.. 2556

.. 2556

1 25563,000

2 ()2556

19,000

116()

.10120

ISBN 978-616-11-1866-2

.. 2556

2 ()

.. 2556

1-12

..25562()

()

.. 2556 2 ()

(Abbreviation)

1 1

1.1 3

1.2 4

1.3 5

2 11

2.1 14

2.2 TheStopTBStrategy 14

2.3 15

3 19

3.1 21

3.2 23

3.2.1 23

3.2.2 25

3.2.3 25

3.2.4 27

3.2.5 28

4 (DOT) 31

4.1 33

4.2 36

4.3 37

4.4 41

4.5 43

4.6 45

4.7 (refer&transfer) 49

4.8 49

4.9 50

4.10 51

4.11(DOT) 53

.. 2556 2 ()

5 57

5.1 59

5.2 60

5.3 61

5.4 62

5.5 64

5.5.1BCG 64

5.5.2 65

6 71

6.1 73

6.2 73

6.3 74

6.3.1 75

6.3.2 75

6.3.3 79

7 85

7.1 87

7.2 88

7.3 88

7.4 MDR-TB 95

7.5 97

7.6 MDR-TB 100

7.7 101

7.8 MDR-TB 102

7.9 XDR-TB 102

8 107

8.1 109

8.1.1 109

8.1.2 110

8.1.3 111

8.1.4 112

8.1.5 112

8.1.6 113

.. 2556 2 ()

8.2 113

8.2.1 115

8.2.2 115

8.2.3 115

9 119

9.1 121

9.2 122

9.2.1 122

9.2.2 124

9.2.3 126

9.3 127

9.4 127

10 131

10.1 134

10.2 135

10.3/ 136

11 141

11.1 143

11.2 145

11.3 145

11.4 147

153

1 155

2 / 175

3 / 178

1

4 / 180

2

5 (ISTC) 181

..2556 184

2()

..2555 186

.. 2556 2 ()

1 ZNstaining 24

2 Fluorescenceacid-faststaining 24

3 AFB 24

4 36

5 40

6 40

7 4FDC 41

8 2FDC 41

9

43

10 45

11 48

12 52

13 SLD 63

14 97

15 99

16 144

17 146

.. 2556 2 ()

1 4

2 50

3

(Contactinvestigationandmanagement)

67

4 MDR-TB

DirectsmearXpertMTB/RIF

90

5 MDR-TB

DirectsmearXpertMTB/RIF

91

6 MDR-TB

Directsmear

XpertMTB/RIFLPALPA

92

7 MDR-TB

XpertMTB/RIF

93

8 5 150

.. 2556 2 ()

(Abbreviation)AFB acid-fastbacilli

AFRIMS ArmedForcesResearchInstitute

ofMedicalSciences

AIDS acquiredimmunodeficiency

syndrome

ALT alaninetransaminase

Amk amikacin

Amx amoxycillin

ART anti-retroviraltherapy

AST aspartatetransaminase

BCG BacilleCalmette-Guerin

BSC biologicalsafetycabinet

CBC completebloodcount

CD4 CD4lymphocyte

CDC-US CentersforDiseaseControland

Prevention(USA)

Cfz clofazimine

Cln cinlastatin

Clr clarithromycin

Clv clavulanate

Cm capreomycin

CPT co-trimoxazolepreventive

therapy

CrCl creatinineclearance

Cs cycloserine

CSF cerebrospinalfluid

CXR chestx-ray

CYP450 cytochromep450

DOT directlyobservedtherapy

DOTS theinternationallyagreed

strategyforTBcontrol

DST drugsusceptibilitytesting

DTC districtTBcoordinator

E ethambutol

EFV efavirenz

ELISA enzyme-linkedimmunosorbent

assay

EPI expandedprogramon

immunization

EPTB extrapulmonarytuberculosis

Eto ethionamide

FDC fixeddosecombination

FLD firstlinedrug

FLDST first-linedrugsusceptibilitytesting

H,INH isoniazid

HAART highlyactiveantiretroviral

therapy

HEPA high-efficiencyparticulateairfilter

HIV humanimmunodeficiencyvirus

IC infectioncontrol

ICNurse infectiouscontrolnurse

ICF intensifiedcasefinding

IFN- interferongammaIGRA interferongammareleaseassay

IOM InternationalOrganizationfor

Migration

Ipm imipenem

IPT isoniazidpreventivetherapy

IRIS immunereconstitution

inflammatorysyndrome

ISTC internationalstandardsfor

tuberculosiscare

.. 2556 2 ()

