TUBERCULOSIS in FIJI
National TB Programme
Keywords: Tuberculosis, TB-Diabetes Mellitus (DM), Fiji
Tuberculosis (TB) is an infectious disease that is still a major threat to the population of Fiji. The populations most commonly affected by TB are those with low socioeconomic status, poor housing, and unhealthy lifestyles mainly in semi- urban and densely populated areas. In addition to this, other co-morbid conditions such as TB-HIV and TB-Diabetes Mellitus (DM) are challenges which the National TB Programme needs to address to fully control TB in Fiji.
The most recent data from WHO Global Report 2011 shows that Fiji has an incidence rate of 27/100,000 and a prevalence rate of 40/100,000 population. In 2010 there were approximately 191 active TB cases and in 2011 about 213 cases recorded by the national programme. The increase in case detection can be attributed to Advocacy, Communication and Social Mobilization (ACSM) activities, sensitizing medical staff on TB suspect identification, improvement of diagnostic services and other strategic activities supported by the Global Fund. Out of the 213 TB cases in 2011, Central/Eastern division represented 42%, Western 41% and Northern 17%. TB affects mostly the productive age group between 15 and 55 years old who are exposed to various social and environmental determinants. Males represent a higher number of TB cases than females. An estimated 7 to 11% of total TB cases are represented by children under the age of 15 years.
The Treatment Success Rate (TSR) of new smear positive TB cases in 2010 was at a low 67%. Out of the 33% that were not successfully treated, 6% had died, 24% had defaulted and 3 % were transferred out with their outcomes not recorded. The NTP is designing strategies to increase the TSR and especially reduce the number of defaulters through intensive follow up. The NTP continues to apply the Stop TB strategies in controlling TB in Fiji and eliminating it as a public health problem (1<1 million population).
CLINICAL PRESENTATION: SIGNS & SYMPTOMS
Any person with symptoms or signs suggestive of TB should be investigated for tuberculosis.
The most common symptom of pulmonary TB is a productive cough for more than 2 weeks, which may be accompanied by other respiratory symptoms including shortness of breath, chest pains, coughing up blood (haemoptysis) and/or constitutional symptoms including loss of appetite, weight loss, fever, night sweats, and fatigue.
The diagram below show the steps involved in diagnosing an active TB case.
AFB microscopy of sputum smear is a vital procedure in diagnosing TB and below is the steps to guide in the collection and transportation of sputum samples.
- Demonstrate to the patient how a good sputum specimen is produced by taking a deep breath and coughing deeply.
- Find an outdoor location, away from others, for the patient to expectorate sputum into the sputum container. For children, the use of nebulizers may help in stimulating the airways in order to obtain a good sputum sample.
- Ask the patient to screw the lid onto the container before returning it you.
- Make sure that the lid on the container is firmly close. Place the container inside a plastic bag. Wash your hands.
- When two specimens have been collected, send both the specimens together with the request form to the laboratory as soon as possible. If it cannot be despatched immediately store in a fridge if one is available or a cool place if there is no fridge.
- The specimen should be sent to the nearest DOTS centre within two days. Otherwise it should be sent to the nearest microscopy centre for fixing and then transfer to the DOTS centre.
TB suspects can be referred to any of the 3 DOTS Centers (Tamavua, Lautoka Hospital-Tagimoucia Ward and Labasa Hospital) using the Referral Form (Tub1).
All care providers for patients with Tuberculosis should ensure that persons (especially if symptoms suggestive of TB, children <5years of age, persons with HIV infection, and contacts to MDR/XDR- TB) who are in close contact with patients who have infectious TB are screened and attended to accordingly.
The key objectives of screening are to assess if the contact:
■ has undiagnosed TB
■ is at high risk of developing TB if infected.
■ is at high risk of having been infected by the index case
TB in HIGH RISK GROUPS
People living with HIV infection who are also infected with TB are at great risk of developing active TB. HIV testing of TB patients is conducted at all 3 DOTS Centers.
People with Diabetes Mellitus (DM) are 3 times more likely to get active TB. Type 2 diabetes involving chronic high blood sugar, is associated with altered immune response to TB. This leads to patients with diabetes and TB take longer to respond to anti-TB treatment. Screening for diabetes in TB patients is conducted at all DOTS centers
NTP now uses Fixed Dose Combination (anti-TB medicines) for intensive and continuation phase of treatment. Regimens are available for adults and children and for new patient and re- treatment cases.
The standard regimen for adults is: 2RHZE/4RH ( 2 months of Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol; plus 4 months of Rifampicin and Isoniazid). For dosage information, refer to the TB Technical Guidelines.
Evaluation of treatment outcome in new pulmonary smear-positive patients is used as a major indicator of programme quality. Outcomes in other patients (retreatment, pulmonary smear- negative, extra¬pulmonary) are analysed in separate cohorts. Each registered patient should have his/her outcome recorded in the register as soon as treatment course is completed. The following treatment outcome definitions should be used for sputum smear-positive patients.