Dots Prof Zul

DOTS MANAGEMENT IN DOTS MANAGEMENT IN TUBERCULOSISTUBERCULOSIS

Zul DahlanZul DahlanDepartment of Internal Medicine Department of Internal Medicine

Medical Faculty of Padjadjaran University Medical Faculty of Padjadjaran University

Hasan Sadikin Hospital , BANDUNGHasan Sadikin Hospital , BANDUNG

MinilectureMinilecture

INTRODUCTIONINTRODUCTION Tuberculosis is an infectious disease that Tuberculosis is an infectious disease that

remain to be a major health problem in in remain to be a major health problem in in the world including Indonesia. the world including Indonesia.

Indonesia like other countries had adapted Indonesia like other countries had adapted WHO DOTS strategy for national TB control WHO DOTS strategy for national TB control and had succeed in variety of setting.and had succeed in variety of setting.

This presentation will disclose a few aspect This presentation will disclose a few aspect in the implementation of DOTS in the in the implementation of DOTS in the management tuberculosis, in pulmonary management tuberculosis, in pulmonary and extrapulmonary sites.and extrapulmonary sites.

World Health Organization

Country

1. India

2. China

3. Indonesia

7. Philippines

8. Pakistan

10. Russia

13. Viet Nam

22. Afghanistan

1,008,937

1,275,133

212,092

75,653

141,256

145,491

78,137

21,765

184

107

280

330

175

132

189

321

1,856

1,365

595

249

247

193

148

70

Population (thousands)

Cases (thousands)

Rate x105

Estimated Annual Incidence of TB Estimated Annual Incidence of TB in Selected High Burden Countries, in Selected High Burden Countries,

20002000

Implementation of DOTS, 2000Implementation of DOTS, 2000

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2001

Not implementing DOTS

Implementation in 10 to 90% of popImplementation in > 90% of pop

Implementation in < 10% of pop

No report

Low incidence non-DOTS country

10 FACTS OF TUBERCULOSIS10 FACTS OF TUBERCULOSIS

1.1. Mortality caused by TB increase every years Mortality caused by TB increase every years 2.2. TB has killed more young and adults more than TB has killed more young and adults more than

other infectious diseases other infectious diseases 3.3. TB mortality rate about 2 – 3 millions people every TB mortality rate about 2 – 3 millions people every

year can be preventedyear can be prevented4.4. Every second at least one person will be infectedEvery second at least one person will be infected5.5. Every 10 seconds one person will dieEvery 10 seconds one person will die6.6. Every year 1 percent world population will be Every year 1 percent world population will be

infected infected 7.7. Totally one third of world population have been Totally one third of world population have been

infected by TBinfected by TB8.8. Without treatment 1 active TB patient will infect Without treatment 1 active TB patient will infect

10-15 persons in 1 year10-15 persons in 1 year9.9. Similar with influenza, TB spread through air while Similar with influenza, TB spread through air while

the patient coughing, talking or sneezing the patient coughing, talking or sneezing 10.10. Death caused by TB usually occur slowly related to Death caused by TB usually occur slowly related to

chronic damage of lung and its complicationschronic damage of lung and its complications

10 FACTS ABOUT TUBERCULOSIS IN 10 FACTS ABOUT TUBERCULOSIS IN WOMEN AND CHILDWOMEN AND CHILD

TB IS THE CAUSE OF DEATH OF WOMEN MORE FREQUENTLY THAN TB IS THE CAUSE OF DEATH OF WOMEN MORE FREQUENTLY THAN CAUSE BY MATERNAL COMPLICATIONCAUSE BY MATERNAL COMPLICATION

TB IS CAUSE THE DEATH IN 1 MILLION WOMEN MORE THAN BY TB IS CAUSE THE DEATH IN 1 MILLION WOMEN MORE THAN BY OTHER INFECTION DISEASESOTHER INFECTION DISEASES

10% OF WOMAN AT REPRODUCTIVE AGE AT 1990 DIED BECAUSE OF 10% OF WOMAN AT REPRODUCTIVE AGE AT 1990 DIED BECAUSE OF TBTB

TB IS THE CAUSE OF DEATH OF 100.000 CHILDREN YEARLY, WHICH TB IS THE CAUSE OF DEATH OF 100.000 CHILDREN YEARLY, WHICH MAKE THEM ORPHAN AND BECOME FAMILY FUND GETTERMAKE THEM ORPHAN AND BECOME FAMILY FUND GETTER

