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Manual on Tuberculosis, HIV and Lung Diseases: A Practical Approach
Raksha Arora, VK Arora
1:
Evidence-based Medicine (EBM)
REFERENCES
Internet Resources:
NHS Public Health Resource Unit
Critical Appraisal and ‘How to’ Texts
EBM Journals and Summary Resources
SUMMARY
Standards for Diagnosis
Standards for Treatment
Standards for Public Health Responsibilities
Research Needs
Introduction
Purpose
Audience
Scope
Rationale
Companion and Reference Documents
Standards for Diagnosis
Standards for Treatment
Standards for Public Health Responsibilities
Research Needs
2:
Epidemiological Situation of Tuberculosis and its Trends in India
INTRODUCTION
METHODS TO MEASURE EPIDEMIOLOGICAL SITUATION OF TB AND ITS TRENDS
Epidemiological Indicators of TB
Prevalence of TB Disease
Definitions
Incidence of Disease
Annual Risk of TB Infection (ARTI)
TB Specific Mortality Rate
Other Methods of Monitoring Epidemiological Situation of TB
Mathematical Modeling
Routine Surveillance
EPIDEMIOLOGICAL BURDEN OF TB IN INDIA
Results of Community based Studies
Prevalence of TB
Incidence of TB
ARTI
TB Specific Mortality Rates
Present Magnitude of TB Disease
Prevalence of TB
Incidence of TB
TB-Specific Mortality Rate
EPIDEMIOLOGICAL TRENDS OF TB AND PROGRESS TOWARDS MILLENNIUM DEVELOPMENT GOALS (MDGS)
Trends, Observed from Community based Studies
Prevalence of TB
Incidence of TB
ARTI
Trends in TB-Specific Mortality Rates
Progress towards Millennium Development Goals (MDGs)
MONITORING EPIDEMIOLOGICAL TRENDS OF TB IN FUTURE
MESSAGES
3:
Global Progress towards TB Control Targets
INTRODUCTION
Control Strategy: Preventing Infection
Control Strategy: Stopping Progression from Infection to Active Disease
Control Strategy: Diagnosing and Treating Active Disease
Global targets for TB Control
GLOBAL PROGRESS IN IMPLEMENTING THE STOP TB STRATEGY
DOTS
Expansion and Enhancement
Political Commitment
Quality Assured Sputum Smear Microscopy
DOT (Directly Observed Treatment)
Drug Supply
Financing for TB Control
Monitoring and Surveillance
TB/HIV Coinfection, Multidrug Resistant TB (MDR-TB and Other Challenges)
HIV/TB Co-infection
MDR-TB
Contribution of the DOTS Strategy to Health System Strengthening (Integrating TB Control within Primary Health Care)
Engaging the Private Sector in TB Control
Empowering TB Patients and their Communities
Advocacy, Communication and Social Mobilization
Community Participation in TB Care
Operational Research
PROGRESS TOWARDS TB CONTROL TARGETS IN SEA REGION
TB INCIDENCE IN 2006 AND TRENDS SINCE 1990
THE FUTURE
4:
How to Measure Impact of TB Control
5:
Annual Risk of Tuberculous Infection as an Epidemiological Indicator in the Present Scenario
INTRODUCTION
USES OF ARTI AS AN EPIDEMIOLOGICAL INDICATOR
METHODOLOGY OF ESTIMATING ARTI
Objectives
Study Population
Sampling
Tuberculin
Training of Field Team
Field Procedures
Planning of Field Activities
Registration of Eligible Children
Tuberculin Testing
Reading of Tuberculin Reactions
Maintaining Standard of Field Work
Referral of Children
Tuberculin Testing of Sputum Smears Positive TB Cases
Analysis of Tuberculin Survey Data
Estimation of Prevalence of Tuberculous Infection
Computation of ARTI
Estimation of Trends in ARTI
LIMITATIONS OF TUBERCULIN SURVEYS
INTERPRETATION OF ARTI ESTIMATES
6:
Multidrug Resistant Tuberculosis: A Clinical Case Based Approach
INTRODUCTION
DEFINITION
MAGNITUDE OF PROBLEM
RISK FACTORS OF DRUG RESISTANCE
SOURCES AND CAUSES OF DRUG RESISTANCE
ISSUES IN DIAGNOSIS OF MULTI-DRUG RESISTANT TUBERCULOSIS
ISSUE IN TREATMENT OF MULTI-DRUG RESISTANT TUBERCULOSIS
Basic Principles of Chemotherapy in Multidrug Resistant Tuberculosis31–35
Drugs Used in MDR-TB and their Toxicities
Regimen for Multidrug Resistant Tuberculosis
RNTCP Category IV Regimen (Dots Plus)35,37
Duration of Treatment
Monitoring of Treatment
Adjuvant Therapies
Surgery
7:
Geriatric Tuberculosis in South East Asia Region
ETIO-PATHOGENESIS
HIV Infection
Co-morbid Medical Diseases like Diabetes Mellitus, Silicosis, Cancer or Renal Disease
Therapy with Immunosuppressive Drugs
Cigarette Smoking, Alcohol or Drug Abuse
Living in Migrant Camps, Homeless Shelters and Institutions
Stress
Genetic Susceptibility
MANIFESTATIONS
Case History
Diagnosis
Hematology
Sputum Microscopy
Tuberculin Skin Test
Chest Radiology
Culture and Sensitivity Techniques
Serological Methods
Molecular Biological Techniques
Miscellaneous Methods
Differential Diagnosis
Non-tubercular Pneumonia
Drug Resistant TB or Atypical Mycobacterial Infection
Carcinoma
Pulmonary Edema
Management
PREVENTION
8:
Paradoxical Response to Chemotherapy in Tuberculosis
INTRODUCTION
CLINICAL PRESENTATION