IUATLD InternationalUnionAgainst

TuberculosisandLungDisease

K,Km kanamycin

LED light-emittingdiode

Lfx levofloxacin

L-J lowenstein-Jensen

LPA lineprobeassay

LTBI latenttuberculosisinfection

Lzd linezolid

MAC mycobacteriumaviumcomplex

MDGs millenniumdevelopmentgoals

MDR-TB multidrugresistanttuberculosis

Mfx moxifloxacin

MOTT mycobacteriumotherthan

tuberculosis

MTBC mycobacteriumtuberculosis

complex

NNRTIs non-nucleosidereverse

transcriptaseinhibitors

NTM nontuberculousmycobacterium

NTP Nationaltuberculosiscontrol

programme

NVP nevirapine

O,Ofx ofloxacin

P,PAS para-aminosalicylicacid

PCP pneumocystiscariniipneumonia

PITC provider-initiatedHIVtestingand

counseling

PMDT programmaticmanagementof

drugresistantTB

PPD purifiedproteinderivative

PPM public-publicor

public-privatemix

PTB pulmonarytuberculosis

PTC provincialTBcoordinator

Pto prothionamide

R rifampicin

RTC regionalTBcoordinator

S,Sm streptomycin

SGOT serumglutamic-oxaloacetic

transaminase

SGPT serumglutamic-pyruvate

transaminase

SLD secondlinedrug

SLDST second-linedrugsusceptibility

testing

TAD treatmentafterdefault

TAF treatmentafterfailure

TB/HIV HIV-relatedTB

TLTI treatmentoflatenttuberculosis

infection

Trd terizidone

TST tuberculinskintest

UNAIDS JointUnitedNationsProgramme

onHIV/AIDS

UVGI ultravioletgermicidalirradiation

WHO WorldHealthOrganization

XDR-TB extensivelydrugresistant

tuberculosis

Z,PZA pyrazinamide

ZN ZiehlNeelsen

.. 2556 2 ()

1 .. 2556 2 ()

1

3 .. 2556 2 ()

1

(Tuberculosis TB) Mycobacterium

Mycobacterium Mycobacterium

tuberculosis ( 80)

Mycobacterium tuberculosis complex (MTBC)

Mycobacterium africanumMycobacterium bovis

MycobacteriumMycobacterium

AtypicalMycobacteriumMycobacteriumotherthantuberculosis(MOTT)

NontuberculousMycobacteria (NTM) 50

Mycobacterium aviumcomplex (MAC)

Mycobacterium

(droplets)

droplets

1.1

4 .. 2556 2 ()

droplets

(TBinfection)

90

10 (TB disease) 5%

2 5%

502

1

(TB infection and TB disease)1.2

(ExposuretoTB)

70% 30%(TBinfection)

*90%(LatentInfection)

50

10%(ActiveTB)25%25%

*

Source:StateGovernmentofVictoria,DepartmentofHealthServices,Australia.

5 .. 2556 2 ()

(primary tuberculosis)

primaryfocus

Ghonsfocus(mid-zone)

(lymphaticvessels)(hilarlymphnode)

primaryfocusprimarycomplex

(pleuraleffusion)

(atelectasis)

(bronchiectasis) (broncho-pneumonia)

(secondaryorpost-primarytuberculosis)

10

30-40150-705-7

..2536(..1993)(global

emergency)

1.3

6 .. 2556 2 ()

1 3

(prevalence)12

(infectious) (incidence) 8.6

1.3

22..2541

(..1998)80

1

.. 2555 (.. 2012)

80,000119

30

60,00050

..2537(..1994)9

..2543(..2000)15-40

62-7

..2542(..1999)

2.4..2544-2553

(..2001-2010)1-2

112

..2550-2552(..2007-2009)855,826862

93

3.4

7 .. 2556 2 ()

20-37

.. 2555

(..2012)8.61.112.8

1.3320,000(24.6)

..2554(

272555)91

15

9068

15

ThaiWorkingGroupA2*(TheAsianEpidemicModel(AEM)ProjectionforHIV/AIDSin

Thailand:2005-2025)..2553(..2010)

1,138,020

641,633 499,324

10,853

3

1..2540-

2541 (.. 1997-1998)

25.4 (multidrug resistant tuberculosis: MDR-TB)

2.012..25442545(..20001-2002)

14.8

(MDR-TB)0.933..2548-2549(..2005-2006)

15.7

1.65

8 .. 2556 2 ()

/

5-7

..2555(..2012)(MDR-TB)

1,760(800960)

..2553(..2010)400300

100

2(secondlinedrugs)

1. .:

.2:

,2546.

