2. MDR TB
Dr F. Mansouri
1395/5/14

3. Pulmonary Tuberculosis a Major Public health concern

4. Tuberculosis Captain of all the Men of Death

5. History of TB TB has affected humans for millennia
Historically known by a variety of names, including:
Consumption
Wasting disease
White plague
TB was a death sentence for many

6. (11 December 1843 – 27 May 1910)
Discovery of Tubercle bacilli in 1882. 

7. Tuberculosis is a Social Disease with a Medical Aspect.
Sir William Osler in 1902
( )

8. M. tuberculosis Resistance
In TB, resistance is always the expression of poor individual or general management of patients

9. M(X)DR-TB

10. problem…..It is costly, deadly,
MDR TB is a manmade
problem…..It is costly, deadly,
debilitating, and the biggest threat to our current TB control strategies.

11. بیماری سل مقاومت دارویی
بیماری سل مقاومت دارویی
مقدمه
بروز مقاومت دارویی در سل با معرفی داروی ضد سل در دنیا در سال 1943 معنا یافته و شروع به افزایش کرد.
اما متاسفانه در ادامه و بدنبال استفاده وسیع از ریفامپین (که از دهه هفتاد در قرن بیستم مصرف آن شروع شد)، سل مقاوم به چند دارو در جهان ظهور کرده و به سرعت به معضلی اساسی و تهدید کننده برای برنامه کنترل سل بسیاری از کشورها و در نتیجه جهان مبدل شد.

12. بیماری سل مقاومت دارویی
بیماری سل مقاومت دارویی
مقدمه
اگر چه دلایل رخداد پدیده مقاومت دارویی سل را به عوامل
میکروبی،
بالینی و
برنامه ای تقسیم می کنند.
اما در یک جمله می توان گفت که؛ سل مقاوم به دارواساساً یک پدیده ساخته دست بشر است

13. Evolution of drug-resistant TB
Drug susceptible TB*
MDR-TB
1990
XDR-TB
2006
Total DR ?
*or limited resistance
Manageable with 4 drug regimen - DOTS
Resistance to H&R
Treatable with 2nd line drugs
Resistance to 2nd line drugs
Treatment options seriously restricted
Resistance to all available drugs
No treatment options

14. عوامل موثر در ایجاد مقاومت دارویی در سل
عوامل مرتبط با ارائه کنندگان خدمات درمانی
عوامل مرتبط با دارو
عوامل مرتبط با بیمار
عدم وجود دستورالعمل مناسب و جامع کشوری
عدم تبعیت پزشکان از دستورالعمل کشوری
آموزش ناکافی پزشکان و کارکنان بهداشتی- درمانی مرتبط
عدم پایش صحیح درمان بیماران
ضعف ساختاری یا اعتباری برنامه کنترل سل
عدم آموزش بیماران و خانواده آن ها
ضعف در اطلاع رسانی به مردم در زمینه رایگان بودن درمان ضدسل
کیفیت نامناسب دارو
نامنظمی در تأمین برخی داروهای ضد سل
نامناسب بودن شرایط ذخیره سازی دارو
تجویز دوز غلط یا ترکیب نامناسب دارویی
تمکین ضعیف بیماران به درمان
نا آگاهی بیماران
عدم دسترسی / عدم اطلاع از وجود درمان ضدسل رایگان
مشکلات موجود برای ایاب و ذهاب بیماران به مرکز بهداشتی درمانی
نگرش منفی جامعه نسبت به بیماری
ابتلا به سوءجذب
اعتیاد / سوء مصرف مواد

15. TB has killed more people…
but receives less funding
TB has killed more people…
30,000,000
HIV/AIDS death
Malaria
$43 billion
HIV/AIDS
Global Funding
Tuberculosis
$7 Billion TB
The easy answer is to say we need more $$
TB has killed more than any other infectious disease in history (totals are for last 200 years)
But current funding for TB falls far short of HIV or Malaria
But everyone doing research these days needs more money- regardless of your field. So like everyone else, we need to make the most of what we have.
Source: Financing Global Health 2012, IHME; Aeras
Source: Nature Vol 502, No Suppl, S2 (2013)

16. They do not cause the mutation
An important Fact
Anti-TB Drugs select
the resistant mutants
They do not cause the mutation

17. M. tuberculosis Resistance Natural Resistant Mutants according to Bacillary Population
INH 1 x Bacilli
RIF 1 x Bacilli
SM 1 x Bacilli
EMB 1 x Bacilli
PZ 1 x Bacilli ?
Quinolones 1 x Bacilli ?
Others 1 x Bacilli ?

