Monday, November 26, 2012

STOP TB -How do we do it ?

 At the plenary session of the 1st South African HIV Clinician Society Conference in Cape Town cure was not high on this Prof's list of hopes "We are going to be saddled with treatment for the next forty years " says  Prof Brian Gazzard of UK . We need to focus on good regimens that are tolerable.  I must say this has been something I have said to a number of my patients too. Absolutely, the search must continue and the research will go on, but in the meantime, we have got excellent tools at our disposal - Antiretroviral drugs. And they WORK. So, we need to focus on getting the best out of the treatments and using them to our best advantage and making them work for our Southern African population. While the search for a cure goes on.

A Fascinating session on Tuberculosis looking at the three I's - Infection control (i.e. how to prevent the spread of the bug in hospitals and public institutions, and between people ),  Intensive Case Finding (i.e. figuring out who actually has got TB disease - which really is the hardest part) , and Isoniazid Preventive Therapy (using a course of a single TB drug to prevent a person from getting diseased with TB)


TB  ( presented by Prashini Moodley , Prof Gary Maartens , Dr Tom Boyles)
The three I 's
INFECTION CONTROL
There is still lots of work to be done in this area, and even our newest TB hospitals are not necessarily getting it right :
TB hospitals do not meet the environmental standards required to prevent spread of TB and to allow for good ventilation. Certainly KZN Is leading the way in monitoring and setting standards .
What is apparent is that the :Ventilation , uv radiation , air filters , negative pressure air flow all are vital components in killing and eliminating TB bacilli.
Personal protective gear : the N95 mask (a thick mask with an orange colour that makes one look like Donald Duck) is uncomfortable and unpleasant to wear and there is confusion about how long it can be worn. It is also costly, and there certainly is not consistent use in hospitals by staff.

Interestingly, Good nutrition can help children to withstand TB disease (they might still get infection , but not necessarily disease )

Major forms of contact with TB are in school s and public transport and not just the people you live with.We used to the think that a TB contact was someone in the household, but now understand that even a half hour journey sitting next to someone on a taxi may be enough to transmit TB infection. Thanks to HIV.

Early ARV treatment will help decrease susceptibility to TB disease. Our TB epidemic and the fact that South AFrica has the 5th highest burden of TB disease IN THE WORLD, is exclusively thanks to the HIV epidemic and South Africas delayed response to it (in the 90's and early 2000's.) Yes, we are still paying the price for earlier government's denialism.

INTENSIVE CASE FINDING
Undiagnosed TB is common in hiv . Always consider TB as possibility in an hiv +person
As many as 31% of people with hiv have TB. !!!
It is essential to rule out active TB before giving INH preventive therapy.
It is extremely difficult rule out TB. Because essentially there always remains an element of doubt. Our WHO symtom screening tool is just not good enough according to Gary Maartens and wecwill still be missing more than. 80% of cases.
Adding a CXR. Delayed thIngs . IncludIng a low BMI or CD4 <200 helps a little but not much .
The pcr gene expert definitely improves case finding but will still miss 25% of cases
The CRP is a good rule out test I.e. if it's low it's a good way to rule out TB.
INH PREVENTIVE THERAPY
The BOTUSA study compared different lengths of ipt and different test results. Alarming result was a 3fold increase mortality in pts taking ipt who were tst -
Short course ipt works. Longer is better but the tst becomes essential if going longer.
Vit D supplementation , increasing ARV access and stopping smoking and improving TB adherence are all other components to help STOP TB .