Federal Ministry of Health Ethiopia Tuberculosis, Leprosy and TB/HIV Prevention and Control Programme Manual Fourth Edition 2008 TABLE OF CONTENTS CONTENT Page FOREWORD .............................................................................. X ACKNOWLEDGEMENT ................................................... XI LIST OF ABBREVIATIONS .......................................... XV 1. INTRODUCTION ...................................................................... 1 2. THE GLOBAL AND NATIONAL BURDEN OF TUBERCULOSIS AND LEPROSY ................................................. 2 2.1 GLOBAL BURDEN OF TUBERCULOSIS ................................................ 3 2.2 NATIONAL BURDEN OF TUBERCULOSIS: ........................................... 3 2.3 GLOBAL BURDEN OF LEPROSY .......................................................... 5 2.4 NATIONAL BURDEN OF LEPROSY ...................................................... 6 3. PRINCIPLES OF TB AND LEPROSY CONTROL ............... 8 3.1 GLOBAL STRATEGY TO PREVENT AND CONTROL TB ........................ 8 3.2 THE STOP TB STRATEGY: .................................................................. 9 3.3 GLOBAL PLAN TO STOP TB 2006-2015 .......................................... 10 3.4 GLOBAL STRATEGY FOR FURTHER REDUCING THE LEPROSY BURDEN AND SUSTAINING LEPROSY CONTROL ACTIVITIES ....................... 11 4. TB AND LEPROSY CONTROL PROGRAMME IN ETHIOPIA ....................................................................................... 12 4.1 GENERAL OBJECTIVES OF TLCP (TUBERCULOSIS AND LEPROSY CONTROL PROGRAM) ................................................................................. 12 4.2 SPECIFIC OBJECTIVES OF TLCP ...................................................... 12 4.3 BASIC STRATEGIES IN REACHING THE OBJECTIVES ......................... 13 4.4 ORGANIZATIONAL STRUCTURE AND FUNCTIONS ............................ 14 5. TUBERCULOSIS ..................................................................... 18 5.1 DEFINITION .................................................................................... 18 5.2 TRANSMISSION AND PATHOGENESIS ............................................... 18 5.3 NATURAL HISTORY ........................................................................ 19 5.4 CASE DETECTION, CASE FINDING .................................................. 21 5.4.1 Objectives ..................................................................................... 21 5.4.2 Case finding strategies: ................................................................ 22 5.5 IDENTIFICATION OF SUSPECTS ........................................................ 22 ii 5.6 DIAGNOSTIC METHODS................................................................... 25 5.6.1 Microscopic examination of sputum smears ......................... 25 5.6.2 Radiological examination ...................................................... 27 5.6.3 Culture .................................................................................. 27 5.6.4 Histo-pathological examination ............................................ 28 5.7 GENERAL DEFINITIONS ................................................................... 29 5.8 CLASSIFICATION OF TUBERCULOSIS CASES .................................... 29 5.9 DEFINITION OF TYPE OF CASES ....................................................... 31 5.10 SERIOUSNESS OF ILLNESS: .............................................................. 32 5.11 TREATMENT OF TB ........................................................................ 33 5.11.1 Drugs used for the chemotherapy of TB ................................ 33 5.11.2 Phases of chemotherapy ........................................................ 34 5.11.3 Patient categories and treatment regimens ........................... 35 5.11.4 Treatment regimen for Category I and III: ........................... 37 5.11.5 Treatment regimen for Category II [Retreatment regimen] .. 39 5.11.6 Side effects ............................................................................. 39 5.11.7 Anti-TB drug treatment in special situations ......................... 41 5.11.8 Indications for hospitalization ............................................... 44 5.12 FOLLOW-UP DURING TREATMENT................................................... 44 5.12.1 Follow-up during the initial phase of treatment .................... 45 5.12.2 Follow up during the continuation phase of treatment .......... 45 5.12.3 How to improve treatment compliance .................................. 46 5.13 DEFINITIONS OF TREATMENT OUTCOME ......................................... 53 6 TUBERCULOSIS IN CHILDREN .............................. 53 6.1 PRIMARY PULMONARY TUBERCULOSIS .......................................... 