18. Drug Mutation Rate Rifampin 10-8 Isoniazid 10-6 Pyrazinamide
Spontaneous mutations
develop as bacilli
proliferate to >108
Drug
Mutation Rate
Rifampin
10-8
Isoniazid
10-6
Pyrazinamide
M. tuberculosis bacteria become resistant to anti-TB drugs by acquiring mutations that confer resistance. Such mutations develop spontaneously as the bacteria proliferaet in the host.
Rif-R mutants arise at a frequency of 1 in 10exp-8
INH-R and PZA-R mutants arise at a frequency of 10exp-6
So, prior to treatment, the population of bacteria in a TB pateint already contains drug-resistant bacteria.

19. INH RIF INH PZA Multidrug therapy:
No bacteria resistant to all 3 drugs
Drug-resistant mutants in large bacterial population
INH
RIF
PZA
Monotherapy: INH-resistant bacteria proliferate
If one treats this population with three effective drugs, all bacteria are killed.
However, if one treats with only one drug, say INH, one selects for INH resistant bacteria. --
INH

20. INH RIF INH Spontaneous mutations develop as bacilli
proliferate to >108
INH resistant bacteria multiply
to large numbers
INH
RIF
INH
These bacteria then can multiply to large numbers and once again spontaneous mutations can arise. In this case acquisition of a second drug resistance. Treatment with two drugs then leads to selection of the MDR strain and its proliferation can lead to the acquisition of additional resistance. This sort of amplification of drug resistance can occur one drug at a time to ultimately lead to XDR TB. -
INH mono-resist.
mutants killed,
RIF-resist. mutants proliferate  MDR TB

21. >108 organisms in TB cavity 1 resistant RIF 100 resistant INH
100 resistant Strep
100 resistant EMB
Likelihood of Natural Resistance
Rifampin /108
INH, Strep, EMB /106

22. 0 resistant INH+Rif+EMB
For New Cases Never Treated
>108 Organisms in
TB Cavity
1 resistant RIF
100 resistant INH
100 resistant Strep
100 resistant EMB
0 resistant INH+Rif
0 resistant INH+Rif+EMB

23. If Treated With INH Only Organisms Multiply 100 organisms
resistant to INH
remain in
cavity
If Treated
With INH Only
108 Organisms:
1 resistant RIF
100 resistant INH
100 resistant Strep
100 resistant EMB
New 108 Organisms:
1 resistant Rif
108 resistant INH
100 resistant Strep
100 resistant EMB
Organisms Multiply

24. If Treated with INH and RIF MDR-TB 108 Organisms: 1 organism resistant
1 Resistant Rif
108 Resistant INH
100 Resistant Strep
100 Resistant EMB
1 organism
resistant
to RIF and INH
MDR-TB
Organisms Multiply

25. problem…..It is costly, deadly,
MDR TB is a manmade
problem…..It is costly, deadly,
debilitating, and the biggest threat to our current TB control strategies.

26. غالبا نارسایی تنفسی برای تمام عمر حفظ يك منبع آلودگي از نوع مقاوم
مقايسه هزينه ، طول مدت درمان و اثر بخشي رژيم هاي درماني موجود ميان يك بيمار مبتلا به سل حساس به دارو و يك بيمار به سل مقاوم به چند دارو
موارد مقاوم به چند دارو
موارد حساس به دارو
بین 25 تا 250 میلیون تومان
کمتر از 000,200 تومان
هزينه
40 تا 60 درصد
بیش از 95%
اميد بهبودي
18 تا 24 ماه
6 ماه
طول دوره درمان
100% موارد
4 تا 6 ماه
کمتر از 10% موارد
به مدت کوتاه
نیاز به بستری
غالبا نارسایی تنفسی برای تمام عمر
ندارد
معلوليت
حفظ يك منبع آلودگي از نوع مقاوم
حذف یک منبع انتشار
اپيدميولوژي