TB ATTACK THE YOUNG AT PRODUCTIVE AGE TB ATTACK THE YOUNG AT PRODUCTIVE AGE

CHILDREN IS VERY SENSITIVE TO SUFFER SEVERE TB DISEASES, CHILDREN IS VERY SENSITIVE TO SUFFER SEVERE TB DISEASES, SUCH AS BRAIN TB AND SPINAL TBSUCH AS BRAIN TB AND SPINAL TB

WOMEN MOVEMENT HAS AN IMPORTANT ROLE IN TUBERCULOSIS WOMEN MOVEMENT HAS AN IMPORTANT ROLE IN TUBERCULOSIS ERADICATION PROGRAM IN VAROIUS PART OF THE WORLDERADICATION PROGRAM IN VAROIUS PART OF THE WORLD

BACKGROUND OF TB PROBLEM IN BACKGROUND OF TB PROBLEM IN DEVELOPING COUNTRIES DEVELOPING COUNTRIES

-Annually there are 1 millions new TB patients

- And TB is responsible for an annual 3 millions death

- 97 % patients located in developing c’ tries 25% can be

avoided

- In Indonesia : TB is third major cause of mortality ( SKRT ‘95)

MANAGEMENT OF TB IS BASED ON :-Species of causal mycobacterium - Infected organs- Advanced and progression of diseases

THE STRATEGY IS TO MORBIDITY & MORTALITY

* HIGH MORBIDITY AND MORTALITY RATE

FACTORS THAT PLAY ROLE IN THE FACTORS THAT PLAY ROLE IN THE MANAGEMENT OF TBMANAGEMENT OF TB

1. MYCOBACTERIUM: . SPECIES- . VIRULENCE

2. HOST : . IMMUNITY. ADHERENCE

3. MANAGEMENT & MEDICINE

CURED

INTERACTION

TREATMENT FAILURE IN TREATMENT FAILURE IN TUBERCULOSISTUBERCULOSIS

1. ASPECT OF ETIOLOGIC DIAGNOSIS :1. ASPECT OF ETIOLOGIC DIAGNOSIS :

- TB MANIFESTATION - TB MANIFESTATION MICOBACTERIOSISMICOBACTERIOSIS

2. HOST ASPECT :2. HOST ASPECT :

- IMMUNITY DEFICIENCY- IMMUNITY DEFICIENCY

3. DRUG ASPECT :3. DRUG ASPECT :

- RESISTANT MYCOBACTERIUM - RESISTANT MYCOBACTERIUM

- ADHERENCE TO THERAPY - ADHERENCE TO THERAPY

4. SOURCE OF INFECTION :4. SOURCE OF INFECTION :

- EASIER TRANSPORTATION BETWEEN COUNTRIES- EASIER TRANSPORTATION BETWEEN COUNTRIES

AFB/ PA/ DNA

EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY – DOTS METHOD

22. HOST FACTOR. HOST FACTOR

. GENETIC SENSITIVITY TO TB :. GENETIC SENSITIVITY TO TB : - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - FAMILIAL SYNDROMES : DISSEMINATION POST BCG - MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN- MENDELIAN SENSITIVITY : IMPAIRMENT OF IFN FUNCTION FUNCTION

.. INADEQUATE DRUGS DOSAGEINADEQUATE DRUGS DOSAGE

.. COMPLIANCECOMPLIANCE

EFFORT TO CONTAIN TUBERCULOSIS : - IDENTIFY MYCOBACTERIUM RESISTANCY - ADHERENCE TO TB THERAPY –> DOTS METHOD

COMPLIANCECOMPLIANCE

Tb Patient frequently did not have their medicine Tb Patient frequently did not have their medicine regularly and continuously because of :regularly and continuously because of :

Limited effort because of false understanding : Limited effort because of false understanding :

. Stopping medicine halfway because they are. Stopping medicine halfway because they are

feeling better feeling better TB relapse again TB relapse again

. “Taking the medicine too long “. “Taking the medicine too long “

. “Medicine too much”. “Medicine too much” High cost of therapy High cost of therapy Drug side effect/ untoward effect Drug side effect/ untoward effect

WITH TUBERCULOSIS :WITH TUBERCULOSIS :