54 6.2 ACUTE DISSEMINATED TUBERCULOSIS ........................................... 56 6.3 POST-PRIMARY PULMONARY TUBERCULOSIS ................................. 57 6.4 EXTRA-PULMONARY TUBERCULOSIS IN CHILDREN ......................... 58 6.5 DIAGNOSIS OF PAEDIATRIC TB ...................................................... 59 6.5.1 Contact with a TB case .......................................................... 61 6.5.2 Sputum microscopy ............................................................... 61 6.5.3 Chest radiography ................................................................. 61 6.5.4 Tuberculin Skin Test (TST or Mantoux Test) ......................... 62 6.5.5 Lumbar puncture for TB meningitis ...................................... 62 6.5.6 Diagnosis of Tuberculosis in HIV-positive children .............. 63 6.6 TREATMENT OF TUBERCULOSIS IN CHILDREN ................................. 64 6.7 ADMINISTERING TREATMENT AND ENSURING ADHERENCE ............ 70 6.8 FOLLOW UP ................................................................................... 70 6.9 ADVERSE REACTIONS TO TB DRUGS IN CHILDREN.......................... 71 7 TB/HIV COLLABORATIVE ACTIVITIES ......................... 72 7.1 IMPACT OF HIV ON TUBERCULOSIS ............................................... 72 7.2 IMPACT OF TUBERCULOSIS ON HIV ............................................... 73 7.3 DIAGNOSIS OF TB IN HIV-POSITIVE PATIENTS ............................... 74 iii 7.4 PREVENTION AND MANAGEMENT OF TB AMONG PLHI ................. 77 7.4.1 Isoniazid Preventive Therapy (IPT) ...................................... 78 7.4.2 Co-trimoxazole Preventive Therapy (CPT) ........................... 78 7.4.3 Treatment of TB in PLHIV .................................................... 78 7.4.4 Anti-TB Treatment and Anti-Retroviral Therapy (ART) ........ 79 8 DRUG-RESISTANT TB AND MULTI-DRUG RESISTANT TB …………………………………………...……………………..8 0 8.1 MDR-TB OR MULTI DRUG RESISTANT TUBERCULOSIS ................. 81 8.2 EXTENSIVELY DRUG-RESISTANT TUBERCULOSIS (XDR-TB) ........ 82 8.3 TREATMENT OF MDR-TB .............................................................. 83 8.4 FOLLOW-UP OF MDR TB PATIENTS ............................................... 85 9 PREVENTION OF TB ............................................................. 86 9.1 MAIN GROUPS AT RISK ................................................................... 86 9.2 MEASURES OF PREVENTION ........................................................... 87 10 LEPROSY ................................................................................. 92 10.1 EPIDEMIOLOGY ............................................................................... 92 10.2 CASE-FINDING ................................................................................ 93 10.3 DIAGNOSTIC METHODS................................................................... 94 10.4 CASE DEFINITIONS ....................................................................... 108 10.5 SIGNS OF ACTIVE LEPROSY: .......................................................... 108 10.6 CHEMOTHERAPY .......................................................................... 109 10.6.1 PB-MDT regimen ................................................................ 110 10.6.2 MB-MDT regimen ............................................................... 111 10.6.3 Phases of chemotherapy ...................................................... 111 10.7 TREATMENT OF SPECIAL CASES .................................................... 114 10.8 ADVERSE EFFECTS OF MDT ......................................................... 114 10.9 FOLLOW-UP DURING TREATMENT................................................. 115 10.10 RETRIEVAL OF ABSENTEES ........................................................... 118 10.11 DEFINITIONS OF TREATMENT OUTCOMES ..................................... 118 10.12 COMPLICATIONS OF LEPROSY AND THEIR MANAGEMENT .............. 119 10.13 PREVENTION OF LEPROSY ............................................................. 128 10.14 RELAPSE ....................................................................................... 128 11 COMMUNITY PARTICIPATION IN TBL CONTROL ... 130 11.1 OBJECTIVES ................................................................................. 130 11.2 PROGRAM IMPLEMENTERS OF COMMUNITY-BASED CARE ............. 130 11.3 IMPLEMENTATION OF COMMUNITY BASED CARE .......................... 132 12 PUBLIC-PRIVATE MIX (PPM) IN TB CARE .................. 136 iv 12.1 RATIONALE FOR PPM IN ETHIOPIA ................................................. 136 12.2 EXPERIENCE OF PPM ETHIOPIA ...................................................... 137 12.3 A STEP BY STEP APPROACH FOR SCALIN UP PPM DOTS ................... 137 13 ADVOCACY COMMUNICATION