27. فراوانی موارد تحت درمان خط دوم ضد سل در کشور از سال 1381 تا 1387
فراوانی موارد تحت درمان خط دوم ضد سل در کشور از سال 1381 تا 1387
1387
1386
1385
1384
1383
1382
1381 9 18 44 31 25 8 3
تعداد موارد قطعي مبتلا به MDR-TB 35 16 7 2
تعداد مواردي كه باشك به MDR-TB تحت درمان با داروهاي خط دوم ضد سل قرار گرفته اند

28. Treatment Of Tuberculosis
XDR TB
Treatment Of Tuberculosis
1884—sanatorium treatment (boosting of patients own resistance)
cod liver oil , antimony and copper salts
gold salts (sanocrysin, myocrisin)
1930—collapse therapy

29. Chemotherapy Of Tuberculosis
XDR TB
Chemotherapy Of Tuberculosis
: Dapson And Sulfa
: SM,PAS
: INH, PZA
: ETB, RMP
: Conventional chemotherapy
: Short course chemotherapy
: MDR- TB
: XDR- TB
: TDR -TB ……………

30. World Health Assembly 1991
"…attain a global target of cure of 85% sputum-positive patients under treatment and detection of 70% of cases by the year 2000"
First, a reminder about the targets.

31. اهداف جهاني تعيين شده از سوي سازمان جهاني بهداشت براي برنامه سل كشورها:
- بهبودي كامل حداقل 90% موارد جديد مبتلا به سل ريوي اسمير خلط مثبت تا سال 2015
- ايجاد دسترسي همه جانبه(Universal Access) به خدمات مرتبط با برنامه كنترل سل. (بجاي هدف "كشف حداقل 70 % بيماران مبتلا به سل) .

32. RESURGENCE OF TUBERCULOSIS AS GLOBAL HEALTH PROBLEM
XDR TB
RESURGENCE OF TUBERCULOSIS AS GLOBAL HEALTH PROBLEM
GLOBAL EPIDEMIC OF HIV
PROBLEM OF MULTI-DRUG RESISTANT TUBERCULOSIS.
GLOBAL EMERGENCY
1993

33. World Health Assembly 2012 Call from Member States
At the 65th World Health Assembly in May 2012, Member States called upon WHO to develop a new post-2015 TB strategy and targets, and present this to Member States at the 67th World Health Assembly in 2014.

34. Post 2015 Strategy اهداف (Targets)
2035
شاخص
95%
کاهش موارد مرگ مسلول نسبت به 2015
Decreasing TB death rate
90%
کاهش میزان بروز سل نسبت به 2015
Decreasing TB incidence rate
خانوارهای مواجه با هزینه های کمرشکن سل
Families exposed to catastrophic expenditures

35. The End TB Strategy: Vision, goal, targets
Vision: A world free of TB
Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB epidemic (<10 cases per 100,000)
Target 1
95% reduction in deaths due to TB (compared with 2015)
Target 2
90% reduction in TB incidence rate (compared with 2015)
Target 3
No affected families face catastrophic costs due to TB

36. BURDEN 9 million people fell ill with TB in 2013
1.5 million men, women and
children died from TB in 2013
1.1 million people living with HIV developed TB, with 360,000 associated deaths in 2013
people developed MDR-TB (multidrug-resistant TB) in 2013, with 210,000
associated deaths

37. PROGRESS
37 million lives saved between 2000 and 2013 through effective TB diagnosis and treatment
45% decline in TB mortality rate and 41% decline in TB prevalence rate since 1990
HIV-related TB deaths down by 34% in the last decade
Fragile progress in MDR-TB with the number of people diagnosed tripling and a three-fold increase in treatment coverage since 2009