1. Tuberculous Lymphadenopathy
2. Tuberculous Pleurisy
3. Pulmonary Tuberculosis /Miliary tuberculosis
4. Central Nervous System Tuberculosis
CASE REPORT
PATHOGENESIS OF PARADOXICAL RESPONSE
DIAGNOSIS AND TREATMENT
9:
Challenges of Management of XDR-TB
INTRODUCTION
MAGNITUDE OF THE PROBLEM
CASE HISTORY
CHALLENGES OF XDR-TB
Public Health Threat
Diagnostic Issues
Drug Resistance Survey
Newer Anti-tuberculosis Drugs Development
TB Control Measures
Prevention of XDR-TB
Vaccination
Infection Control Measures
TB-HIV Co-infection Management
10:
Genomics of Tubercle Bacilli and its Clinical Relevance
INTRODUCTION
GENOME
GENOMICS
COMPARATIVE GENOMICS AMONG TUBERCLE BACILLI
COMPARATIVE GENOMICS AMONG CLINICAL STRAINS
PROTEOMIC STUDIES
FUNCTIONAL GENOMICS
NEW DEVELOPMENTS/CLINICAL RELEVANCE OF MYCOBACTERIAL GENOMICS
LIMITATIONS
FUTURE RESEARCH
11:
Cross-resistance among Anti-TB Drugs
12:
Tuberculosis in General Gynecological Practice: A Practical Approach
SYMPTOMATOLOGY
Differential Diagnosis
Diagnosis
Investigations in Genital TB
Endoscopy
Treatment (Table 12.4)
Medical Treatment
DOTS (Directly Observed Treatment Short Course Strategy) Treatment
Alternative Treatment (Non-DOTS)
Monitoring
Surgical Treatment
Laproscopic and Hysteroscopic Surgery and Tuboplasty
In vitro Fertilization (IVF)
13:
Miliary Tuberculosis
INTRODUCTION
Pathogenesis and Pathology
Clinical Features
Investigations
Tuberculin Skin Testing and Interfeon-gamma Immunological Test
Microbiological Studies
Chest Radiographs
High Resolution Computed Tomography (HRCT)
Ultrasonogram
Blood Studies
Urinary Findings
Pulmonary Function
Fiberoptic Bronchoscopy and Bronchoalveolar Lavage
Molecular Methods
Treatment
Miliary Tuberculosis and its Sequelae
Case History
Diagnosis: Miliary tuberculosis.
14:
Female Pelvic Tuberculosis: A Diagnostic and Management Challenge
INTRODUCTION
Case 1
Comments
Case 2
Comments
15:
Female Genital Tuberculosis
INTRODUCTION
PATHOPHYSIOLOGY
PATHOLOGY
Tuberculosis of Fallopian Tubes
Endometrial TB
Tuberculosis of Ovary
Tuberculosis of Cervix
Tuberculosis of Vulva and Vagina
CLINICAL FEATURES
PHYSICAL EXAMINATION
DIAGNOSIS
Endometrial Biopsy and Curettage
Rapid Molecular Techniques for Identifying and Detecting Mycobacterium Tuberculosis
RADIOLOGICAL EXAMINATION
X-ray Chest
Plain X-ray Abdomen
Ultrasonography
Hysterosalpingogram (HSG)
Urine Examination and IVP
Laparoscopy
Exploratory Laparotomy
COMPLICATIONS
Infertility
Ectopic Pregnancy
Congenital Tuberculosis
TREATMENT
Chemotherapy
Surgical Management
16:
Issues in Development of New Vaccines Against Tuberculosis
17:
New TB Drugs Development
WHY NEW ANTI TB DRUGS?
Strategies to Find New Drugs
Improve Existing Agents
Develop Broad Spectrum Antibacterial Agents
Find New Chemical Entities Active against M. tuberculosis
TB Drug Development Process
NEWER ANTI-TB DRUGS IN DEVELOPMENT
Moxifloxacin
Mechanism of Action
Clinical Research
PA-824
Mechanism of Action
Clinical Research
Riminophenazines
Mechanism of Action
Clinical Research
Nitromidazole Analogs
Mechanism of Action
Clinical Research
Multifunctional Molecules
Mechanism of Action
Clinical Research
Quinolone Analogs
Mechanism of Action
Clinical Research
InhA Inhibitors
Mechanism of Action
Clinical Research
Pleuromutilins
Mechanism of Action
Mycobacterial Gyrase Inhibitors
Clinical Research
Malate Synthase Inhibitors
Clinical Testing of Drug Candidates
18:
Advocacy, Communication and Social Mobilization—Tools and Benefits
INTRODUCTION
TOOLS
Benefits
Benefits of Advocacy
Benefits of Communication and Social Mobilization
SUCCESS STORIES
DANTB Communication and Education Project in Orissa, India25
Women Volunteers as DOTS Care Providers in Myanmar26
Community based TB Care Projects in Montero, Bolivia27
19:
Advances in Sputum Smear Microscopy
20:
Advances in the Laboratory Diagnosis of Tuberculosis
21:
Conventional and Automated Detection of Acid Fast Bacilli
INTRODUCTION
Detection of AFB-historical Background
Conventional Detection of AFB
Digestion and Decontamination Procedures
Microscopic Examination
Culture
Drug Susceptibility Testing
Identification
22:
Expanding Liquid Culture System for Tuberculosis
INTRODUCTION
EXISTING KNOWLEDGE
SHORTCOMINGS AND LIMITATIONS
RECENT DEVELOPMENTS/UPDATES/PROGRESS
PROCESSING FOR CULTURE
BENEFITS/ADVANTAGES
23:
Drug Susceptibility Testing for Second-line anti-TB Drugs in LJ Medium
BACKGROUND
MATERIALS REQUIRED
PREPARATION OF DRUG CONTAINING LJ MEDIA
PREPARATION OF STANDARD SUSPENSION
INOCULATION PROCEDURE
READING THE LJ SLOPES
INTERPRETATION OF RESULTS
QUALITY CONTROL OF DRUG MEDIA
QUALITY CONTROL OF RESISTANCE CRITERIA USED IN THE LABORATORY
24:
Biosafety in Mycobacteriology
INTRODUCTION
Risk Assessment for M.tuberculosis
