Tuberculosis Study Guide - M.M. Savula 2002

Organization of Tuberculosis Control. Dispensary Surveillance

Success in overcoming tuberculosis is possible with the correct and well-coordinated Organization of anti-tuberculosis measures. Positive results can only be achieved through close cooperation between anti-tuberculosis institutions, the general healthcare network, and the sanitary-epidemiological service, with the support of government authorities. Tuberculosis detection is carried out by physicians of virtually any specialty whom patients consult. In adults, these are primarily general practitioners, and in children, pediatricians. The pediatric service is also responsible for tuberculin Skin testing and BCG vaccinations.

The main organizational and methodological center for all this work is the Academician T.G. Yanovsky National Institute of Phthisiology and Pulmonology of Ukraine, and in the regions, regional tuberculosis dispensaries.

A tuberculosis dispensary is a specialized medical institution that organizes and implements anti-tuberculosis measures among the population: Prevention, detection, Treatment, registration, and follow-up of tuberculosis patients and their contacts, as well as cured individuals with residual post-tuberculosis changes who are at risk of relapse.

In cooperation with the sanitary-epidemiological service, the regional dispensary monitors the timeliness, completeness, and quality of anti-tuberculosis measures. Tuberculosis hospitals and sanatoriums operate either within dispensaries or independently.

In cities and districts, municipal and district dispensaries, as well as tuberculosis clinics, have been established. In addition to organizational and methodological work, they carry out active surveillance of registered patient cohorts, outpatient treatment, and health-promotion activities in tuberculosis foci.

For the purpose of differentiated follow-up, treatment, and preventive measures, the cohorts under the Supervision of the tuberculosis dispensary are divided into dispensary follow-up groups:

Group 0 - adults, adolescents, and children who require clarification of The activity of the tuberculosis process, as well as children and adolescents who need Differential Diagnosis for suspected tuberculosis or clarification of The Nature of positive tuberculin reactions (post-vaccination vs. infectious). Follow-up is permitted for up to 6 months, during which a detailed examination and, if necessary, trial treatment are conducted.

Group I - patients with newly diagnosed or chronic active respiratory tuberculosis, with or without bacterial shedding, who require treatment, anti-epidemic, and social measures. If patients are treated on an outpatient basis, their follow-up examination is conducted once a month.

Group II - patients with active, regressing respiratory tuberculosis transferred from Group I. To prevent relapses, they are prescribed three-month courses of anti-tuberculosis drugs twice a year. Follow-up at the dispensary is once every 3 months, and monthly during treatment.

Group III - individuals transferred from Groups I and II who have achieved clinical cure, as well as newly identified children and adolescents with inactive post-tuberculosis Changes in the respiratory Organs. If necessary, children are treated, and adults are prescribed Chemoprophylaxis. Follow-up by a phthisiologist is twice a year.

Group IV - adults in contact with a patient shedding Mycobacterium tuberculosis. Children and adolescents who have family or household contact with a patient shedding Mycobacterium tuberculosis, or with a patient with active tuberculosis without bacterial shedding, as well as in cases where a bacterial shedder is identified in kindergartens or adolescent institutions. Adults, children, and adolescents in contact with tuberculosis-infected livestock. Children from families of livestock breeders working on tuberculosis-infected farms. Follow-up is conducted throughout the entire period of contact and for one year after its termination. Follow-up by a phthisiologist is once every 6 months.

Group V - patients with Extrapulmonary tuberculosis (subgroup A - active, B - regressing) and those cured of it (subgroup C). They are monitored by appropriate specialists who determine the duration of the follow-up period.

Group VI - children and adolescents with tuberculin skin test conversion ('virage') or hyperergic reactions to tuberculin, children unvaccinated during the neonatal period, and children with complications of BCG Vaccination.

Examination by a phthisiologist is twice a year. Chemoprophylaxis is prescribed as indicated.

Group VII - adults with residual inactive post-tuberculosis changes in the respiratory organs. Examination by a phthisiologist is once a year. If There is a risk of relapse (exacerbation of severe co-morbidities), they are prescribed chemoprophylaxis.

The mandatory set of examinations during dispensary follow-up includes: fluorography or chest X-ray (at scheduled intervals), complete Blood count and urinalysis, testing for Mycobacterium tuberculosis, and, in cases of differential diagnosis, tuberculin skin tests.

In rural areas, feldsher-obstetric station (FAP) staff actively participate in the dispensary follow-up of registered residents within their service area. For all individuals subject to dispensary supervision, the feldsher fills out an outpatient medical record, indicating the diagnosis, dispensary registration group, and recording the medical history, Complaints, Objective Examination findings, phthisiologist's recommendations regarding follow-up and treatment, and therapy outcomes. In addition, a duplicate of the dispensary follow-up control card is filled out for each patient. These control cards are used to create a card index, organized by dispensary registration groups and, within each group, by the dates scheduled for follow-up at the TB dispensary. Once a quarter, the feldsher reconciles their card index with that of the district phthisiologist and ensures that patients regularly visit the TB dispensary.