38. World free of TB دنیای بدون سل
چشم انداز “Vision”
World free of TB
دنیای بدون سل

39. Global Burden of TB in 2013 1.5 million 9 million 480,000
Estimated number of cases
Estimated number of deaths
1.5 million
80,000 in children
510,000 in women
9 million
126 per 100,000
550,000 in children
3.3 m in women
480,000
All forms of TB
Multidrug-resistant TB
HIV-associated TB
1.1 million (13%)
360,000
210,000

40. 480,000 MDR-TB, 9% with XDR Highest % in the former USSR countries
India, China, Russia, Pakistan and Ukraine
have 60% of all MDR-TB cases

41. Global estimates of MDR-TB
3.5% (95% CI: 2.2–4.7%) among new cases
20.5% (95%CI: 13.6–27.5%)of previously treated cases
(range: ‒ ) new MDR-TB cases worldwide
(range: – ) MDR-TB cases among patients with pulmonary TB notified in 2013.
9.0% (95% CI: 6.5–11.5%) of MDR-TB cases have XDR-TB
Global Tuberculosis Report 2014

42. 48% MDR treatment success globally

43. Global progress on impact - 2014
TARGETS ON TRACK
Reduction in TB mortality rate of 45% since 1990
37 million lives saved since 2000
86% cure rate and 61 million patients cured,
BUT….
incidence falling too slowly at 1.5%/year

44. *WHO: Global Tuberculosis Report 2014
Background*
Estimated 9 million people who developed TB in 2013
56% in South-East Asia and Western Pacific Regions
25% in African Region
Between 1990 and 2013:
45% decrease in TB mortality rate
41% decrease in TB prevalence rate
Review slide content
State that TB remains a major global health problem, responsible for ill health among millions of people each year. TB ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV)
*WHO: Global Tuberculosis Report 2014

45. MDR-TB: Five priority actions

46. Targets for low-incidence countries
<100 cases per million
Current TB burden-2012
in low-incidence countries
<10 cases per million
Pre-elimination: 2035
in low-incidence countries
<1 case per million
Elimination: 2050

47. 3 pillars and 4 Principles
Bold policies and supportive systems
Integrated, patient-centered TB care and prevention
Intensified research and innovation
Government stewardship and accountability, with monitoring and evaluation
Building a strong coalition with civil society and communities
Protecting and promoting human rights, ethics and equity
Adaptation of the strategy and targets at country level, with global collaboration

48. The End TB Strategy components
1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION
Early diagnosis, universal DST, screening of contacts and high-risk groups
Treatment of all, including DR-TB, patient support
Collaborative TB/HIV activities, management of co-morbidities
Preventive treatment of persons at high risk, vaccination against tuberculosis
2. BOLD POLICIES AND SUPPORTIVE SYSTEMS
Political commitment, adequate resources for tuberculosis care and prevention
Engagement of communities, civil society, and public and private care providers
Universal health coverage policy, regulatory frameworks for notification, vital registration, rational use of medicines, infection control
Social protection, poverty alleviation and actions on other determinants of TB
3. INTENSIFIED RESEARCH AND INNOVATION
Discovery, development, rapid uptake of new tools
Research to optimize implementation, impact - promote innovations

49. CHALLENGES
US$ 2 billion funding gap per year for implementation of existing TB interventions. There is an additional gap of US$ billion for research.
3 million people with TB are missed by health systems every year and therefore may not get adequate care they need
TB/HIV response needs acceleration . Antiretroviral treatment, treatment of latent TB infection and other key interventions still need further scale-up
MDR-TB remains a crisis Widening gaps between people diagnosed with MDR-TB and those put on treatment. This could compromise recent gains

50. THE END TB STRATEGY
* The United Nations is in the process of defining a post-2015 development agenda. A set of “Sustainable Development Goals” (SDGs) are being developed for 2030; TB is proposed to be part of the agenda and goals.