Risk Assessment of Microbiological Techniques Leading to Infection
Basic Laboratory Practices
Health and Medical Surveillance
BIO-SAFETY LEVEL 3 FACILITY SAFEGUARDS FOR THE CONTAINED USE OF M. TUBERCULOSIS
I. Laboratory Design and Equipment
II. Laboratory Work with M. tuberculosis Positive Clinical Specimens and Cultures
III. Infected Animals with M. tuberculosis Complex Species
Biological Safety Cabinets and Containment
Guidelines for Proper use of a Class II Safety Cabinet
Disinfection, Inactivation of M. tuberculosis and Waste Management
Disposal of Biomedical Waste Generated in the Laboratory as per RNTCP Laboratory
LABORATORY BIOSAFETY INTERIM GUIDELINES FOR XDR M. TUBERCULOSIS STRAINS
Infection Control in Health Care Workers and RNTCP
Conclusion
25:
HIV-TB Coinfection
TREATMENT OF HIV-ASSOCIATED TB
CONCOMITANT TB/HIV INFECTION MANAGEMENT ISSUES
TREATMENT-SHORTENING STRATEGIES
ADJUNCTIVE THERAPY
Cotrimoxazole
Micronutrient Supplementation
Immunomodulation
COLLABORATIVE ACTIVITIES BETWEEN TB AND HIV/AIDS CONTROL PROGRAMS
RESEARCH PRIORITIES
THE WAY FORWARD
Acknowledgments
Establish the Mechanisms for Collaboration
Decrease the Burden of TB among People Living with HIV/AIDS
Decrease the Burden of HIV Infection among Patients with TB
26:
HIV Related Lung Diseases in Children
INTRODUCTION
EPIDEMIOLOGY
Pulmonary Tuberculosis
Infection with Mycobacteria Other than Tuberculosis (MOTT)
Bacterial Pneumonias
Pneumocystis Jerovecci Pneumonia
Viral and Fungal Pneumonias
Lymphoid Interstitial Pneumonitis (LIP)
Immune Reconstitution Inflammatory Syndrome (IRIS)
Bronchiectasis
Chronic Respiratory Diseases
Pulmonary Malignancies
27:
Universal Work Precautions and Post-exposure Prophylaxis (PEP) for HIV following Needle Stick Injury
PATHOGENESIS OF HIV INFECTION
EXPOSURES PRESENTING A RISK FOR TRANSMISSION
Measures to Decrease the Risk of Exposure to HIV
Importance of Universal Precautions
Universal Precautions
Protective Barriers
Safe Handling of Sharps
Ensuring Universal Precautions
Understanding of Universal Precautions by HCWs
Reduce Unnecessary Procedures
Make Adequate Supplies Available
Ensure Adherence to Universal Precautions
RATIONALE FOR ADMINISTERING PEP
Epidemiologic Studies
Clinical Studies
Animal Studies
POST-EXPOSURE PROPHYLAXIS (PEP) FOLLOWING NEEDLE STICK INJURY
Exposure Reporting
Management of Exposure Site
Clinical Evaluation
Assessment of Exposure and Source Patient
Initial Assessment of Exposure
Selecting a Chemoprophylaxis Regimen
Adherence to Prophylaxis Regimen
Follow-up
Side Effects/Toxicity
Advisability of Expert Consultation
Pre-exposure Prophylaxis (PrEP)
Prevention
Care, Support and Treatment
Impact Mitigation
Programme Management
Monitoring and Evaluation
28:
Radiology of TB, HIV and Lung Health
EXAMINATION TECHNIQUE AND NORMAL FINDINGS
RADIOLOGY OF TUBERCULOSIS
Introduction
PULMONARY TUBERCULOSIS
Primary Tuberculosis
Postprimary Tuberculosis
CARDIAC TUBERCULOSIS
SKELETAL TUBERCULOSIS
Tuberculous Spondylitis(Pott Disease)
Extraspinal Tuberculous Osteomyelitis
TUBERCULOUS ARTHRITIS
GASTROINTESTINAL TUBERCULOSIS
Ileocecum and Colon
Peritoneum
Lymph Nodes
Liver and Spleen
TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM
Meningeal Involvement
Parenchymal Involvement
RADIOLOGY OF HIV (AIDS)
Pneumocystis Carinii Pneumonia (PCP)
Radiographic Findings
BACTERIAL PNEUMONIA
MYCOBACTERIAL INFECTION
Mycobacterium Tuberculosis (MTB)
Mycobacterium Avium Intracellulare (MAI)
FUNGAL INFECTION
Cryptococcal Neoformans
NONINFECTIOUS PULMONARY DISEASE IN AIDS
Kaposi's Sarcoma
LYMPHOMA
LUNG HEALTH
Pneumonia
Goals of Diagnostic Imaging in Pneumonias
Pathology
Radiologic Findings
Plain Chest Radiograph
Lobar Pneumonia
Bronchopneumonia
Interstitial Pneumonia
CT Scan Findings
EMPHYSEMA
Radiologic Findings
Plain Chest Radiograph
CT Scan Findings
BRONCHIECTASIS
Radiologic Findings
CT Scan findings
CHRONIC BRONCHITIS
Radiologic Findings
CT Scan Findings
29:
Magnitude of the Problem of Smoking in South-East Asia
INTERNATIONALLY COMPARABLE ESTIMATES OF SMOKING PREVALENCE IN SOUTH EAST ASIA
Global Youth Tobacco Survey
COUNTRYWISE PROFILE OF SMOKING IN SOUTH-EAST ASIA REGION
Bangladesh
India
Indonesia
Thailand
Korea
30:
Smoking and Tuberculosis
INTRODUCTION
SMOKING AND PULMONARY TUBERCULOSIS
Smoking and Tuberculin Reactivity
Smoking and Tuberculosis Disease
Pulmonary Tuberculosis
Extrapulmonary Tuberculosis
Smoking and Death due to Tuberculosis
DOSE RESPONSE RELATIONSHIP
Tuberculin Reactivity
Tuberculosis Disease
Tuberculosis Death
EFFECT OF SMOKING CESSATION
Latent Tuberculosis Infection (LTBI)
Tuberculosis Disease
Tuberculosis Death
EFFECT OF CONFOUNDERS
Socioeconomic Conditions
Alcohol Use