- - Treatment is more than treatmentTreatment is more than treatment

- Treatment is prevention of :- Treatment is prevention of :

. further spreading of infection. further spreading of infection

. further process of disease. further process of disease

BASIC PRINCIPLES OF ANTI BASIC PRINCIPLES OF ANTI TUBERCULOSIS DRUGSTUBERCULOSIS DRUGS

Drug is effective during active multiplication phase of Drug is effective during active multiplication phase of

mycobacterium, not in dormant phasemycobacterium, not in dormant phase

Use in combination of 4 – 5 drugs, for 6 months of Use in combination of 4 – 5 drugs, for 6 months of

therapy or more therapy or more

The use of still effective drug for etiologic mycobacteriumThe use of still effective drug for etiologic mycobacterium

Patient has to take the medicine regularly, continuously in Patient has to take the medicine regularly, continuously in

adequate dosage and periodadequate dosage and period

1. Political commitment of policy makers, including provision of financial support

2. Diagnosis TB initiated by microscopic examination

3. Short term TB therapy using combination of anti tuberculosis drug (ATD) under direct supervising of drug taking supervisors (PMO)

4. Continuous supply of ATD for patients

5. Data collecting And Reporting for future supervising and evaluation of TB eradication program

5 COMPONENTS OF DOTS STRATEGY

DOTSDOTS

Direct Observed Treatment Short-CourseDirect Observed Treatment Short-Course

ACCURATE DIAGNOSIS,ADEQUATE PERIOD

FREE ANTI TB DRUGS

TAKING DRUGS UNDER SUPERVISING

MONITORING AND EVALUATION

POLITICAL

COMMITMENT

INCLUDING

FINANCIAL SUPPORT

TAKING COMBINATION DRUGS ON SUFFICIENT DOSAGE, REGULARLY, AND CONTINOUSLY

CURED

DIAGNOSISDIAGNOSIS

SPUTUM EXAMINATION :SPUTUM EXAMINATION :

. 3 times, Ziehl Neelsen smear. 3 times, Ziehl Neelsen smear

POSITIVE RESULT :POSITIVE RESULT :

Positive In 2 of 3 AFB smears, orPositive In 2 of 3 AFB smears, or

Positive in 1 AFB smear and chest x- ray (+)Positive in 1 AFB smear and chest x- ray (+)

MICROSCOPIC EXAMINATIONMICROSCOPIC EXAMINATION

More objective and reliable than chest x ray More objective and reliable than chest x ray

0102030405060708090

100

AFB Exam Chest xray

98%

70%

Agreement of medical Practitioner

CHEST X-RAY EXAMNATION CHEST X-RAY EXAMNATION Causing over- diagnosis of TBCausing over- diagnosis of TB

0102030405060708090

100

Suspect with positive Chest x-ray

True positive TB case

OVER DIAGNOSIS

TB CLASSIFICATION TB :TB CLASSIFICATION TB :

Related to 4 aspects :Related to 4 aspects :

- Organ involved in TB process : lung/ extra-lung - Organ involved in TB process : lung/ extra-lung

- result of sputum examination : AFB (+)/ AFB (-)- result of sputum examination : AFB (+)/ AFB (-)

- Previous history of TB therapy :- Previous history of TB therapy :

. New/ exacerbation, relapse, migration/ drop. New/ exacerbation, relapse, migration/ drop

out, failureout, failure

- Degree of severity of disease: mild or severe - Degree of severity of disease: mild or severe

DECISION ON CATEGORY OF THERAPY

IMPLEMENTATION OF TB THERAPYIMPLEMENTATION OF TB THERAPY

Aspect–aspect :Aspect–aspect : Decision on the category of TB therapyDecision on the category of TB therapyTherapy supervising :Therapy supervising :

. Healthcare officer, family, friend, etc. Healthcare officer, family, friend, etc

Monitoring of sputum ACB, duringMonitoring of sputum ACB, during : :

- intensive period - intensive period

- the end of therapy/ 1 month before the - the end of therapy/ 1 month before the

- follow up of sputum conversion - follow up of sputum conversion

Monitoring of therapy :Monitoring of therapy :

- cured, drop out, not cure - cured, drop out, not cure

THE CHOICE OF ANTITUBERCULOSIS DRUG BASED THE CHOICE OF ANTITUBERCULOSIS DRUG BASED ON CATEGORIESON CATEGORIES

Alternative of Combined Drug

CategoryOf therapy

Classification and Type of TB Patient TB

Intensive phase

(daily or 3x / week)