51. + + + + + + ethambutol pyrazinamide kanamycin (8+ months) minimum
who.int/tb/challenges
minimum
20 months! + +
ofloxacin
cycloserine
PAS granules + +
+ ?
truvada
pyridoxine
efavirenz
TMP/sulfa

52. The End TB Strategy - Components
1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION
Early diagnosis of tuberculosis including universal drug-susceptibility testing, and systematic screening of contacts and high-risk groups
Treatment of all people with tuberculosis including drug-resistant tuberculosis, and patient support
Collaborative tuberculosis/HIV activities, and management of co-morbidities
Preventive treatment of persons at high risk, and vaccination against tuberculosis
2. BOLD POLICIES AND SUPPORTIVE SYSTEMS
Political commitment with adequate resources for tuberculosis care and prevention
Engagement of communities, civil society organizations, and public and private care providers
Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control
Social protection, poverty alleviation and actions on other determinants of tuberculosis
3. INTENSIFIED RESEARCH AND INNOVATION
Discovery, development and rapid uptake of new tools, interventions and strategies
Research to optimize implementation and impact, and promote innovations

54. «حذف بیماری سل در جهان» هدف تعیین شده برای سال 2050 تعریف حذف سل:
میزان بروز کمتر از یک مورد سل در یک میلیون نفر جمعیت

55. Estimated TB Incidence Rate- 2013 میزان بروز تخمینی سل - 2013
9 million New Cases
1.1 million HIV+ (13%)
1.5 million Death
11/30/2018

56. 39%
Lost cases
Where are these cases?
61%
Detected &
Registered

57. کشورهای دارای بار بالای بیماری سل-2013
High Burden Countries (HBCs) 1
Afghanistan 12
Myanmar 2
Bangladesh 13
Nigeria 3
Brazil 14
Pakistan 4
Cambodia 15
Philippines 5
China 16
Russian Federation 6
DR Congo 17
South Africa 7
Ethiopia 18
Thailand 8
India 19
Uganda 9
Indonesia 20
UR Tanzania 10
Kenya 21
Viet Nam 11
Mozambique 22
Zimbabwe
11/30/2018

58. کشورهای دارای بار بالای بیماری سل-2013
High Burden Countries (HBCs) 1
Afghanistan 12
Myanmar 2
Bangladesh 13
Nigeria 3
Brazil 14
Pakistan 4
Cambodia 15
Philippines 5
China 16
Russian Federation 6
DR Congo 17
South Africa 7
Ethiopia 18
Thailand 8
India 19
Uganda 9
Indonesia 20
UR Tanzania 10
Kenya 21
Viet Nam 11
Mozambique 22
Zimbabwe
11/30/2018

59. مقایسه وضعیت سل ایران با کشورهای همسایه، منطقه و جهان- 2013
مقایسه وضعیت سل ایران با کشورهای همسایه، منطقه و جهان- 2013
Incidence R.
Prevalence R.
Mortality R. 1
Afghanistan
189
340 42 2
Pakistan
275
342 56 3
Azerbaijan 85
105
3.9 4
Armenia 49 60
5.7 5
Turkmenistan 72
103 25 6
Iraq 45 75
2.3 7
Turkey 20 23
0.42
EMR
121
165
World
126
159 16
Iran 21 32
3.2

60. TB Notification Rate- I. R
TB Notification Rate- I.R.IRAN میزان بروز گزارش شده سل – ایران 1393
Type of TB
Notification
No.
Rate (/100,000)
All
10,044
12.90
Pulmonary TB
Smear +
4975
6.39
Smear -
1964
2.52
Extra Pulmonary TB
2795
3.59
11/30/2018

61. نقشه پراکندگی میزان بروز سل گزارش شده- 1393
Notification rate / 100,000
11/30/2018

62. میزان بروز گزارش شده سل به تفکیک استان- 1393
میزان بروز گزارش شده سل به تفکیک استان- 1393
سیستان و بلوچستان
گلستان
گیلان قم
خوزستان
هرمزگان
خراسان رضوی
یزد
خراسان جنوبی

63. میزان بروز گزارش شده سل به تفکیک دانشگاه 1393
یزد
سمنان
تهران
خراسان جنوبی
شهید بهشتی
رقسنجان
زابل
ایرانشهر
گلستان
زاهدان
گیلان بم
دزفول
نیشابور
اهواز
آبادان قم
گناباد
هرمزگان
مشهد