Human Immunodeficiency Virus (HIV)
EFFECT ON CASE MANAGEMENT
Default from Treatment
Relapse after Treatment
Severity of Disease
ENVIRONMENTAL TOBACCO SMOKE
Tuberculin Reactivity
Tuberculosis Disease
Tuberculosis Death
DRUG RESISTANCE
POSSIBLE BIOLOGICAL MECHANISMS
Indirect Mechanisms
Cholinergic Anti-inflammatory Pathway
Other Direct Mechanisms Postulated
Increased Reactivation of Tuberculosis
CONCLUSION
31:
Tobacco Cessation: A Clinical Topic
INTRODUCTION
Benefits of Tobacco Cessation
Long Term Benefits of Tobacco Cessation
Case History I
Addiction
Measuring the Severity of Addiction
Cessation
Dealing with ‘Failure’
Types of NRT
Case History II
CESSATION PRACTICES IN INDIA
32:
Pharmacology of Smoking Cessation
INTRODUCTION
NEUROBIOLOGY OF SMOKING13
PHARMACOTHERAPY
NICOTINE REPLACEMENT THERAPY (NRT)
Gum
Lozenge
Patch
Inhaler
Nasal Spray
BUPROPION
VARENICLINE
CLONIDINE
NORTRIPTYLINE
OTHER MEDICATIONS
NEWER DRUGS
COMBINATION THERAPY
COMBINATION OF PHARMACOTHERAPY AND COUNSELING
RELATIVE EFFECTIVENESS OF MEDICATIONS
EXTENDED THERAPY
DRUG INTERACTIONS
CLINICAL MANAGEMENT OF THE SMOKER
33:
Recent Advances in COPD—Indian Perspective
DEFINITION
EPIDEMIOLOGY
Diagnosis
1. Suspecting COPD
2. Establishing the Diagnosis
3. Staging of Severity
4. Diagnosis of Complications
i. Acute Exacerbation of COPD
ii. Chronic cor Pulmonale
iii. Chronic Respiratory Failure
iv. Other Complications
5. Systemic Manifestations
Case History
Commentary
Management (Table 33.1)
A. Initial Treatment Measures
1. Bronchodilator Therapy
2. Glucocorticoids
3. Antibiotics
4. Management of Respiratory Failure and Other Complications
B. Long-term Management
1. Risk Factor Reduction
2. Patient Education
3. Pharmacotherapy
4. Long-term Oxygen Therapy (LTOT)
5. Domicilliary Ventilatory Support
6. Vaccinations
7. Rehabilitation
The Indian Perspective of COPD Management
34:
Constraints of Management of COPD in Resource Limited Countries
INTRODUCTION
REVIEW OF LITERATURE AND EPIDEMIOLOGY
Risk Factors
Tobacco Smoke
Solid Fuel Combustion
Outdoor Air Pollution
Occupational Pollutants
Other Risk Factors
Limitations of Managing COPD with Limited Resources
RAMPANT SMOKING PREVALENCE EVEN AMONG YOUNGSTERS
Increasing Environmental Pollution
Lack of Diagnostic Facilities (Spirometry) and Prevalence of TB
Lack of Buying Power of the Patient
Salient Features for Treatment of COPD with Limited Resources
NO NATIONAL PROGRAM
CASE HISTORIES
Case 1
Flow Volume Loop
Case 2
CONCLUSION
35:
Critical Respiratory Care in Avian Influenza Patients in Resource Limited Countries
INTRODUCTION
DEFINITION
INITIAL ASSESSMENT AND STABILIZATION OF PATIENT IN ACUTE VENTILATORY FAILURE
Assessment
Emergency Management Considerations
PRINICIPLES OF MANAGEMENT OF ACUTE VENTILATORY FAILURE
Respiratory Care Includes
OXYGEN THERAPY EQUIPMENT
VENTILATORY SUPPORT: Positive pressure ventilation INDICATIONS (TABLE 35.1)
Noninvasive Mechanical Ventilation
Indication for NIV (Figs 35.4 and 35.5)
Non Invasive: Advantages
Resource Limiting Countries: Cost Considerations
Requirement for Successful NIV
Disadvantages/Limitations
Type of Mask
Type of Ventilators
Modes of Ventilation
Invasive Positive Pressure Mechanical Ventilation
Care of Patients Requiring Ventilation
Tracheal Intubation: Considerations
Ventilator Settings (Table 35.2)
SEDATION AND PARALYSIS
Ventilatory Support: Practical Management Guidelines
Positive Airway Pressure Therapy: PEEP/CPAP
Discontinuation of Mechanical Ventilation
Clinical Parameters
Objective Respiratory Parameters for Weaning
Methods of Weaning
Role of Nursing and Paramedical Staff in Treating AVF
Other Respiratory Care Techniques
COPD and C3 Critical Care
Suggested Algorithm for Ventilatory Management of Acute Exacerbation of COPD
ARDS and Critical Care
Other Supportive Measures
36:
Critical Care in Respiratory Failure
INTRODUCTION
HISTORY AND EPIDEMIOLOGY
Existing Knowledge
Respiratory Causes of Admission to ICU
Oxygen Therapy
NIPPV
NIPPV Protocol
Mechanical Ventilation
Indicators of Respiratory Distress
Indications of Endotracheal Intubation and Mechanical Ventilation14
Airway Management
Recommendations for the Process of Intubation15
Potential Problems During Intubation
Role of Tracheostomy in ICU
Ventilatory Strategy
Ventilatory Strategey in COPD
Case Scenario
Method of Ventilation
Case Scenario
Monitoring
Monitoring of Ventilation
Weaning from the Ventilator
Patient Assessment
Weaning Modes
T-Piece and CPAP Trial
SIMV with PS Trial
Other Aspects of Respiratory Critical Care
Humidification
Physiotherapy
Position
Pharmacological Adjuncts
Sedation
Indications for Muscle Relaxants
Recent Developments in Ventilatory Management of ALI and ARDS
Future Challenges
Conclusion
37:
COPD—Definition and Management
EVOLUTION OF DEFINITION OF COPD
EPIDEMIOLOGY: PREVALENCE, MORBIDITY, MORTALITY AND ECONOMIC BURDEN
RISK FACTORS
Exposures to Particles and Gases (Smoking, Occupational, Air Pollution)
Genetic Factors, Gender, Age, Socioeconomic Status and Nutrition
PATHOPHYSIOLOGY OF COPD
CLINICAL PRESENTATION
INVESTIGATIONS TO CONFIRM DIAGNOSIS AND INITIAL EVALUATION
Pulmonary Function Tests
Radiological Evaluation
Arterial Blood Gases and Pulse Oximetry
CLASSIFICATION
COMPONENTS OF MANAGEMENT
Pharmacological Therapy
Nonpharmacological Management
Pulmonary Rehabilitation
Use of Oxygen
Noninvasive Ventilation
Surgery
WHAT'S NEW IN GOLD 2007
CLINICAL CASES
Case 1
Comments
Case 2
Comments
38:
Constraints of Management of Bronchial Asthma in Resource Limited Countries
INTRODUCTION
REVIEW OF LITERATURE AND EPIDEMIOLOGY
RISK FACTORS
LIMITATIONS OF MANAGING ASTHMA WITH LIMITED RESOURCES
Indiscriminate Use of Tobacco
Increasing Environmental Pollution Due to Uranisation
Change in Dietary Pattern
Lack of Diagnostic Facilities (Spirometry)
Lack of Buying Power and Inhibitions of the Patient
No National Program
CASE STUDIES
Case 1
Case 2
CONCLUSION
39:
Epidemiology of Obstructive Sleep Apnea
INTRODUCTION
EPIDEMIOLOGY
Descriptive Studies
Analytic Studies
Observational
Interventional
OBSTRUCTIVE SLEEP APNEA; DEFINITION EPIDEMIOLOGICAL VS. CLINICAL
PREVALENCE OF OBSTRUCTIVE SLEEP APNEA
RISK FACTORS (PREDICTORS) OF OSA
Demographic Factors
Age
Gender
Ethnicity
Alcohol
Smoking
Clinical Features
Obesity
Craniofacial Anatomy
Nasal Obstruction
Upper Airway Dimensions
Pharyngeal Collapsibility
CONSEQUENCES OF OBSTRUCTIVE SLEEP APNEA
Hypertension
Cardiac
Cardiac Arrhythmias
Ischemic Heart Disease
Heart Failure
Neurological and Neuropsychological
Sleepiness
Cognitive Functions
Driving and Road Traffic Accidents
Stroke
METABOLIC SYNDROME, INSULIN RESISTANCE AND DIABETES MELLITUS
40:
Lung Cancer
INTRODUCTION
Lung Cancer in India
ETIOLOGY OF LUNG CANCER
Smoking
Passive Smoking
Occupational Risks
Diet
Air Pollution
Chronic Lung Diseases and Lung Cancer
Other Host Factors and Lung Cancer
Familial Predisposition to Lung Cancer
Oncogenes and Lung Cancer
HISTOLOGICAL CLASSIFICATION OF LUNG CANCER
Clinical Features
Chest Skiagram
CT Scan
Mediastinoscopy
Magnetic Resonance Imaging (MRI)
Radionuclide Scans
PET Scanning
Cytology
Sputum
Bronchial Washings and Brushings
Bronchoscopy
Hematological and Biochemical Investigation
Tumor Markers/Products
STAGING OF LUNG CANCER (TABLE 40.9)
TNM—Tumor, Node, Metastasis
Functional Evaluation
MANAGEMENT OF LUNG CANCER
Small Cell Lung Cancer
Radiotherapy
Surgery
Immunotherapy and Others
Non-Small Cell Lung Cancer (NSCLC) Surgery
Radiotherapy
Indications
Chemotherapy
Molecular Targeted Therapy
41:
Stem Cell Therapy in Pulmonary Medicine
INTRODUCTION
Embryonic and Adult (somatic) Stem Cells
Cell Compartments in the Lung and Functional Integration
Stem Cell Plasticity and the Lung
Migration, Targeting and Engraftment
Effects of Stem Cell Engraftment in the Lung
THERAPEUTIC POSSIBILITIES
Embryonic Stem Cells
Challenges for Lung Regenerative Medicine
42:
Investigation of Tuberculosis Outbreaks including MDR
INTRODUCTION
Definition for TB Outbreak
Criteria is based on Surveillance and Epidemiology
Suspected TB Outbreak
Initiating the Outbreak Response Plan (ORP)
Goals of Outbreak Repsonse
Legal Authority
Reporting of a TB Outbreak
TB Outbreak Response Team Members
TB Outbreak Response Team Responsibilities
Notifying of a TB Case Cluster
Predicting Tuberculosis Outbreaks Based on the First 2 Cases
Characteristics of Outbreaks
Traditional and Molecular Biological Tools in Outbreaks
Active Screening in Special Situations
Novel Diagnostic Methods in Outbreaks
Outbreaks in High-Incidence Areas
Outbreaks in Low-Incidence Areas
CT Scan of Chest in Outbreaks
Social Networks in Outbreaks
Recent Developments
ANNEXURES
Contents
Introduction
ANNEXURE 1.1: BACKGROUND
Chapter Objectives
Recent Developments
Prevention of MDR-TB
Expansion of the DOTS Package
Introduction of DOTS-Plus
Integration of TB services
Causes of Drug-resistant Tuberculosis
Addressing the Sources of MDR-TB
Magnitude of the MDR-TB Problem in India
Drug Resistance
Multi-drug Resistant Tuberculosis and DOTS-Plus
Special Considerations for DOTS-Plus
ANNEXURE 1.2: FRAMEWORK FOR EFFECTIVE CONTROL OF MULTIDRUG-RESISTANT TUBERCULOSIS
Chapter objectives
The DOTS-Plus framework for the management of multidrug-resistant TB
Sustained political and administrative commitment
Diagnosis of drug-resistant TB through quality assured, timely culture and DST
Appropriate treatment strategies utilizing second-line anti-TB drugs under appropriate management conditions