2. 2540-2549..

3. 2550-2555.

.

4. 2553..

5. 2550-2552 .

.

6.

2548-2552-..2554.

7. .2550-2552.

2554:32(2):92-100.

8. AkksilpS,WattanaamornkiatW,KittikraisakW,NateniyomS,etal.Multi-drugresistant

TBandHIVinThailand:overlapping,butnotindependentlyassociatedriskfactors.The

SoutheastAsianJournalofTropicalMedicineandPublicHealth2009:40(5):1264-78.

9 .. 2556 2 ()

9. HemhongsaP,TasaneeyapanT,SwaddiwudhipongW,etal.TB,HIV-associatedTBand

multi-drug resistant TB on Thailands borderwithMyanmar, 2006-2007. Journal of

TropicalMedicineandInternationalHealth2008:13(10):1288-96.

10. Tuberculosis:EpidemiologyandControl.WorldHealthOrganization,2002.

11. WHOreport2013.Globaltuberculosisreport2013:Geneva,WorldHealthorganization.

(WHO/HTM/TB/2013.11).

11 .. 2556 2 ()

2

13 .. 2556 2 ()

2

(Theinternationally

agreedstrategyforTBcontrol:DOTSstrategy)..2539(..1996)

TheStopTBStrategy..2549(..2006)

(Millennium Development Goals: MDG)

8

6(combatHIV/AIDS,Malariaand

otherdiseases)223

24 (case detection)

(TheStopTBStrategy)..2554(..2011)

(TheGlobalPlantoStopTB2011-2015)..2554-2558

4 (1)

DOTS(2)(3)

(4)

14 .. 2556 2 ()

1. 80

(successrate)90..2558(..2015)

2. 50..2558(..2015)

..2533(..1990)

1

(DOTS)

(DOT)

2

/

3

4

The Stop TB Strategy 6

2.2

2.1

15 .. 2556 2 ()

(Internationalstandardsfortuberculosiscare:ISTC)

5

6

6

1)

national tuberculosis control

programme:NTP

NTP

2) (.)

NTP

2.3

16 .. 2556 2 ()

3) (.)

NTP

4) (.)

5) / /

1. (Intensifiedcasefinding:ICF)

2.

1. (ISTC)

2. .

BCG(BacilleCalmette-Guerin)

(ExpandedProgramonImmunization:EPI)

/

(.)

.

17 .. 2556 2 ()

.

1. firstlinedrugssecondlinedrugs

2./

3.electronic

1. .

2549.2549.

2. .

2558.2:

,2554.

3. .

..2550.1:,2550.

4. ..

http://www.undp.or.th/thai/focusareas/mdgprogramme.html.

5. AnexpandedDOTSframeworkforeffectivetuberculosiscontrol.WHO/CDS/TB/2002.27.

6. Frameworkforeffectivetuberculosiscontrol.WHO/TB/94.179.

7. http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm.

8. The global plan to STOP TB 20062015. Actions for life towards a world free of

tuberculosis.WHO/HTM/STB/2006.35.

9. TheglobalplantoSTOPTB20112015.Transformingthefighttowardseliminationof

tuberculosis.

10. The STOP TB strategy. Building on and enhancing DOTS tomeet the TB-related

MillenniumDevelopmentGoals.WHO/HTM/TB/2006.368.

11. UnitedNationsDevelopmentProgramme.TheMillenniumDevelopmentGoals.Fastfacts.

http://content.undp.org/go/cms-service/download/asset?asset_id=2883030.

18 .. 2556 2 ()

12. UnitedNationssitefortheMDGIndicators.UnitedNationsStatisticDivision.Officiallist

ofMDGindicators.

13. WhatisDOTS?AguidetounderstandingtheWHO-recommendedTBcontrolstrategy

knownasDOTS.WHO/CDS/CPC/TB/99.270.

14. WHOlaunchesnewstopTBstrategytofighttheglobaltuberculosisepidemic.http://

www.who.int/mediacentre/news/releases/2006/pr12/en/.

19 .. 2556 2 ()

3

21 .. 2556 2 ()

3.1.1 (patient-initiatedpathway)passivecasefinding

/

3

3.1

22 .. 2556 2 ()

3.1.2 (screening pathway)

(intensifiedcasefinding:ICF)

patient-initiated

1) (contacts of TB cases) (

5)

2) (clinical risk groups)

(silicosis)(chronicobstructive

lungdisease)(malnutrition)

3) (riskpopulations)

3

(6

8)

(activecasefinding)

(TBpreva-

lencesurvey)

2

( )

(hemoptysis)2

(TB suspect)

(specimen)

23 .. 2556 2 ()

3 2

50

2

1 (spot sputum)

2(collectedsputum)

EQA (external quality assurance) smear

microscopy

3.2.1

(..)