64. Age Median (per Day) میانه سنی بیماران مبتلا به سل (برحسب روز) ایران - 1393
Nationality
SS+
SS- EP
All
Iranian 52 55 56 49
Non-Iranian 47 50 30 40 54 48
11/30/2018

65. Age Median میانه سنی بیماران مبتلا به سل در دانشگاه های کشور - 1393
11/30/2018

66. Age Median میانه سنی بیماران مبتلا به سل در دانشگاه های کشور - 1393
11/30/2018

67. نسبت مرد به زن (M/F Ratio) ایران- 1393
Type of TB
M/F Ratio
نسبت مرد به زن
All 1
Pulmonary TB
Smear +
1.4
Smear -
1.1
Extra Pulmonary TB
0.9
11/30/2018

68. نسبت مرد به زن (M/F Ratio) در دانشگاه های کشور - 1393
11/30/2018

69. نسبت مرد به زن (M/F Ratio) در دانشگاه های کشور - 1393
11/30/2018

70. Extra-pulmonary TB درصد ارگان درگیر در موارد جدید سل خارج ریوی
11/30/2018

71. Reporting center فراوانی نسبی موارد جدید سل در سال1393 برحسب مرکز گزارش دهنده
11/30/2018

72. مقاومت دارویی Drug Resistance
11/30/2018

73. نقشه پراکندگی میزان شیوع Primary MDR-TB
(%)
World
3.5
EMRO
3.6
11/30/2018

74. نقشه پراکندگی میزان شیوع Secondary MDR-TB
(%)
World 21
EMRO 22
11/30/2018

75. کشورهای دارای بار بالای MDR-TB1
Armenia 14
Latvia 2
Azerbaijan 15
Lithuania 3
Bangladesh 16
Myanmar 4
Belarus 17
Nigeria 5
China 18
Pakistan 6
DR Congo 19
Philippine 7
Estonia 20
Republic of Moldova 8
Ethiopia 21
Russian Federation 9
Georgia 22
South Africa 10
India 23
Tajikistan 11
Indonesia 24
Ukraine 12
Kazakhstan 25
Uzbekistan 13
Kyrgyzstan 26
Vietnam
11/30/2018

76. High MDR-TB Burden Countries1
Armenia 14
Latvia 2
Azerbaijan 15
Lithuania 3
Bangladesh 16
Myanmar 4
Belarus 17
Nigeria 5
China 18
Pakistan 6
DR Congo 19
Philippine 7
Estonia 20
Republic of Moldova 8
Ethiopia 21
Russian Federation 9
Georgia 22
South Africa 10
India 23
Tajikistan 11
Indonesia 24
Ukraine 12
Kazakhstan 25
Uzbekistan 13
Kyrgyzstan 26
Vietnam
11/30/2018

77. MDR-TB Prevalence Rate
Primary
MDR-TB
(%)
Secondary 1
Armenia
9.4 43 2
Azerbaijan 13 28 3
Pakistan
4.3 19
EMR
3.6 22
World
3.5 21
Iran
0.84
12.4
11/30/2018

78. National Drug Resistance Survey Result I.R.IRAN- 2014
MDR-TB (confidence Interval)
Primary
0.84% ( )
Secondary
12.40% ( )

79. سل و اچ آی وی TB-HIV
11/30/2018

80. Known HIV Status نسبت موارد سل دارای وضعیت HIV مشخص- 2013
World
48%
Iran
31.9%
11/30/2018

81. HIV co-infection میزان شیوع اچ آی وی در موارد جدید سل- 2013
HIV Sero-prevalence among TB cases
World
13 %
Iran
3.8 %
11/30/2018

82. نتیجه درمان Treatment Outcome
11/30/2018

83. >=90% Success Rate (%) Target New Cases 87.8 Retreatment Case 80.7
Success Rate in different patient groups موفقیت درمان در گروه های مختلف بیماران- 1392
Success Rate (%)
Target
New Cases
87.8
>=90%
Retreatment Case
80.7
TB-HIV cases
66.8
11/30/2018