Uninterrupted supply of quality-assured second-line drugs
A recording and reporting system designed for DOTS-plus
Summary
ANNEXURE 1.3: GOVERNMENT COMMITMENT AND COORDINATION
Chapter objectives
General considerations
Political commitment
Sufficient Economic Support
Regulatory and operational documents
Coordination
Summary and a check list
ANNEXURE 1.4: CASE-FINDING AND DEFINITIONS
Chapter objectives
Case finding strategy
Case finding strategy
Drug Resistant Cases
Bacteriology
Treatment outcome definitions for RNTCP DOTS-Plus patients
Cohort analysis
ANNEXURE 1.5: DIAGNOSIS AND EVALUATIONS
Chapter objectives
Patient flow (refer to Figure A1.4.1)
Culture and DST
Diagnostic examination
Follow-up smear and culture schedule during treatment
Pre-treatment evaluation
Monitoring progress during treatment
Clinical monitoring
Investigations during treatment
ANNEXURE 1.6: LABORATORY ASPECTS
Chapter objectives
General considerations
Organization and development of the laboratory network
Job Responsibilities under DOTS-Plus
Culture of sputum specimens
Specimen collection
Homogenisation and decontamination
Digestion and decontamination procedures
PROCESSING OF SPUTUM SPECIMENS CONTAINING CPC and NaCl
Inoculation and incubation
Culture examination and identification
Examination schedule
Reading of cultures
Recording and reporting of laboratory results
Identification tests
Drug susceptibility tests
DST methods
Quality assurance programme
Proficiency testing
Accreditation of IRLs for Culture and DST under RNTCP
ANNEXURE 1.7: TREATMENT OF MULTI-DRUG RESISTANT TUBERCULOSIS
Chapter objectives
Referral of a confirmed MDR-TB case to indoor facility at the DOTS-Plus site
Deciding on treatment
Classes of anti-TB drugs
Category IV regimen
Drug dosages and administration
Treatment Duration
Treatment Outcomes
Providing patient and family counseling
ANNEXURE 1.8: MDR-TB IN SPECIAL SITUATIONS
Chapter objectives
MDR-TB in pregnancy3–7
MDR-TB with co-Infected HIV Infection8–13
MDR-TB requiring surgery14–17
MDR-TB in patients with renal impairment18
MDR-TB in patients with pre-existing liver disease19
MDR-TB in patients with seizure disorders19, 20
MDR-TB in patients with psychosis21, 22
Management of contacts of MDR-TB23–27
ANNEXURE 1.9: MONITORING AND MANAGEMENT OF ADVERSE DRUG REACTIONS
Chapter objective
Monitoring for early detection of adverse reactions
Common adverse reactions to the drugs used
Aminoglycosides – Kanamycin and Amikacin
Quinalones/Ofloxacin8,9
Ethambutol
Pyrazinamide
Ethionamide
Cycloserine10
PAS
Adverse effects, suspected drugs, and management strategies
Gastrointestinal symptoms (nausea and vomiting)
Giddiness
Ocular toxicity
Renal toxicity
Renal toxicity
Cutaneous reactions
Hepatitis
Neurological symptoms
Psychiatric disturbances11
Vestibuloauditory disturbances
Hypothyroidism
Role of DOTS-Plus committee in the management of adverse reactions
ANNEXURE 1.10: TREATMENT DELIVERY AND ADHERENCE
Chapter objectives
Education of patients and their families
Treatment delivery settings
Initial in-patient care
Ambulatory care
Adherence
Directly observed therapy
Who can deliver DOT for MDR-TB patients?
Maintaining confidentiality
Socioeconomic interventions
Social and emotional support
Follow-up of the non-adherent patient
Early and effective management of adverse drug reactions
ANNEXURE 1.11: HUMAN RESOURCE DEVELOPMENT FOR DOTS-PLUS UNDER RNTCP
Chapter Objectives
General considerations
Challenges in HRD for DOTS-Plus
Quality: Skills of existing staff
Quantity: Positioning of staff
Framework for HRD
The long-term goal for HRD for DOTS-Plus
Challenges for RNTCP in reaching the goal
System for HRD for DOTS-Plus
ANNEXURE 1.12: LOGISTICS OF SECOND-LINE ANTI-TB DRUGS
Chapter objectives
RNTCP Category IV regimen: second-line anti-TB drugs
Drug management cycle of second-line anti-TB drugs
ANNEXURE 1.13: RNTCP DOTS-PLUS RECORDING AND REPORTING SYSTEM
Chapter objectives
Aims of the information system
Scope of the information system
Records, reports and flow of information
DOTS-Plus treatment card (Annexure VIII)
RNTCP DOTS-Plus Register (Annexure IX)
Patient Identity Card (Annexure X)
Request forms for sputum examination, culture and DST (Annexure I)
Laboratory registers
Quarterly report of Category IV (DOTS-Plus) case finding (Annexure XI)
Six Month Interim Report (Annexure XII)
Culture conversion Report of Category IV Cases (Annexure XIII)
Treatment Outcome Report of Category IV Cases (Annexure XIV)
Computerized systems
Training
ANNEXURE I: RNTCP REQUEST FOR CULTURE AND DRUG SENSITIVITY TESTING
ANNEXURE II HISTORY OF ANTI-TUBERCULAR DRUGS
ANNEXURE III: REFERRAL FOR DST REGISTER, HELD AT THE DTC
ANNEXURE IV:IRL CULTURE AND DST REGISTER
