MDR TB Dr F. Mansouri 1395/5/14

Pulmonary Tuberculosis a Major Public health concern

Tuberculosis Captain of all the Men of Death

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

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

Tuberculosis is a Social Disease with a Medical Aspect. Sir William Osler in 1902 (1849-1919)

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

M(X)DR-TB

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.

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.

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

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

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

TB has killed more people… but receives less funding TB has killed more people… 30,000,000 HIV/AIDS death 1813-2013 Malaria $43 billion HIV/AIDS Global Funding Tuberculosis $7 Billion TB 1990-2010 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. 7470 Suppl, S2 (2013)

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

M. tuberculosis Resistance Natural Resistant Mutants according to Bacillary Population INH 1 x 105-106 Bacilli RIF 1 x 107-108 Bacilli SM 1 x 105-106 Bacilli EMB 1 x 105-106 Bacilli PZ 1 x 102-104 Bacilli ? Quinolones 1 x 105-106 Bacilli ? Others 1 x 105-106 Bacilli ?

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.

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

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

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

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

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

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

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.

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

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

Treatment Of Tuberculosis XDR TB Treatment Of Tuberculosis 1884—sanatorium treatment (boosting of patients own resistance) 1890---cod liver oil , antimony and copper salts 1920---gold salts (sanocrysin, myocrisin) 1930—collapse therapy

Chemotherapy Of Tuberculosis XDR TB Chemotherapy Of Tuberculosis 1935-40 : Dapson And Sulfa 1940-50 : SM,PAS 1950-60 : INH, PZA 1960-80 : ETB, RMP 1950 - : Conventional chemotherapy 1980 - : Short course chemotherapy 1990- : MDR- TB 2006- : XDR- TB 2009 - : TDR -TB ……………

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.

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) .

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

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.

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

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

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 480 000 people developed MDR-TB (multidrug-resistant TB) in 2013, with 210,000 associated deaths

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

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

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

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

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 480 000 (range: 350 000‒610 000) new MDR-TB cases worldwide 300 000 (range: 230 000–380 000) 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

48% MDR treatment success globally

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, 1995-2013 BUT…. incidence falling too slowly at 1.5%/year

*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

MDR-TB: Five priority actions

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  

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

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

CHALLENGES US$ 2 billion funding gap per year for implementation of existing TB interventions. There is an additional gap of US$ 1.39 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

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.

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

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

«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

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

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

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

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

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

TB Notification Rate- I. R TB Notification Rate- I.R.IRAN-2014 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

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

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

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

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

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

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

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

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

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

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

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

مقاومت دارویی Drug Resistance 11/30/2018

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

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

کشورهای دارای بار بالای MDR-TB 1 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

High MDR-TB Burden Countries 1 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

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

National Drug Resistance Survey Result I.R.IRAN- 2014 MDR-TB (confidence Interval) Primary 0.84% (0.3-1.4) Secondary 12.40% (6.2-18.5)

سل و اچ آی وی TB-HIV 11/30/2018

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

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

نتیجه درمان Treatment Outcome 11/30/2018

>=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

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

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

Worldwide MDRTB Treatment Success 2009 WHO Global Tuberculosis Report 2012. http://www.who.int/tb/publications/global_report/en/index.html

Tuberculosis anywhere is everywhere

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

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

Prevention & Control of Tuberculosis in Prisons & Jails

Prevention & Control of Tuberculosis in Prisons & Jails

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

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

2020 2025 2030 2035 Getting there: Milestones TARGETS TARGETS TARGETS 35% reduction in TB deaths <85/100 000 TB incidence rate No affected families with catastrophic costs due to TB TARGETS 75% reduction in TB deaths <55/100 000 TB incidence rate No affected families with catastrophic costs due to TB TARGETS 90% reduction in TB deaths <20/100 000 TB incidence rate No affected families with catastrophic costs due to TB GOAL 95% reduction in TB deaths <10/100 000 TB incidence rate No affected families with catastrophic costs due to TB Key words: 4 , four stages, movement, timeline, years, period, ahead, steps, aspects

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

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

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.

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.

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.

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.

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

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

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.

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.

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

اهداف جهانی برنامه کنترل سل

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

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

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

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

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

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

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

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

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

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

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