In recent years, amid economic crises, opinions are increasingly voiced regarding the high cost and insufficient effectiveness of certain anti-tuberculosis measures. It has been estimated that detecting a single patient requires performing about 1,800 fluorographies, and detecting one sick child requires 14,470 tuberculin skin tests. Therefore, many countries have shifted from mass fluorography screenings to targeted screenings in high-risk groups. However, there is no equivalent alternative to fluorography and Tuberculin Diagnostics.

Due to the worsening Epidemiological situation of tuberculosis worldwide, especially in poor countries, the World Health Organization has developed and proposed the Structure/175.html">Implementation of the so-called DOTS strategy in countries with high epidemiological indicators and limited financial resources. DOTS is an acronym for the English program name - Directly Observed Treatment, Short-course.

The strategy includes 5 essential elements:

1. Detection of tuberculosis patients in primary healthcare facilities based on the analysis of clinical symptoms and sputum smear Cell/15.html">Microscopy for MTB.

2. Provision of short-course Chemotherapy (6-8 months) to identified patients, initially in a hospital Setting and subsequently on an outpatient basis under the strict supervision of healthcare workers, trained representatives of non-governmental organizations, or volunteers (e.g., former tuberculosis patients).

3. Ensuring an uninterrupted supply of essential anti-tuberculosis drugs for free, continuous, and directly observed treatment throughout the entire course.

4. Monitoring the treatment outcomes of each patient with an evaluation of its efficacy.

5. Support for the program by regional governments, healthcare management authorities, and the media. WHO calls for securing financial support from both governmental and non-governmental organizations and making Tuberculosis Treatment an integral part of the country's existing healthcare program.

The goal of the DOTS program is to detect at least 70% of smear-positive tuberculosis patients and achieve sputum conversion in 85% of patients with newly diagnosed Pulmonary Tuberculosis.

Implementing this program helps reduce the number of patients with infectious forms of tuberculosis, thereby lowering the risk of transmission among the population. At the same time, cure rates increase, while mortality and the prevalence of drug-resistant tuberculosis decrease. However, according to WHO projections, the annual incidence of tuberculosis will be cut in half only after 10 years.

In 1999, the DOTS strategy was implemented in 110 countries, including several regions of Ukraine.

Implementing the DOTS program requires extensive preparatory work, training primary healthcare staff, instructing laboratory technicians in sputum smear microscopy, and establishing a well-organized workflow with strict treatment monitoring during the outpatient phase. Directly observed chemotherapy is a key requirement and a major strength of the program (despite being logistically challenging), as treatment failure is frequently caused by patients prematurely discontinuing therapy or making unmotivated interruptions in their treatment regimen.

A major point of contention for many phthisiologists is that the program relies solely on sputum smear microscopy for Diagnosis and treatment evaluation. Although this method is inexpensive, it can only detect patients with cavitary forms of tuberculosis (unlike chest radiography, which detects early, minimal lesions). Sputum conversion during treatment is crucial from an epidemiological standpoint, but it does not always mean the patient is "cured," as residual cavities often remain in the Lungs, potentially leading to disease progression. Therefore, in our country, the criteria for treatment efficacy include both achieving sputum conversion and the healing of lung cavities.

However, this program does not require excessive financial expenditure and allows for a relatively rapid reduction of the TB infection reservoir in resource-limited countries.

Questions

1. What are the primary Functions of a tuberculosis dispensary?

2. Which dispensary follow-up group do patients with active respiratory tuberculosis belong to?

3. Which individuals are monitored in dispensary registry Group IV? How often should they be examined at the TB dispensary?

4. Which dispensary follow-up group do patients with extrapulmonary tuberculosis belong to?

5. Which individuals are monitored in dispensary registry Group VII? How often are they examined at the TB dispensary?

6. In which group and for how long are patients with tuberculous lesions of undetermined activity monitored?

7. Which individuals are monitored in dispensary registry Group VI?

Case Study

- A 52-year-old patient lives in the district (family members include his wife, mother, and a 20-year-old son), who was treated in a tuberculosis hospital for two months for Infiltrative pulmonary tuberculosis, MBT-. Due to family circumstances, he is continuing his treatment at home.

1. Which dispensary registry group does the patient belong to?

2. How often should he visit the TB dispensary?

3. Which dispensary registry group do his family members belong to?

4. How often should they undergo follow-up examinations at the TB dispensary?