Late Phase

I New case AFB (+)New case AFB (-)Chest x-ray (+) with advanced

lung damage/ severe disease

New case of TB Severe extra pulmonary TB

case

2 HRZE*2 HRZE

2 HRZE

4 HRZE*4 HR

6 HE

II Patients : relapse failure drop out (after default)

2 HRZES / 1 HRZE*2 HRZES / 1

HRZE

5 H3R3E3*5 HRE

New case TB AFB (-) , Chest x-ray (+), mild disease

2 HRZ*2 HRZ

4 H3R3*6 HE

III Mild new ekstrapulmonary case 2 HRZ 4 HR

IV Chronic case Consultation to specialist for secondary medicine

Ward patients : Ward patients : 696 patients 15 – 24 years (34.1 %)696 patients 15 – 24 years (34.1 %)

Admitted TB at various departments :Admitted TB at various departments :Internal medicine : 76.1 %Internal medicine : 76.1 %Pediatric Pediatric : 8.5 %: 8.5 %NeurologyNeurology : 6.4 %: 6.4 %Orthopaedic Orthopaedic : 4.6 %: 4.6 %SurgerySurgery : 2.9 %: 2.9 %GynaecologyGynaecology : 0.6 %: 0.6 %

TB PREVALENCE AT RS HASAN SADIKIN ’95 - 98

. Pleura . Pleura : 16,2 %: 16,2 %

. Meningeal . Meningeal : 9,9 %: 9,9 %

. Peritonitis . Peritonitis : 8,3% : 8,3%

. Spondylitis . Spondylitis : 4,0 %: 4,0 %

. Limphadenitis: 2,2 %. Limphadenitis: 2,2 %

. Pericarditis . Pericarditis : 1,0%: 1,0%

. . Coxitis Coxitis : 1.0 %: 1.0 %

. Supracondylus. Supracondylus : 0.7 %: 0.7 %

. Skin. Skin : 0,4 % : 0,4 %

. Sinovitis : 0,3 %

. Hepar : 0,1 %. Renal : 0,1 %

• PULMONARY TB 55 %

TB MANIFESTATION AT HASAN SADIKIN HOSPITAL

• EXTRAPULMONARY TB 45 %

457 patients (M=53 %, W=46.4 %)457 patients (M=53 %, W=46.4 %)30.7 % UMUR 21 – 30 yrs30.7 % UMUR 21 – 30 yrs15.7 % > 60 yrs15.7 % > 60 yrsAFB (+) culture (+) = 14.9 %AFB (+) culture (+) = 14.9 %culture (+) = 12.7 %culture (+) = 12.7 %

TB PATIENTS TB PATIENTS

26.3 % 26.3 % 73.6 % 73.6 % DROP OUT DROP OUT CONTINUE CONTINUE

36.8 % 36.8 % 63.2 % 63.2 % REGULAR NOT REGULARREGULAR NOT REGULAR

34.3 %34.3 % 65.7 %65.7 % CUREDCURED NOT CURED NOT CURED

OUPATIENT CLINIC OF INTERNAL MDICINE DEPARTMENT OF ASAN SADIKIN HOSPITAL 1993

CLINIICAL STUDY OF TB CLINIICAL STUDY OF TB LYMPHADENITIS AT LYMPHADENITIS AT HASAN SADIKIN HASAN SADIKIN HOSPITALHOSPITAL

1.1. TB CULTURE FROM LYMPHADENITIC TB CULTURE FROM LYMPHADENITIC TISSUE – TISSUE – MISNADIARLY - 1994MISNADIARLY - 1994

- 27 SPECIMEN : - 43.5% MTC- 27 SPECIMEN : - 43.5% MTC - 56,5% MNTB- 56,5% MNTB

2.2. PCR + SEQUENCING OF GEN 16S rDNA PCR + SEQUENCING OF GEN 16S rDNA SEGMENT OF MYCOBACTERIUM – SEGMENT OF MYCOBACTERIUM – 2003 - ZUL DAHLAN2003 - ZUL DAHLAN

