Dots

1. DOTS By JONATHAN ABISH DAVID 2 nd year MBBS

2. TUBERCULOSIS TB is caused by Mycobacterium tuberculosis TB can affect any organ system: bone, kidney, CNS; 80% are pulmonary

3. SYMPTOMS OF TUBERCULOSIS NIGHT SWEATS COUGH 2+WEEKS LOSS OF APPETITE FEVER WEIGHT LOSS FATIGUE

4. TB: A Global Emergency 1/3 of the world (2 billion people) infected 1 person infected/second resulting in >30 million new infections, 8 million new cases Left untreated 1/3 die, 1/3 self-cure, 1/3 remain infectious TB kills 1 person every 10 seconds = 5000/day = 2-3 million each year

5. Problem of TB in India Estimated incidence 1.96 million new cases annually 0.8 million new smear positive cases annually 75 new smear positive PTB cases/1lakh population per year Estimated prevalence of TB disease 3.8 million bacillary cases in 2000 1.7 million new smear positive cases in 2000 Estimated mortality 330,000 deaths due to TB each year Over 1000 deaths a day 2 deaths every 3 minutes

6. ANTI- TB DRUGS FIRST LINE SECOND LINE ISONIAZID THIOACETAZONE RIFAMPICIN PAS PYRAZINAMIDE ETHIONAMIDE ETHAMBUTOL CYCLOSERINE STREPTOMYCIN KANAMYCIN CAPREOMYCIN AMIKACIN NEWER DRUGS CIPROFLOXACIN OFLOXACIN CLARITHROMYCIN AZITHROMYCIN RIFABUTIN ISONIAZID RIFAMPICIN PYRAZINAMIDE ETHAMBUTOL

7. WHAT IS DOTS Directly Observed Therapy Shortcourse is a program to help cure TB. A DOT Lay Worker meets with clients to help with TB medication, and provide support and education . DOT by definition means watching clients swallow each dose of anti-TB medication  

8. Directly Observed Treatment Shortcourse Why? Many patients don’t take medicines regularly, even if excellent health education provided Who ? All patients... impossible to predict which patient will take medicine (1/3 not adherent) What ? Observer watches and helps patient swallow tablets Where ? Anywhere! (home, clinic, work, school, etc ) Who does it? HCW, community liaisons, teachers, Direct observation ensures treatment for entire course with the right drugs, in the right doses, at the right intervals

9. DIRECT OBSERVED TREATMENT SHORTCOURSE (DOTS) INTENSIVE PHASE ( 2-3 months) UNDER DIRECT SUPERVISION OF A HEALTH WORKER OR TRAINED PERSON CONTINUATION PHASE (4-6 months) A MULTIBLISTER COMBIPACK WITH DRUGS FOR 1 WEEK IS GIVEN OF WHICH THE FIRST DOSE IS TAKEN UNDER SUPERVISION

10. Global Situation Since 1995,over 21 million patients have been diagnosed and treated in DOTS programmes In 2007, 5.5 million new and relapse TB cases were initiated on treatment under DOTS strategy Of 2.5 million new smear positive patients registered in 2006, 85% were successfully treated under DOTS

11. DOTS Regimen Category Type of Patient Regimen Duration in months Category I Color of box: RED New Sputum Smear Positive New Sputum Smear Negative New Extra Pulmonary New Others 2 (HRZE) 3 , 4 (HR) 3 6 Category II Color of box: BLUE Sputum Positive relapse Sputum Positive failure Sputum Positive treatment after default 2 HRZES) 3 , 1 (HRZE) 3 5 (HRE) 3 8 Test at month 2 3 H-ISONIAZID R- RIFAMPICIN Z-PYRAZINAMIDE E- Ethambutol

12. Contd . Category Type of Patient Regimen Duration in months Category III Color of box: GREEN Sputum Negative, extra pulmonary not Seriously ill 2 (HRZ) 3 , 4 (HR) 3 6

13. DRUG DOSE ISONIAZID 600 mg RIFAMPICIN 450 mg PYRAZINAMIDE 1500 mg ETHAMBUTOL 1200 mg STREPTOMYCIN 750 mg DOSAGE

14. MULTI DRUG RESISTANT TB (MDR-TB) ATLEAST RESISTANT TO ISONIAZID AND RIFAMPICIN TREATMENT BASED ON DOTS – PLUS DOTS- PLUS INTENSIVE PHASE 6-9 MONTHS KANAMYCIN OFLOXACIN CYCLOSERINE ETHINAMIDE ETHAMBUTOL PYRAZINAMIDE CONTINUATION PHASE 18 MONTHS OFLOXACIN CYCLOSERINE ETHIONAMIDE ETHAMBUTOL

15. EXTENSIVELY DRUG RESISTANT TB ( XDR TB) Resistance to I soniazid and R ifampicin + resistance to any of the F luoroquinolones + resistance to any one of the injectible second line drugs

16. EXTREMELY DRUG RESISTANT TB (XDR TB) INTENSE PHASE (6-12 months) Caperomycin PAS Moxifloxacine Clofazimine Linezolid Amoxicillin / C lavulanate CONTINUATION PHASE (18 months) PAS Moxifloxacine Isoniazid Clofazimine Linezolid Amoxicillin / Clavulanate

17. DURING PREGNANCY The drugs Streptomycin, Fluoroquinolones , Ethionamide , Protionamide are avoided

18. DOSAGE FOR CHILDREN DRUGS Isoniazid Rifampicin Pyrizinamide Ethambutol streptomycin THERAPHY PER DOSE (THRICE A WEEK) 10-15 mg/kg 10 mg/kg 35 mg/kg 30 mg/kg 15 mg/kg

19. Advantages of DOTS The client is supported to successfully complete the full course of medication. The client is monitored closely for side effects of medications and supported to work through the side effects appropriately. The client is encouraged and supported to complete required check ups – blood work, chest x-rays, etc. Reduces the possibility of tb germs becoming resistant to the medication

20. Adverse reactions to anti-TB drugs Drugs Isoniazid Rifampicin pyrazinamide Adverse effects Peripheral neuropathy Hepatitis Vomitting , abdominal pain Hepatitis Joint pains , hepatitis

21. Drugs Ethambutol streptomycin Adverse effects Optic neuritis Renal damage Auditory & vestibular nerve damage

22. 2015