1,100(lightmicroscopy)

smear Ziehl Neelsen (ZN)

LED(fluorescentlight-emittingdiode)

3.2

24 .. 2556 2 ()

1 ZN staining

Grading

()

0AFB/100 Negative - 200

1-9AFB/100 actualcellcounts

(AFB)

actualcellcounts

(AFB)

100

10-99AFB/100 Positive 1+ 100

1-10AFB/ Positive 2+ 50

>10AFB/ Positive 3+ 20

:acid-fastbacilli:AFB

2 fluorescence acid-fast staining

AFB

0AFB/30 Negative

1-29AFB/30 AFB

>29AFB/30 1+

1-10AFB/ 2+

>10AFB/ 3+

3 AFB

SCALE

(1,000 x field = HPF)

MICROSCOPY SYSTEM USED

LIGHT MICROSCOPY

(ZN Stain)FLUORESCENCE MICROSCOPY (Fluorescent Stain)

1,000 x magnification: 1

length = 100 HPF

200-250 x magnification: 1

length = 30 fields

400 x magnification: 1 length

= 40 fields

Negative 0AFB/1lengthor100HPF 0AFB/1lengthor30fields 0AFB/1lengthor40fields

Scanty 1-9AFB/1lengthor100HPF 1-29AFB/1lengthor30fields 1-19AFB/1lengthor40fields

1+ 10-99AFB/1lengthor100HPF 30-229AFB/1lengthor30fields 20-199AFB/1lengthor40fields

2+ 1-10AFB/1HPFonaverage 10-100AFB/1lengthonaverage 5-50AFB/1lengthonaverage

3+ >10AFB/1HPFonaverage >100AFB/1fieldonaverage >50AFB/1fieldonaverage

:WHOIUATLD

25 .. 2556 2 ()

24

AFB

AFB

AFB10,000/1

smear

AFB

(laboratoryregisterbook)

treatmentcard primarydefault

(scantyactualnumber)

1

(sputumsmearpositivecase)

3.2.2 (chest x- ray: CXR)

3.2.3 (culture)

74

1

(drugsusceptibilitytestingforfirstlinedrug)33

2(drugsusceptibilitytestingforsecondlinedrug)4

26 .. 2556 2 ()

1. (sputumsmearnegativepulmonarytuberculosis)

2. MDR-TB

2

3.

culture

(decontamination)

2

1.

decontamination

2.

biologicalsafetycabinet(BSC)

BSCclassII

decontaminationprocedure

aseptictechniquecerebrospinalfluid(CSF)

LowensteinJensen(L-J)culture

L-J 2%Ogawamedium

BBLMGIT

BactecMGIT960Oxygenconsuming

27 .. 2556 2 ()

48

(Nogrowth)BactecMGIT960

26Nogrowth

(drugsusceptibilitytesting:DST)

1.

2.

3.

4.

5. 3

1

12-14

3.2.4 (molecular examination; nucleic acid amplification)

Rapid identification Mycobacterium tuberculosis

(M. tuberculosis)

AFB

Xpert MTB/RIF real-time

polymerasechainreaction(cartridge)

rifampicin

()

() rifampicin

10099

XpertMTB/RIF

XpertMTB/RIF

3

28 .. 2556 2 ()

1. relapse,TAF

2.

3.

GenotypeMTBDR (HAIN Test) line probe assay (LPA)

isoniazid rifampicin

2

98 3

XpertMTB/RIF

3.2.5

(tuberculinskintest:TST)

BCGBCG

TST

TST5

BCG

BCG

interferongammareleaseassay(IGRA)

(latent TB infection) Incubate purified protein

derivative (PPD) control antigen interferon gamma

(IFN-) lymphocyte sensitized enzyme-linkedimmunosorbentassay(ELISA)

(activetuberculosisdisease)

1. ....

5:2546:ISBN974-331-083-5.

2. . . :

,2529.

29 .. 2556 2 ()

3. .

.

,2552.

4. .

.4:2547:ISBN974-297-224-9.

5. KawaiM.,andFujikiA.Minimumessentialoflaboratoryprocedurefortuberculosiscontrol.

6. KubicaGP.,DyeWE.,CohnML.,andMiddlebrookG.Sputumdigestionanddecotamination

withN-acetyl-L-cystein-soduimhydroxideforcultureofmycobacteria.AmRevRespir

Dis1963:87:775-9.

