pp kuliah tobacco tb _ indonesia [tamb materi pp kuliah prof barmawi bag tbc)

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  • 8/11/2019 PP Kuliah Tobacco TB _ Indonesia [Tamb Materi PP Kuliah Prof Barmawi Bag TBC)

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    Tobacco and Tuberculosis

    Mini Lecture 1Module: Tobacco effects on respiratory system

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    Objectives of the Mini Lecture

    GOAL OF MINI LECTURE: Provide students with

    knowledge on the harmful effects of tobacco on tuberculosis,

    and skill to address smoking and to provide smoking

    cessation counseling for tuberculosis

    LEARNING OBJECTIVES

    Learners will be able to:

    Understand the burden of smoking among TB patients

    Understand the association between smoking and TB,and impact of smoking on TB

    Conduct counseling to encourage TB patients to quit

    smoking

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    CORE SLIDES

    Tobacco and tuberculosisMini Lecture 1

    Module: Tobacco effects on respiratory system

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    Global Burden of TB

    DOTS programmes (1995-2006): 31.8 million new and

    relapse cases, and 15.5 million new smear-positive cases

    In 2006: 9.2 million new cases (139 per 100 000), including

    4.1 million new smear-positive cases and 0.7 million HIV-positive cases

    83% of the burden were in Africa (23%), South-East Asia

    (35%) and Western Pacific (25%).

    12 among the 15 countries with the highest estimated TB

    incidence rates are in Africa, partly explained by the

    relatively high rates of HIV co-infection.

    (World Health Organization, 2007)

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    Tuberculosis in Indonesia

    TB as the third leading cause of death in Indonesia

    TB incidence decreased by 2.4% during 2004-2005 and

    its prevalence also decreased in the last 30 years

    Multidrug resistance new (1.6%), relapse cases (14%)

    DOTS adopted in 1995 with coverage of 98% (2000-2005)

    DOTS success rate treatment (90%), re-treatment (82%)(WHO, 2008)

    National Tuberculosis Programmes - Indonesia Stop TB

    Initiative /Gerdunas (Gerakan Terpadu Nasional)(Soemantri et al., 2007; MoH Indonesia, 2001)

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    Smoking: a risk factor for TB

    Smoking increases the risk of TB infection, the RR

    estimate for smokers is 1.73 (95% CI 1.46-2.04)

    compared to non-smokers.

    Smoking increases the risk of TB disease, the RRestimate for smokers ranges from 2.3 to 2.7 compared to

    non-smokers.

    Smoking increases the risk of TB mortality, the RR

    estimate for smokers is 1.60 (95% CI 1.31-1.95)

    compared to non-smokers.

    The risk estimates for TB infection, disease, and mortality

    are not independent.

    (Bates et al., 2007)

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    Passive smoking and tuberculosis

    Exposure to second-hand smoke increases the odds of

    getting TB infection by 3.3 times than the non-smokers.

    The risk of TB infection due to passive smoking exposureis significantly higher among children than adults.

    Evidence of dose-response relationship between

    exposure intensity and the risk of TB infection depends on the number of cigarettes consumed by familymember and the proximity of contact with smoking

    members.(Lin et al., 2007)

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    Smoking and Respiratory Infection

    the mechanisms

    Structural changes

    peribronchiolar inflammation and fibrosis

    mucosal permeability and changes in pathogen adherence

    impairment of the mucociliary clearance disruption of the respiratory epithelium

    Immunologic mechanisms

    decreased immune response & circulating immunoglobulins

    CD4 lymphopenia, CD8+ lympocyte counts depressed phagocyte activity, and decreased release of

    proinflammatory cytokines.(Arcavi and Benowitz, 2004)

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    Smoking cessation for TB patients

    q The clinical encounter is a teachable moment when the

    patient may be more receptive to cessation messages1

    q The physicians should take advantage of the clinical

    encounter to deliver cessation messages to all TB patients

    who smoke2

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    Engaging DOTS provider in

    smoking cessation

    In many countries with high TB prevalence, smoking

    cessation is not integrated in the TB control programmes,

    neither is DOTS provider involved.

    (Siddiqi and Lee, 2008)

    Smoking cessation should be integrated in TB management

    program and guideline. Health professionals should be

    provided appropriate knowledge and skills to provide

    cessation counseling to TB patients.(Slama et al., 2007)

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    OPTIONAL SLIDES

    Tobacco and tuberculosisMini Lecture 1

    Module: Tobacco effects on respiratory system

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    Burden of TB in 5 countries with

    highest number of TB patients

    TB Estimates (2006)India China

    Indon

    esia

    South

    Africa

    Nigeri

    a

    Incidence / 100,000 168 99 234 940 311

    Prevalence / 100,000 299 201 253 998 615

    Death / 100,000 28 15 38 218 81

    Case Detection Rate (%) 64 79 73 71 20

    DOTS treatment success (%) 86 94 91 71 75

    (World Health Organization, 2007)

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    Smoking TB clinical manifestation,

    conversion and relapses

    TB smokers has higher possibility of experiencing

    pulmonary TB, clinical manifestations, having cavitary

    lesions, and to be smear-positive.

    Smoking is not associated with sputum conversion two

    months after treatment, but smoking prolongs the

    conversion time among smokers than among non-smokers.

    Smoking is an independent predictor of TB relapse

    (OR=3.1), in addition to irregular treatment (OR=2.5) and

    drug resistance (OR=4.8)(Chiang et al., 2007)

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    Immunopathogenesis of smoking

    and tuberculosis

    Nicotine can reactivate latent mycobacterium tuberculosis

    by down-regulation of TNF- by the macrophages in the

    lungs lack of nitric oxide switch off the latent Tb state.(Davies et al., 2006)

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    Iron, smoking and tuberculosis

    Smoker inhales 1.1 g of iron from smoking 1 pack ofcigarettes.

    Iron levels in alveolar macrophages are higher in

    asymptomatic TB smoker (2 fold) and symptomatic TBsmoker (4.6-7 fold) than in nonsmokers.

    Iron loading promotes overgrowth of M.tuberculosis in

    bronchoalveoral macrophages and decreases the

    phagocytosis ability of macrophages.

    (Boelaert et al., 2007)

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    Smoking among TB patients in

    Indonesia

    Predictors for smoking relapse: young, started smoking at

    early age, perception that any level of smoking is harmless(Ng et al., 2008)

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    Quitting among TB patients in

    Indonesia

    30% of TB patients in Indonesia were never asked about

    their smoking behaviour or advised about quitting

    60% relapsed smoker received only general healthmessages and not TB-specific smoking messages.(Ng et al., 2008)

    Involving all health professionals in smoking cessation is

    essential