ELECTROFOREGRAMELECTROFOREGRAM

NCBINCBI results results ofof BLAST BLAST BLASTN 2.2.1 APR-13-2001BLASTN 2.2.1 APR-13-2001 QUERY = QUERY = ((576 LETTERS576 LETTERS))DATABASE : nt DATABASE : nt 958, 081 SEQUENCES; 4, 118, 683, 734 TOTAL LETTERS 958, 081 SEQUENCES; 4, 118, 683, 734 TOTAL LETTERS

Distribution of 638 Blast Hits on the Query SequenceMouse-over to show define and scores. Clik to show alignments

0 100 200

< 40 40 - 50 50 - 80 80 - 200 >= 200

300 400 500

Color Key for Aligment scores

Sequences producing signficant alignments Score(bits)

EValue

gi |175326|gb|M29563.1|MSGRR16SI M.gordonae 16S ribosomal RNA 480 e-133gi | 44345|emb|X52923.1|MGO16SRN Mycobacterium gordonae 16S… 478 e-132gi | 885642 |gb| U17276.1|MSU17276 Mycobacterium sp ( strain 33 …. 476 e-131gi |15620526 |gb| AF330038.2|AF330038 Mycobacterium montefiore … 438 e-120gi |12044813 |emb| AJ276890.1| AMY27690 Mycobacterium cf trip … 430 e-118

Table – Frequency Species of Mycobacterium Found in Various Organs

Organ

Lung Pleura Gland Peritoneum Total I.M. NonTuberculosis -MNTB 1. M. gordonae 2. M. alvei 3. M. ratisbonen 4. M. concordense 5. M.mucogenicum 6. M. avium 7. M. fortuitum 8. Uncultured Mycob. 9. M.peregrinum 10. M.septicum 11. M.paratuberculosis Total  II. M. Tuberculosis Complex 1. M. africanum 2. M. tuberculosis 3. M. canetti Total

43121111000

14  

640

10

31311010110

12  

431

8

30000201001

7  

1250

17

11001000000

3  

000

0

115433322111

36 (50,7%)  

22121

35 (49,3%)

Mycobact’rium Species

TABLE - GROUP OF MYCOBACTERIUM FOUND TABLE - GROUP OF MYCOBACTERIUM FOUND IN IN MULTIORGAN IN PATIENT MULTIORGAN IN PATIENT DIAGNOSED DIAGNOSED TUBERKULOSIS TUBERKULOSIS

83,1%

16,9%

MTC49,3%

MNTB50,7%

SLOW GROWING

FAST GROWING

WORKING TEAM ON PULMONARY & EXTRAPULMONARY TB ERADICATION

PROGRAM

TRAINING DOKTER/PERAWAT/

PARAMEDIS

PULMONARY & EXTRAPULMONARY

TUBERCULOSIS CENTRAL CLINIC

TEMPORARILY EVERY MONDAY MORNING

RESPIROLOGY TEAM

DIRECTOR

Director of Dr. Hasan Sadikin Hospital

COORDINATOR

RESPIROLOGY TEAM, RSHS/FKUP

PULMONOLOGY CLINIC

CLINIC OF INTERNAL MEDICINE & OTHER

DEPARTMENT

CLINIC

Doctor

REPORTING

Paramedic

DRUG

FARMACY

HOME VISIT

Social worker

Labora-

tory

DOTS CORNER CENTRAL DOTS CLINIC OF TUBERCULOSIS

DOTS PROGRAM AT HASAN SADIKIN HOSPITAL BANDUNG

TB PATIENTS

OTHER CLINICS

NEURO

CLINIC

ORTHOPAEDI

C CLINIC

INTERNAL MEDICINE

CLINIC

PEDIATRIC CLINIC

TBE (+)

THERAPY (+)

TBP +/- TBE

THERAPY

TBP +/- TBE

THERAPY

POJOK DOTS

DIAGNOSIS/ CATEGORICAL THERAPYDIAGNOSIS/ CATEGORICAL THERAPY

PATIENT PATIENT PATIENTS PATIENTS TB/ TBETB/ TBE CHILD CHILD

PATIENTSPATIENTS

ADULTADULTAFB (+)/ (-)AFB (+)/ (-)