7. KubicaGP.,KaufmanAJ.,andDyeWE.Commentsontheuseofthenewmucolicagent,

N-acetyl-L-cystein,asasputumdigestantfortheisolationofmycobacteria.AmRevRespir

Dis1964:89:284-6.

8. Petroff,SA.Anewandrapidmethodfortheisolationandcultivationoftuberclebacilli

directlyfromthesputumandfecae.JExpMed1915:21:38-42.

9. TheResearchInstituteofTuberculosis,JATA,1988:p.53-4.

10. VanDeunA.andF.Portaels.Limitationandrequirementforqualitycontrolofsputum

smearmicroscopyforacid-fastbacilli.IntJTubercLungDis1998:2(9):75676.

11. VestalA.L.Procedure for the isolationofmycobacteriaDHEWpublicationNo. (CDC)

79-8230U.S.DeptofHealthEducationandWelfarePublicHealthService.Atlanta,Georgia.

1978.P.129-30.

12. WorldHealthOrganization.Earlydetectionoftuberculosis:Anoverviewofapproaches,

guidelinesandtools.WHO/HTM/STB/PSI/2011.21.WorldHealthOrganization2011.

31 .. 2556 2 ()

4

(Directly observed therapy: DOT)

33 .. 2556 2 ()

4 (Directly observed therapy: DOT)

1)(TBsuspect)

2

( ) / (

)

2)(TBCase)(definitecase)

3) (Definite case) Mycobacterium

tuberculosis complexculturemolecularlineprobe

assayM. tuberculosis

AFBsmear1definitecase

1.

(pulmonarytuberculosis:PTB)

miliary TB

(mediastinal and/or hilar lymph node)

(Pleuraleffusion)

4.1

34 .. 2556 2 ()

(extrapulmonarytuberculosis:EPTB)

2.

M. tuberculosis

(PTB+)

smear1

(PTB-)

smear2

smear2culture

M. tuberculosis

65 50

/

(PTB sputum smear not done)

3.

6

35 .. 2556 2 ()

1. (new)

1

2. (relapse) recurrent

(true relapse) (re-infection)

smearculture

3. (treatmentafterfailure)

(new patient regimen)

5 (remained positive)

(becamepositive)

2

4. (treatmentafterdefault)

2

smearculture

5. (transferin)

6. (other)

1

(bacteriologicallynegative

relapse)(bacteriologicallynegativeextrapulmonaryTB)

36 .. 2556 2 ()

4

+ - -

+

+

+

+ -

+ -

100

1)

(initialphaseintensivephase)

(continuationphase)2

dormantform

2)

3) (6

89)

4)

(DOT)

4.2

37 .. 2556 2 ()

(Dailypackage)(FixedDoseCombination:FDC)

DOT

2

1. 1(Firstlinedrugs:FLD)

(Isoniazid:H,INH)

(Rifampicin:R,RMP)

(Pyrazinamide:Z,PZA)

(Ethambutol:E,EMB)

(Streptomycin:S,Sm)

FDCHRHRZHRZEFDC

30-70

2. 2(Secondlinedrugs:SLD)

(Kanamycin:K,Km)

(Levofloxacin:Lfx)

(Ethionamide:Eto)

(Para-aminosalicylicacid:P,PAS)

(Cycloserine:Cs)

(Ofloxacin:O,Ofx)

4.3

38 .. 2556 2 ()

2010

3

1. (new patient regimen)

2HRZE / 4HR

1

culture(DST)

24H,R,Z,E4

2H,R

1 (1HRZE)

(2)

relapsefailureH

(pre-treatmentisoniazidresistance)

(delay response)

9-12

6-9

9-12

2. 1 (re-treatment regimen with first-line drugs)

2HRZES / 1HRZE / 5HRE

(treatmentafterdefault)(relapse)

cultureDST

39 .. 2556 2 ()

3 2 5H,R,Z,ES 3

41 5

3H,R,E

:

1 3

DST

3. (Empirical MDR regimen)

> 6Km5LfxEtoCs + PAS / > 12 LfxEtoCs + PAS

MDR-TB

DSTMDR-TBmoleculartest

MDR-TBEmpiricalMDR-TBcultureDST

DST (individualized or

tailoredregimen)

(5)6

4(

4Fluoroquinolone1)

18

8

4 20

18

empiricalMDRregimenDOT

(7)

: K S

(14)

(5)(6)

40 .. 2556 2 ()

5

././ ././

(maximum dose)

H 4-6 5 300./

R 8-12 10 600./

Z 20-30 25 2000./

E 15-20 15 1600./

S 12-18 15 1000./

S

S15././

6

**(.)

(.)*

H

4-6 ./

R

8-12 ./

Z

20-30 ./

E

15-20 ./

***35-49 300 450 1,000 800

50-59 300 600 1,500 1,000

60-69 300 600 1,500 1,200

70 300 600 2,000 1,200

*

**

***35(5)

41 .. 2556 2 ()

7 4FDC

4FDC (H75 R150 Z400 E275)

H

(.)

