. Vaira Leimane, MDR Training Centre of Excellence, Latvia Dr. Jose Caminero Luna, Consultant – IUATLD, Spain Dr. Thelma Tupasi, Tropical Disease Foundation, Inc, Philippines The work of some persons, who dedicated work to this program Dr. Karin Weyer, Medical Research Council, South Africa, for her excellent authorship Dr. Hernan Reyes, Switzerland, for contributing the chapter on TB and prisons Dr. Patrizia Carlevaro, Switzerland, coordinating, inspiring and moving the MDR-TB work of the international NGO-community Foundation for Professional Development, South Africa: Dr. Elmie Castleman Mrs. Ronel Chickory Ms. Helga Swart Prof. Pierre JT de Villiers from Stellenbosch University on behalf of Foundation for Professional Development. Ms. Karoline Borgen, for making this work visible on the Internet Mr. Bjorn Hoftvedt, for editing the manuscripts Dr. Terje Vigen, Norway, for allocating resources from the Norwegian Medical Association Dr. Ramin Pasa Parsi, Germany, for coordinating the WMA – project Dr. Delon Human, Switzerland, for starting the project Dr. Michael L. Rich, Partners in Health Ruanda, for the update of the course in the year 2008 Mrs. Minda Nicolas, Partners in Health Ruanda, fort he update of the course in the year 2008 Design: HELP Design Group © 2008 The World Medical Association, 13, Chemin du Levant, 01212 Ferney-Voltaire, France. All Rights Reserved. All rights, including transla- tion into other languages, reserved. No part of this publication may be reproduced in print, by photo static means or in any other manner, or stored in a retrieval system, or transmitted in any form without the expressed written permission of the World Medical Association. Short excerpts (under 300 words) may be reproduced without authorization, on condition that the source is indicated. Course on Multidrug-Resistant Tuberculosis MDR-TB The World Medical Association With support from the Lilly MDR-TB Partnership 6 Introduction 7 Module 1 - TB-MDR STRATEGIES 8 Learning objectives 9 Introduction 9 Development of MDR-TB 10 The DOTS strategy as the cornerstone to prevent MDR-TB 15 Causes of inadequate first-line TB treatment 16 Primary and secondary MDR-TB 17 MDR-TB treatment Table Of Contents Table 17 MDR-TB framework approach 19 MDR-TB treatment components 24 MDR-TB programme requirements 27 Self Assessment Questions and Exercises 28 Module 2 - EPIDEMIOLOGY OF MDR-TB 29 Learning objectives 30 Introduction 30 Epidemiological definitions 32 Magnitude of the global MDR-TB problem 35 Risk factors for MDR-TB 36 Self Assessment Questions and Exercises 37 Module 3 - CASE FINDING STRATEGIES AND CASE DEFINITIONS 38 Learning objectives 39 Introduction 39 Risk groups for MDR-TB 41 Case-finding strategies 41 Strategies for programmes with no access to DST 42 Strategies for programmes with access to DST 44 Case definitions for MDR-TB 44 Why use case definitions? 45 Definitions 46 Case registration for cohort analysis 48 Self Assessment Questions and Exercises 49 Module 4 - DIAGNOSIS OF MDR-TB 50 Learning objectives 51 Introduction 51 Signs and symptoms of MDR-TB 52 Assessing a patient for MDR-TB 53 Medical history 53 Physical examination 54 Laboratory diagnosis of MDR-TB 55 Microscopy 57 Culture 59 Identification of M. tuberculosis 59 Drug susceptibility testing 61 Limitations of DST 62 The role of laboratory services in MDR-TB programmes 64 Self Assessment Questions and Exercises 65 Module 5 - TREATMENT STRATEGIES FOR MDR-TB 66 Learning objectives 67 Introduction 67 Available MDR-TB drugs 71 Standard codes for drugs and regimens 72 Treatment strategies 73 Choosing between different treatment strategies 74 Self Assessment Questions and Exercises 75 Module 6 - DESIGNING MDR-TB TREATMENT REGIMENS Of Contents Table 76 Learning objectives 77 Introduction 77 Designing treatment regimens 77 Basic principles 78 Drug selection and regimen design 81 Standardized treatment regimens 81 Empiric treatment regimens 82 Individualized treatment regimens 83 Duration of injectable agent use 84 Duration of treatment 94 Designing a programme treatment strategy 86 Extrapulmonary MDR-TB treatment 86 Treatment of XDR-TB 88 Self Assessment Questions and Exercises 89 Module 7 - ANCILLARY MEDICATION AND ADJUVANT THERAPIES 90 Learning objectives 91 Introduction 91 Ancillary medications and adjuvant therapies 92 Surgery 95 Self Assessment Questions and Exercises 96 Module 8 - DRUG ADVERSE EFFECTS 97 Learning objectives 98 Introduction 98 Most common drug adverse effects 100 Monitoring of drug adverse effects 101 Management of drug adverse effects 107 Self Assessment Questions and Exercises 108 Module 9 - SPECIAL SITUATIONS 109 Learning objetives 110 Introduction 110 Oral contraception use 110 Pregnancy 111 Breastfeeding 112 Children 116 Diabetes 117 Renal insufficiency 118 Liver disorders 119 Seizure disorders 120 Substance dependency 120 Psychiatric patients 121 MDR-TB treatment failures 121 Patients with suspected MDR-TB treatment failure 122 Patients with apparent MDR-TB treatment failure 122 Suspending therapy 123 Palliative/supportive care 125 Self Assessment Questions and Exercises 126 Module 10 - MDR-TB AND HIV 127 Learning objectives 128 Introduction 128 Clinical presentation of HIV-related MDR-TB 128 Diagnosis of HIV-related MDR-TB 129 MDR-TB treatment 129 Antiretroviral treatment 130 Goals of antiretroviral therapy 130 Timing of initiation of ART in adult MDR-TB patients Table Of Contents Table 132 Concomitant MDR-TB in children with HIV infection 133 Prophylaxis of opportunistic infections 134 Immune reconstitution syndrome 134 Patient monitoring 135 Management of drug adverse effects 137 Self Assessment Questions and Exercises 138 Module 11 - MONITORING AND OUTCOME EVALUATION OF MDR-TB PATIENTS 139 Learning objectives 140 Introduction 140 Patient education and counseling 141 Treatment adherence 141 Directly-observed treatment (DOT) 142 Maintaining confidentiality 142 Social and emotional support 143 Management of treatment interruption and default 144 Patient follow-up after treatment completion 144 MDR-TB documentation 145 Bacteriological investigations 145 Intervals of testing