ANNEXURE V: REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
ANNEXURE VI: FOLLOW-UP SCHEDULE DURING CATEGORY IV TREATMENT
ANNEXURE VII: CHECKLIST FOR INITIAL EVALUATION AND TREATMENT SURVEILLANCE
Initial Evaluation
Routine Surveillance
During treatment
ANNEXURE VIII: RNTCP DOTS-PLUS TREATMENT CARD
ANNEXURE IX: RNTCP DOTS-PLUS TREATMENT REGISTER
RNTCP DOTS-Plus Treatment Register (Page1)
RNTCP DOTS-Plus Treatment Register (Page2)
ANNEXURE X:PATIENT IDENTITY CARD
ANNEXURE XI: RNTCP QUARTERLY REPORT ON CATEGORY IV CASE FINDING
ANNEXURE XII:RNTCP DOTS-PLUS SIX MONTH INTERIM REPORT
ANNEXURE XIII: RNTCP DOTS PLUS 12 MONTH CULTURE CONVERSION REPORT
ANNEXURE XIV: REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
ANNEXURE XV: EVALUATION AT COMPLETION OF CATEGORY IV TREATMENT
ANNEXURE XVI: ROLES OF THE VARIOUS FACILITIES UNDER RNTCP DOTS-PLUS
ANNEXURE XVII: JOB RESPONSIBILITIES FOR VARIOUS CATEGORIES OF STAFF UNDER DOTS-PLUS
ANNEXURE XVIII: SECOND-LINE ANTI-TB DRUG INFORMATION SHEETS
CYCLOSERINE (Cs)
KANAMYCIN (Km)
OFLOXACIN (Ofl)
ETHIONAMIDE (Eto)
Para-Aminosalicylate (PAS)
INTRODUCTION
OBJECTIVES
2. SERVICE DELIVERY COORDINATION AND CROSS REFERRAL
Intensified TB/HIV Package of Services
2.1 Training of Programme Officials and Field Staff on TB/HIV
2.2 Intensified TB case finding at ICTCs, ART, and Care and Support Centres
ICTCs
ART Centres
Care and Support Centres
2.3 Risk-based Referral of TB patients for HIV counselling and testing
2.4 Referral of HIV-infected TB patients to NACP for additional care and support, including antiretroviral treatment
2.5 Routine referral of all TB patients for HIV counselling and testing
2.6 Provision of cotrimoxazole preventative treatment (CPT) for HIV-infected TB patients through the general health system
2.7 Documentation of TB-HIV collaborative activities
3. ADVOCACY, COMMUNICATION AND SOCIAL MOBILIZATION AND INVOLVEMENT OF NGOS WORKING IN NACP AND RNTCP IN TB/HIV COLLABORATIVE ACTIVITIES
3.1 IEC Activities
3.2 Spectrum of Activities that may be Undertaken by NGOS
4. OPERATIONAL RESEARCH TO IMPROVE THE IMPLEMENTATION OF TB/HIV COLLABORATIVE ACTIVITIES
5. INFECTION CONTROL PRACTICES
5.1 Prevent Spread of TB In Facilities Caring For HIV-infected Persons
5.2 Prevent Spread of HIV through Safe Injection Practices in Facilities Providing RNTCP Services
ANNEXURE I: STATE TB-HIV CO-ORDINATION COMMITTEE
Scope of Work of the Committee
Terms of Reference
ANNEXURE II: DISTRICT TB/HIV COORDINATION COMMITTEE
SCOPE OF WORK OF THE COMMITTEE
ANNEXURE III
ANNEXURE IV: SIMPLIFIED REPORTING FORMAT
ANNEXURE V: STANDARD REPORTING FORMAT
ANNEXURE VI: LINE-LIST OF PERSONS REFERRED FROM ICTC TO RNTCP
ANNEXURE VII: INTENSIFIED TB CASE FINDING AT ART CENTRES
Provisional Guidance from NACP and RNTCP
Rationale
WHAT to do
Symptoms
TB diagnosis and treatment
Recording
Supervision
INTENSIFIED TB CASE FINDING AT ART CENTRES
Provisional Guidance from NACP and RNTCP
ANNEXURE VIII: COMPILED STATE REPORTING FORMAT—STANDARD REPORTING STRUCTURE
ANNEXURE IX: COMPILED STATE REPORTING FORMAT—SIMPLIFIED REPORTING STRUCTURE
Contents
3.1: INTRODUCTION
3.2: GUIDELINES FOR SERVICE PROVIDERS
The Goal and Objectives of NACP
Goal
Objectives
Objectives of ART Centers
Functions of ART Center
Medical Functions
Psychological Functions
Social Functions
Eligibility Criteria for Setting-up ART Center
Feasibility Assessment for ART Centers
Preparedness of Institution
Infrastructure
Location and Access to ART Center
Space for ART Center
Furniture and General Equipment
Medical Equipment and Accessories
CD 4 Machines
Computers and Audio—Visual Equipemnt
Human Resources
ART Team
Trained Institutional Faculty
Human Resources and their Job Responsibilities
Drugs and Medicines
ARV Drugs
Drugs for Opportunistic Infections
Linkages and Referrals
Referrals within the Institute
HIV/TB Coordination
Patient Flow for DOTs
Antituberculosis Therapy and Antiretroviral Therapy (ART)
Referrals Outside the Institutions
Community Care Centers
Monitoring and Evaluation
Monitoring Tools
Recording Information
Reporting, Data Transmission and Analysis
Communication Tools
Responsibility of the SACS
Responsibilities of Nodal Officer for ART at SACS
Supply and Monitoring of ARV Drugs
Documents, Guidelines and Monitoring Tools
Increase in Coverage of ART
Financial Management
Bank Account
Audit of Accounts
Guidelines for Expenditure
3.3: PATIENT FOCUSED GUIDELINES
Disease Stages
Stage 1: From Seeking Health Care to Diagnosis
Stage 2: Process from Diagnosis till Need for ART
Stage 3: Process from Decision to Start ART
Confidentiality and Discrimination Issues
Supports from NGOs and Positive Network Groups
3.4: STANDARD OPERATING PROCEDURES (SOP)