DRUGSDRUGS

AMBULATORY SUPERVISING AMBULATORY SUPERVISING PATIENTSPATIENTS

EDDUCATION EDDUCATION PMOPMO

DOTS CORNER

HOME VISITHOME VISITOPTIONALOPTIONAL

SOCIAL WORKER

LABORATORYOFFICER

MEDICALPRACTITIONER

DATA COLLECTINGREPORTING

OFFICER

FARMACY-OFFICER

NATIONAL TRIAL ON DOTS NATIONAL TRIAL ON DOTS STRATEGYSTRATEGY

TRIAL ON 3 PROVINCE - 1995 :TRIAL ON 3 PROVINCE - 1995 :

Sulawesi, Jambi, Jawa TimurSulawesi, Jambi, Jawa Timur

Target :Target : Cure Rate > 85 %Cure Rate > 85 % Involvement 70%Involvement 70%

5 years continuous trial result : 5 years continuous trial result :

50% incidence decreased50% incidence decreased

TB CASES IN HASAN SADIKIN TB CASES IN HASAN SADIKIN HOSPITALHOSPITAL

Prevalence of new TB cases at hospital clinics:Prevalence of new TB cases at hospital clinics:

. Year 2000 : 3443 cases. Year 2000 : 3443 cases

. Year 2001 : 3354 cases. Year 2001 : 3354 cases

DOTS has been implemented since September, DOTS has been implemented since September,

1999 : 1999 :

. Patients visited clinic more regularly,which. Patients visited clinic more regularly,which

improved the cure rate from 34,7% to 86,5%improved the cure rate from 34,7% to 86,5%

APPLICATION OF DOTS AT RSHS- 1994JABAR HELATH

OFFICE- 1994

50 PACKET ATD

CATEGORY I

JPS – BK

(TH. 2000)

MEMBER OF

ASKES (KANWIL)

- Registration to Clinic

- Cytopathological

- pathologic exam.

- Culture and resistancy

COMPLETED NOT COMPLETED

Regitration

Free registration

Half cost is supported

Half cost by Askes- Cytopathological - pathologic exam. Culture and resistancy

STARTING

Personal payment wih

- Registration to Clinic- Cytopathological / pathologic exam. Culture and resistancy

- Examination

RESULT OF 50 PACKET OF ATD RESULT OF 50 PACKET OF ATD CATAGORY I AT HASAN SADIKIN CATAGORY I AT HASAN SADIKIN

HOSPITAL/ RSHS 1999HOSPITAL/ RSHS 1999

RESULT CASES INFORMATIONRESULT CASES INFORMATION  Cure 45 Cure 45 Failure 1 Failure 1 Move out 2Move out 2Default Default 2 2 cases: allergic to ATD 2 2 cases: allergic to ATD

2 Cases: do not control2 Cases: do not control

KESIMPULANKESIMPULAN

1.1. TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH TUBERCULOSIS REMAINS TO BE A MAJOR HEALTH PROBLEM IN INDONESIA WITH A HIGH MORBIDITY PROBLEM IN INDONESIA WITH A HIGH MORBIDITY AND MORTALITY RATE .AND MORTALITY RATE .

2.2. STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN STRATEGY OF DOTS HAS BEEN PROVEN TO BE AN EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT EFFECTIVE METHOD TO ERADICATE UBERCULOSIS. IT MUST BE DONE NATIONALLY AND SUPPORTED BY MUST BE DONE NATIONALLY AND SUPPORTED BY WHOLE COMMUNITY WITH ADEQUATE PERSONNEL, WHOLE COMMUNITY WITH ADEQUATE PERSONNEL, MEDICINE, AND FINANCIAL.MEDICINE, AND FINANCIAL.

3.3. RESISTANT MYCOBACTERIUM TUBERCULOSIS AND RESISTANT MYCOBACTERIUM TUBERCULOSIS AND OTHER SPECIES MAY HAMPER THE ERADICATION OF OTHER SPECIES MAY HAMPER THE ERADICATION OF TUBERCULOSIS AND MIKOBACTERIOSIS. ON THIS TUBERCULOSIS AND MIKOBACTERIOSIS. ON THIS CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC CIRCUMSTANCES CONFIRMATION OF ETIOLOGIC AGENT MUST BE DONE WHICH WILL BE HELPFUL IN AGENT MUST BE DONE WHICH WILL BE HELPFUL IN TREATING THE RESISTANT SPECIES.TREATING THE RESISTANT SPECIES.

THANK YOU THANK YOU

WIPE OUT MYCOBACTERIUM

……….. THE VICIOUS ENEMY