R

(.)

Z

(.)

E

(.)

30-37. 2 150 300 800 550

38-54. 3 225 450 1200 825

55-70. 4 300 600 1600 1100

8 2FDC (H75R 150, H100 R150, H150 R300)

2FDC H

(.)

R

(.)

30-37. H75R150 2 150 300

38-54. H75R150 3 225 450

H100R150 3 300 450

55-70. H75R150 4 300 600

H150R300 2 300 600

(2 )

4.4.1 (2HRZE/4HR)

1) culture DST DST

MDR-TBtreatmentfailureMDR-TB

DST

2)

(2)

2HR

2*

4.4

42 .. 2556 2 ()

*

(drug-to-drug/drug-to-food

interaction)

(immuno-compromisedhost)

NTM

HRHRZE

1

3

3) 3

(2)

3HR4

3

Culture DST Liquid media Rapid test

HR

4) 5

HR

cultureDST

liquidmediarapidtest(Moleculartest)

treatmentfailureMDR-TBempiricalMDR

regimenDST

5)

4.4.2 (2HRZES/1HRZE/5HRE)

culture DST DST

MDR-TBtreatmentfailureMDR-TB

DST

43 .. 2556 2 ()

(Drug to drug Interaction) (Drug to food Interaction)4.4

1) ( 3

)

3HRE

3DST

cultureDST

HRE

2) 5

5HRE

5culture,DSTrapid(molecular)test

treatmentfailureMDR-TB

empirical MDR regimen

DST

3)

9

H -

-

-

-

-

- 12

-

R - -

- 12

-

44 .. 2556 2 ()

Z

E -

-

- 2

- - - - 4

-

Ofx

- 20%

2

Eto - -

- -

-

Cs - -

B12folicacid

9 ()

45 .. 2556 2 ()

9 ()

4.6

PAS - - - -

2

1. majorsideeffect

2. minorsideeffect

10

S

(vertigonystagmus) S

() H,R,Z

() E

purpura R

S

Z,R,H

Z,E AspirinNSAIDSParacetamol

H Pyridoxine50-75

H

IntermittentdosingR

46 .. 2556 2 ()

3

prednisolone

systemic steroid

prednisolone40-60.

HREZ

1/31/22-3

/

H,RZbilirubin

aspartatetransaminase(AST)serumglutamic-oxaloacetic

47 .. 2556 2 ()

transaminase(SGOT)/alaninetransaminase(ALT)serumglutamic-pyruvatetransaminase

(SGPT)R

> 60

AST/ALTtotalbilirubin

AST/ALT totalbilirubin 1-2

1

AST/ALT>3H,RZ

AST/ALT3

3

totalbilirubin>3./.AST/ALT3R

AST/ALT5H,RZ

re-challenge

fulminanthepatitis

AST/ALT10 . ()

BCGM. tuberculosis

(

> 5 .)

IGRA

3.

60-80%

30-40%

3

5.2.2

(definitediagnosis)

()

5.2

61 .. 2556 2 ()

5.3.1

1.

2-3

2.

3.

4. BCG

Mantoux test

2-30.1..4872

1)>5.

steroid

2) >10 .

4

3)>15.BCG

BCG5

80-9010.10-14.

BCG > 15 .

5.3.2 Interferon gamma

BCG

M.tuberculosisInterferongamma

5.3

62 .. 2556 2 ()

ELISPOT(T-spotTB)96100

BCG

ELISPOT

Quanti FERON-TB Gold (QTF-G) 90

95LatentTuberculosisInfectionActiveTB

QTF-G

QTF-G

5.3.3

PCR

1-290PrimerPCR

PCR

(PCR)

intermittentregimen

E 25 ././

(DOT)

5.4.1

Rapid Advice WHO/HTM/

TB/2010.13Guidelinefortheprogrammaticmanagementofdrug-resistanttuberculosis

WHO/HTM/TB/2011.6

5.4

63 .. 2556 2 ()

1. FLD

*isoniazid

H*:10./.(10-15./.)max300./ 1

R:15./.(10-20./.)max600./ 1

Z:35./.(30-40./.) 1

E:20./.(15-25./.) 1

2.

