GERIATRIC TUBERCULOSIS: ISSUES Dr. (Prof.)Vijay Kumar Arora Vice Chancellor Ex Director NITRD Delhi,Ex Director-professor JIPMER, Ex Additional DGHS GOI

Epidemiology

EPIDEMIOLOGY Of overall population, elderly in India Of overall population, elderly in India In 2001: 7.4% In 2001: 7.4% In 2011: 8.3% In 2011: 8.3% In 2015: 10% In 2015: 10% Situational analysis of elderly in India. Central Statistics Office Ministry of Statistics & Programme Implementation Government of India, mospi.nic.in/ mospi_new /upload/elderly_in_india.pdf. Situational analysis of elderly in India. Central Statistics Office Ministry of Statistics & Programme Implementation Government of India, mospi.nic.in/ mospi_new /upload/elderly_in_india.pdf. Rath SP, Das B, Mishra SK (2011) Demographic dynamics of India’s population - A reference study of census-2011 with backdrops and future trends. Int J of Business and Management tomorrow Rath SP, Das B, Mishra SK (2011) Demographic dynamics of India’s population - A reference study of census-2011 with backdrops and future trends. Int J of Business and Management tomorrow A study from South India: older TB patients (>60 yrs) accounted for 14% of all TB patients (24/100,000) A study from South India: older TB patients (>60 yrs) accounted for 14% of all TB patients (24/100,000) Ananthakrishnan R, Kumar K, Ganesh M, Kumar AMV, Krishnan N, et al.(2013) The Profile and Treatment Outcomes of the Older (Aged 60 Years and Above) Tuberculosis Patients in Tamilnadu, South India. PLoS ONE 8(7):e doi: /journal.pone Ananthakrishnan R, Kumar K, Ganesh M, Kumar AMV, Krishnan N, et al.(2013) The Profile and Treatment Outcomes of the Older (Aged 60 Years and Above) Tuberculosis Patients in Tamilnadu, South India. PLoS ONE 8(7):e doi: /journal.pone

Pathogenesis Some infected older persons, given enough time, will eventually eliminate the viable AFB and revert to a negative tuberculin reaction status. Some infected older persons, given enough time, will eventually eliminate the viable AFB and revert to a negative tuberculin reaction status. A major component of the immune system affected by aging is a decline in the ability of aging T- lymphocytes to produce specific cytokines. A major component of the immune system affected by aging is a decline in the ability of aging T- lymphocytes to produce specific cytokines. These older persons have no lasting immunity and are thus susceptible to re infection These older persons have no lasting immunity and are thus susceptible to re infection

Geriatric Tuberculosis in Himachal Pradesh – A Clinico-Radiological Profile V K Arora ; R S Bedi Atypical symptoms Atypical symptoms Delayed action taken Delayed action taken Poor Compliance Poor Compliance 65% had exudative lesions 65% had exudative lesions JAPI 1989, Vol 37, No. 3

Diagnosis: Post-Primary (Reactivation) TB (PA View)

Case Report march 2015

CASE REPORT APRIL 2015

Case Report

Retrospective study, 7439 pts under DOTS, Retrospective study, 7439 pts under DOTS, Jan 1996 to March 2001 Jan 1996 to March 2001 Treatment outcomes of NSP geriatric TB patients vs younger pts Treatment outcomes of NSP geriatric TB patients vs younger pts Lower sputum conversion: 75.3% vs 85.7% Lower sputum conversion: 75.3% vs 85.7% Lower cure rates: 69.2% vs 80.7% Lower cure rates: 69.2% vs 80.7% Higher exclusion rates from DOTS: 2.3% vs 0.15% Higher exclusion rates from DOTS: 2.3% vs 0.15% Higher treatment failure rates Higher treatment failure rates

Objectives Of Programme Achieve 90% notification rate for all Achieve 90% success rate for new and 85% for re-treatment To improve the outcomes of Drug Resistant cases Achieve decreased morbidity and mortality of HIV and TB Improve outcomes TB care in private sector.

Cost effectiveness PPM model

Control Strategies Stopping Progression from infection to active disease Stopping Progression from infection to active disease Diagnosing & treating active disease Diagnosing & treating active disease

Between young and elderly TB patients Between young and elderly TB patients No significant difference in No significant difference in Adverse drug reactions Adverse drug reactions Favorable Treatment outcomes Favorable Treatment outcomes

Management Strategies Strategy for early case detection by improving diagnostic facilities Strategy for early case detection by improving diagnostic facilities Diagnostic algorithm should go beyond the passive case finding Diagnostic algorithm should go beyond the passive case finding Communication strategies to bring people to health facilities Communication strategies to bring people to health facilities Improve the living standards Improve the living standards

Development of the wave of tuberculosis epidemic through time

Future -Strategies New tools : Point of care test New tools : Point of care test New policies : Use of Technology New policies : Use of Technology New Delivery models : Public Private/Private mix New Delivery models : Public Private/Private mix Resources : High allocation Resources : High allocation Innovative amendment in RNTCP Innovative amendment in RNTCP

Diagnosis: Clinical Manifestations Diagnosis: Clinical Manifestations The presence of acute or chronic illnesses existing concurrently with tuberculosis may obscure the diagnosis by altering the presentation The presence of acute or chronic illnesses existing concurrently with tuberculosis may obscure the diagnosis by altering the presentation Tuberculosis in an elderly person with chronic obstructive pulmonary disease (COPD) or lung cancer may be misdiagnosed, delaying therapy or may be completely missed, only to be found at autopsy Tuberculosis in an elderly person with chronic obstructive pulmonary disease (COPD) or lung cancer may be misdiagnosed, delaying therapy or may be completely missed, only to be found at autopsy

Diagnosis: Testing for M. tuberculosis Infection Diagnosis: Testing for M. tuberculosis Infection Mantoux tuberculin skin test (TST) Skin test that produces delayed-type hypersensitivity reaction in persons with M. tuberculosis infection Quantiferon Gold Blood test that measures and compares amount of interferon-gamma (IFN-  ) released by blood cells in response to antigens

Diagnosis: QuantiFERON ® - Gold Test Diagnosis: QuantiFERON ® - Gold Test Cells that recognize the antigen release interferon-  Cells that recognize the antigen release interferon-  Amount of interferon released in response to tuberculin is compared to amount released in response to other antigens 5 Amount of interferon released in response to tuberculin is compared to amount released in response to other antigens 5