84. Tx Outcome in New Pul. SS+ TB Cases نتایج درمان موارد جدید سل ریوی اسمیر مثبت – ایران 1392
(%)
Success Rate
85.4
Failure Rate
3.5
Death Rate
8.1
Interruption Rate
2.3
Transfer out Rate
0.7
11/30/2018

85. Absolute numbers of estimated cases with MDR-TB
0–9
10–99
100–999
1000–9 999
>10 000
No estimate
25 high MDR-burden countries
~ 55% in China + India + Russian Federation

87. Worldwide MDRTB Treatment Success 2009
WHO Global Tuberculosis Report

88. Tuberculosis
anywhere is
everywhere

89. Getting to Zero
Let’s ADD another zero to the level of funding for TB drugs, diagnostics, vaccines and elimination!  $6,300,000

90. + + + + + + ethambutol pyrazinamide kanamycin (8+ months) minimum
who.int/tb/challenges
minimum
20 months! + +
ofloxacin
cycloserine
PAS granules + +
+ ?
truvada
pyridoxine
efavirenz
TMP/sulfa

91. Prevention & Control of Tuberculosis in Prisons & Jails

92. Prevention & Control of Tuberculosis in Prisons & Jails

93. Warning will kill one person in three
A new plague is sweeping across the planet
Soon multidrug resistant tuberculosis
will kill one person in three
The Constant Gardener November 2005

95. A WORLD FREE OF TB Proposed Vision ZERO TB DEATHS ZERO TB CASES ZERO
TB SUFFERING
PROGRAMME
GLOBAL TB

96. 2020 2025 2030 2035 Getting there: Milestones TARGETS TARGETS TARGETS
35% reduction in TB deaths
<85/ TB incidence rate
No affected families with catastrophic costs due to TB
TARGETS
75% reduction in TB deaths
<55/ TB incidence rate
No affected families with catastrophic costs due to TB
TARGETS
90% reduction in TB deaths
<20/ TB incidence rate
No affected families with catastrophic costs due to TB
GOAL
95% reduction in TB deaths
<10/ TB incidence rate
No affected families with catastrophic costs due to TB
Key words:
4 , four stages, movement, timeline, years, period, ahead, steps, aspects

97. Post-2015 TB Strategy Proposed Pillars and Principles
Bold policies and supportive systems
High-quality, integrated TB care and prevention
Intensified research and innovation
Government stewardship and accountability, with monitoring and evaluation
Building a strong coalition with civil society and communities
Protecting and promoting human rights, ethics and equity
Adaptation of the strategy and targets at country level, with global collaboration

98. Post-2015 TB Strategy: Pillar 1
High-quality, integrated TB care and prevention
Early diagnosis of TB including universal drug susceptibility testing; systematic
screening of contacts and high-risk groups
Treatment of all people with TB including drug-resistant TB, with patient-centered support 2 1
I will now go into more details on each of the 3 pillars.
The first pillar is focused on the essential components of TB care and prevention, emphasizing its universality and its quality. It incorporates all technological and system innovations that have been proven to be effective in enhancing the original DOTS and Stop TB Strategies.
In practical terms, there are 4 components of this pillar:
First, rapid diagnosis and universal drug-susceptibility testing for all cases, and systematic screening of contacts and high-risk groups.
Second, treatment to everyone and for all types of TB including drug-resistant disease, with special emphasis on the support needed for the patient.
Third, collaborative activities between TB and AIDS national programmes for TB patients living with HIV and the management of any other relevant co-morbidity.
Fourth, preventive treatment of persons at high-risk and BCG vaccination to newborns.
Preventive treatment of people at high-risk and vaccination for TB 4
Collaborative TB/HIV activities and management of co-morbidities 3
PROGRAMME
GLOBAL TB

99. پیشگیری
اجرای کامل استراتژی DOTS بهترین راه پیشگیری از بروز موارد مزمن سل و گسترش MDR-TB است.
در کشورهایی از جهان که چندین سال است استراتژی DOTS را بخوبی اجرا می کنند، موارد مزمن سل کمتر از 2% کل موارد سل ریوی اسمیر خلط مثبت را تشکیل می دهند.