Entry into HIV Care
Flow of Patient at the ART Center
The Initial Visit
The Second Visit
Visit After ART is Started (After 2 weeks of NVP Initiation)
The Medical Officer
Subsequent Follow-ups Visits (Once a Month)
Counsellor
Staff Nurse
Doctor (SMO/MO)
Further Follow-up Visits
3.5: PUBLIC PRIVATE PARTNERSHIP ON ART
Expansion of ART Programme to NGO/PSUs/Corporate Sector/Trust/Charitable Hospitals
Responsibilities of NACO
II. Responsibilities Of NGO/Corporate/PSUs
Selection of NGO/Trust/Charitable organisation for PPP
ANNEXURE I
ANNEXURE II
ANNEXURE III
Major signs
Minor signs
ANNEXURE IV
Clinical stage 1
Clinical stage 2
Clinical stage 3
ANNEXURE V: TRAINING SCHEDULE FOR ART MEDICAL OFFICERS
Day 1-Monday:
Day 2-Tuesday:
Day 3-Wednesday:
Day 4-Thursday:
Day 5-Friday:
Day 6-saturday:
Day 8-Monday:
Day 9-Tuesday:
Day 10-Wednesday:
Day 11-Thursday:
Day 12-Friday:
Day 13-saturday:
ANNEXURE VI: AGREEMENT BETWEEN NATIONAL AIDS CONTROL ORGANISATION (NACO) GOVERNMENT OF INDIA AND XXYYZZ (NAME OF NGO AND PLACE)
NOW THEREFORE THIS AGREEMENT WITNESSES AS FOLLOWS
I. Purpose of Collaborative ART Project
II. Responsibilities of NACO
III. Responsibilities of XXYYZZ
IV. Commencement
V. Renewal of Agreement
VI. Termination of Agreement
VII. Breach by XXYYZZ
VIII. Settlement of Disputes
LAW APPLICABLE
IX. Adreses for Correspondence
NOW THEREFORE THIS AGREEMENT WITNESES AS FOLLOWS
I. Purpose of Collaborative ART Project
II. Responsibilities of NACO
III. Responsibilities of XXYYZZ
IV. Commencement
V. Renewal of Agreement
VI. Termination of Agreement
VII. Breach By XXYYZZ
VIII. Settlement of Disputes
LAW APPLICABLE
IX. Adreses for Correspondence
ANNEXURE VII: FORMAT TO ASSESS THE PREPAREDNESS OF AN ART CENTER
IV Patient Interview at the center
ART Patient Satisfaction Form (New Patients)
ANNEXURE I
Disposal of Sputum Container with Specimen and Wooden Sticks
Disposal of Used Syringes/Needles/Broken Vials
Disposal of Stained Slides
ANNEXURE II
Standard (Universal) Precautions
Hand Washing
Barrier Protection
Safe Handling of Sharps
Safe Handling of Specimen
Safe Handling of Blood/Body Fluids Spills
Use of Disposable Sterile Items
ANNEXURE III
INTRODUCTION
CONTENTS
ACSM SCHEME: TB ADVOCACY, COMMUNICATION AND SOCIAL MOBILIZATION
INTRODUCTION
Eligibility
Role of NGO
Role of RNTCP (DTO/STO)
Illustration
SC SCHEME: SPUTUM COLLECTION CENTRES
INTRODUCTION
Eligibility
Role of NGO/Collaborating partner
Role of RNTCP (DTO/STO)
Grant-in-aid: Rs. 60,000 per annum, per centre
TRANSPORT SCHEME: SPUTUM PICK-UP AND TRANSPORT SERVICE
INTRODUCTION
Eligibility
Role of NGO/Collaborating partner
Role of RNTCP (DTO/STO)
DMC SCHEME: DESIGNATED MICROSCOPY CUM TREATMENT CENTRE (A AND B)
A. Designated Microscopy and Treatment Centre for a NGO/Private lab
General Description
Role of the NGO
Role of the District Health Society/District TB Centre
Commodity Assistance
In kind
Grant-in-Aid
Requirements/Eligibility Criteria
B. Designated Microscopy Centre - Microscopy only
General Description
Private Practitioner Role
Role of District Health Society
Grant-in-Aid
Requirements/Eligibility Criteria
LT SCHEME: STRENGTHENING RNTCP DIAGNOSTIC SERVICES
INTRODUCTION
Eligibility
Role of NGO/Collaborating partner
Role of RNTCP (DTO/STO)
CULTURE AND DST SCHEME: PROVIDING QUALITY ASSURED CULTURE AND DRUG SUSCEPTIBILITY TESTING SERVICES
INTRODUCTION
Eligibility
Grant-in-aid
Responsibilities of the NGO/Private facility
Responsibility of the Respective STO
ADHERENCE SCHEME: PROMOTING TREATMENT ADHERENCE
INTRODUCTION
Eligibility
Role of the NGO
DOT services
Awareness generation
Counseling services for patients and families
Additional services
Role of the Private Providers
Role of the District Health Society
NGOs supervising DOT services
For DOT
PPs providing DOT
SLUM SCHEME: IMPROVING TB CONTROL IN URBAN SLUMS
INTRODUCTION
Eligibility
Role of NGO/Collaborating Partner
Role of RNTCP (DTO/STO)
TUBERCULOSIS UNIT MODEL
General Description
Role of the NGO
Role of the District Health Society
Commodity Assistance
In kind
Grant-in-Aid
Start-up Activities (one-time only)
Requirements/Eligibility Criteria
TB-HIV SCHEME: DELIVERING TB-HIV INTERVENTIONS TO HIGH HIV RISK GROUPS (HRGS)
Background
Eligibility
Role of NGO/Collaborating Partner
Role of RNTCP (DTO/STO)
PROCEDURES
I. Approvals
II. Period of Assistance
III. Human Resource
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Memorandum of Understanding (MoU) for the participation of Non-Governmental Organisations (NGOs)/Private Providers
1. Parties
2. Period of Co-operation:
3. Terms, conditions and specific services during the period of the MOU.
C. Grant-in-Aid
INDEX
TOC
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