(newpatientregimen)HR,ZE2

H R 4 (2HRZE/4HR)

2HRZE/10HREtoE

(retreatment regimen) H

R,Z,ES2HR,ZE1

HRE5(2HRZES/1HRZE/5HRE)

default 2

(gastricaspirate)

(MDR regimen)

(MDR-TB)

4fluoroquinolone1

> 6Km5LfxEtoCs+PAS / > 12 LfxEtoCs+PAS

13 SLD

././ ()

(.50 .)

Eto 15-20 2 500. 1

PAS 150 2-3 8 12

Cs 10-20 1 500. 1

Km 15-30 1 750. 1

Lfx 7.5-10 2 800. 800.

64 .. 2556 2 ()

5.4.2

1-2803

90410-12

6

2-3

2-3

95relapse1

BCG

5

5.5.1 BCG

BCG

1,200 BCG

5064

78

primary, reactivation exogenous cell

wallantigenrecombinanttechnologyBCG

BCG..2496-2499

(..1953-1956)2..2497-2509(..1954-1966)6..2510

(..1967)5-10

1-2..2520(..1977)EPI10.>15.

2..2538-2540(..1995-1997)..2542-2543(..1999-2000)

5 BCG

9.1 8.2

>15.22.618.72

(retrospective)(prospective)..2547-2549(..2004-2006)

1.64 61.4

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recentinfection

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(contactinvestigation)

67 .. 2556 2 ()

5 >15 . H 10 ././

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3 (Contact investigation and management)

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Isoniazid

6-9TST > 15 Isoniazid 6-9

TST 10-14

Isoniazid 9

< 5 > 5 HIV+

DOTS

:

68 .. 2556 2 ()

H5.(corticosteroid

>10.)

old fibrotic lesion

>10.

recentconverter2

(MDR-TB) 2

69 .. 2556 2 ()

1. . .. 2551.

5:2552:ISBN974-297-547-7.

2.

. .. 2555.

1 : 2555: ISBN978-616-

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3. , .

..2553.

4. ...

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.2550:28:185-9.

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2551:29:115-3.

7. ..

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71 .. 2556 2 ()

6

73 .. 2556 2 ()

1.

10

2.(recurrenttuberculosis)

(endogenousreactivationortruerelapse)

(exogenous re-infection)

/

1. (susceptibility)

6

6.1

6.2

74 .. 2556 2 ()

2.

3.

4.

5.

6.

7.

1. /

2. /

3. /

4. /

5. /

..2543(..2000)

12

..2547(..2004)

72..2548

(..2005)

6.3

75 .. 2556 2 ()

UNAIDS

1

53

6.3.1

1.

2.

3.

4.

6.3.2

3I/

1. (ICF)

/

/

/

..

76 .. 2556 2 ()

(Counselor)

(..)

clusterofdifferentiate

4(CD4)>200cells/mm3CD4

CD45)

H

79 .. 2556 2 ()

3.

(infectioncontrol:IC)

/ (

9)

6.3.3

1.

1-2

provider-initiatedHIVtesting

andcounseling(PITC)

PITC

3C

1) informedconsent

2) counseling

3) confidentiality

80 .. 2556 2 ()

CD4count

2.

81 .. 2556 2 ()

3. (co-trimoxazole

preventive therapy: CPT)

AIDS-definingillness

co-trimoxazole CD4 lymphocyte

4. (anti-retro viral therapy: ART)

CD4

CD4

2CD42DST

MDR-TB

4. MDR-TB:treatmentafterfailure(TAF)ofnewpatientregimen

FLD(5)

DSTMDR-TB

5. MDR-TB:treatmentafterfailure(TAF)ofretreatmentregimen

FLD5DSTMDR-TB

6.MDR-TB:transferin(SLD)

(transferout)

7.MDR-TB:others1-6

.()

.

.

96 .. 2556 2 ()

2

1.

2.

3.

4.(DOT)

(firstlinedrugs:FLD)

5.

6. SLD

97 .. 2556 2 ()

7.5

14

Group 1: First-line oral anti-tuberculosis agents

Pyrazinamide(Z)

(500.)1

20-30

././

2,000./

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(400,500.)1

15-20

././

1,600./

Group 2: Injectable anti-tuberculosis agents

Streptomycin(S)

1

15././ 1,000./

Amikacin(Amk)

1

15././ 1,000./

Kanamycin(Km)

1

15././ 1,000./

Capreomycin(Cm)

1

15././ 1,000./

Group 3: Fluoroquinolones

Levofloxacin(Lfx)

(250,500.)1

7.5-10././ 1,000./

Moxifloxacin(Mfx)

(400.)1

7.5-10././ 400./

98 .. 2556 2 ()

14 ()

Group 4: Oral bacteriostatic second-line anti-tuberculosis agents

Ethionamide(Eto)

(250.)2

15-20././ 1,000./

Prothionamide(Pto)

(250.)2

15-20././ 1,000./

Cycloserine(Cs)

(250.)2(12.)