100. پیشگیری
به عبارت دیگر، بهترین راه پیشگیری از ایجاد مقاومت دارویی، تبعیت از راهنمای کشوری مبارزه با سل یعنی تجویز صحیح و کامل رژیم درمانی حاوی داروهای خط اول ضد سل به صورت تحت نظارت مسقیم روزانه ی یک ناظر مطمئن، علاقمند و آموزش دیده برای موارد سل حساس به دارو است.

101. پیشگیری
البته شناسایی بموقع موارد سل مقاوم و سپس درمان هرچه سریعتر آنها با رژیم های دارویی صحیح حاوی داروهای خط دوم ضد سل نیز می تواند اقدامی موثر برای توقف چرخه انتقال سل مقاوم به دارو باشد.

102. با توجه به سخت بودن تحمل داروهای خط دوم ضدسل برای بیماران و اثربخشی محدود آن ها (که 40 تا 60% گزارش می شود)؛ همچنان بهترین استراتژی موجود در جهان، پیشگیری از بروز این موارد از طریق اجرای کامل راهبرد DOTS می باشد.

103. پيدايش سل مقاوم به درمان (MDR-TB)،
نشانه اي از كنترل ناموفق سل در جامعه است.

104. Each case leads to two cases
-_-_-
1 Infectious case
20 contacts
2 cases
of TB
1 Non-infectious

105. هدف کلي برنامه ملي مبارزه با سل: كاهش هر چه سريعتر شيوع سل در جامعه است تا آنجاكه اين بيماري به عنوان يك مشكل بهداشتي جامعه مطرح نباشد.

106. مقدمه :
بر طبق اهداف توسعه هزاره
و برنامه جهاني مبارزه با سل :
جهان تا سال 2015 م مي بايستي به توقف رشد بروز سل و از آن به بعد كاهش بروز ،نصف شدن شيوع و مرگ ناشي از سل و سپس در سال 2050 م به مرحله حذف سل (بروز كمتر از 1 مسلول درهر ميليون نفر) نا يل گردد.

107. MILLENNIUM DEVELOPMENT GOALS (2015)
Eradicate poverty and hunger
Universal primary education
Empower women
Reduce child mortality
Improve maternal health
Combat HIV/AIDS, malaria and other diseases
Environmental sustainability
Global partnership for development

108. اهداف جهانی برنامه کنترل سل

109. وضعيت سل و شاخصهاي برنامه در دانشگاه علوم پزشكي و خدمات بهداشتي درماني کرمانشاه

110. روند ميزان بروز سل در دانشگاه کرمانشاه از سال 1390 تا 1394
روند ميزان بروز سل در دانشگاه کرمانشاه از سال 1390 تا 1394
در یکصد هزار نفر جمعیت

111. میزان بروز گزارش شده سل – دانشگاه کرمانشاه 1394
نوع بیماری
بروز گزارش شده
No.
Rate (/100,000) کل
224
11.2
سل ریوی
Smear + 90
4.5
Smear - 43
2.2
سل خارج ریوی 78
3.9

112. روند ميانه سني كل موارد جديد بيماران مسلول در دانشگاه کرمانشاه (به تفکیک ملیت) از سال 1390 تا 1394

113. روند نسبت بيماران اسمير مثبت به كل موارد ريوي در دانشگاه کرمانشاه از سال 1390 تا 1394

114. روند منفي شدن اسمير در پايان مرحله حمله اي درمان در موارد جديد سل SS+ دانشگاه کرمانشاه از سال 1390 تا 1394

115. روند نتيجه درمان در كل بيماران جديد دانشگاه کرمانشاه از سال 1390 تا 1393

116. روند نتيجه درمان در بيماران اسمير مثبت جديد دانشگاه کرمانشاه از سال 1390 تا 1393

117. درصد مشخص بودن وضعيت HIV در كل بيماران مبتلا به سل در دانشگاه کرمانشاه از سال 1390 تا 1394

118. درصد مشخص بودن وضعيت HIV در بين زندانيان از سال 1390 تا 1394

119. Thank you for your attention!