10-20././ 1,000./

Para-AminoSalicylicacid(PAS)

(1)3-4

150-200././ 12,000./

Group 5: Anti-tuberculosis agents with unclear efficacy

Clofazimine(Cfz)

(50,100.)

100./ 100./

Linezolid(Lzd)

(600.)

600./ 1,200./

Amoxycillin(Amx)/Clavulanate(Clv)

875/125.2

4.Amx/

250-400.Clv

Clarithromycin(Clr)(500.) 500.2 1,000.

Imipenem/Cinlastatin(Ipm/Cln)

500-1,000.6.

4.50././

()

High-doseIsoniazid(High-doseH) 10-15././ NA

99 .. 2556 2 ()

mono-drug resistance poly-drug resistance

culture DST

MDR-TB

15

()

H(S) R,ZE 69

fluoroquinolone

HZ R,Efluoroquinolone 9-12

HE R,Zfluoroquinolone 9-12

R H,E,fluoroquinolone

Z2

12-18

RE(S) H,Zfluoroquinolone

2-3

18

(6)

RZ(S) H,Efluoroquinolone

2-3

18

(6)

H,E,Z(S) R,fluoroquinolone

1

2-3

18

(6)

MDR-TB

MDR-TB

DSTMDR-TBmoleculartest

MDR-TBEmpiricalMDR-TBcultureDST

DST (individualized or

tailoredregimen)

> 6Km5LfxEtoCs+PAS / > 12 LfxEtoCs+PAS

100 .. 2556 2 ()

(5)6

4

18

8

4 20

18

(MDR-TB regimen) DOT

MDR-TB

(central

nervoussystem)

H,Z,Pto,Eto100%Cs

80-100%

R10-20%

EPAS

Km, Am, S aminoglycoside

smearculture

2

DST

6

cultureconversionculture2

30 (culture conversion)

MDR-TB7.6

101 .. 2556 2 ()

7.7.1 (Interim outcome)

6

culture6culture2

30

(died)>2(defaulted)

(transferout)

7.7.2 (final outcome)

1. (cured) culture 5

1230

2.(completed)culture12

3.(failed)

culture2512

culture13

4.(died)

5.>2(defaulted)2

6.(notevaluated)

smearculture

2366

2

7.7

102 .. 2556 2 ()

MDR-TB7.8

(closecontact)MDR-TB

(indoorlivingspace)

4

MDR-TBMDR-TB

TST(tuberculinskintest)

IGRATestsmear,cultureDST

MDR-TB2

XDR-TB

1. 1(Z,ERifabutin)

2. (12 )

3. FluoroquinolonegenerationMoxifloxacin

4. 4(Eto/Pto,Cs,PAS)

5. 5 (Clofazimine, Linezolid, Thioacetazone, high-dose H, Clarithomycin)

2

6. HDST

7. (localizeddisease)

8. (Infectioncontrol)

9.

10.

XDR-TB

(11)

XDR-TB7.9

103 .. 2556 2 ()

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95-100.

3.

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107 .. 2556 2 ()

8

109 .. 2556 2 ()

8

182551(..

2008)

..2539(..1996)

(144)2544(..2001)

(Tuberculosis Coalition for Technical Assistance and International

CommitteeoftheRedCross,2009(..2552))

8.1.1

(screening pathway)

(1)1

8.1

110 .. 2556 2 ()

(screening method)

.) (symptomscreening)

21

1

1

1

6

2

.)

2

()

2

(patient initiative pathway)

(screeningmethod)

8.1.2

2550(..2007)70

111 .. 2556 2 ()

13

(DOT)

8.1.3 (collaborative TB/HIV activities)

41

2551 (.. 2008)

71

.

(pre-test counseling) (post-test

counseling)

.

pre-testpost-testcounseling

.

co-trimoxazole

112 .. 2556 2 ()

CD4

CD4

CD4

1-2

3-8

6

8.1.4 (TB recording reporting)

(TB03)

4TB07,TB07/1,TB08TB/HIV01M/XDR-TB

PMDT03,PMDT07PMDT07/1

5

8.1.5 (referral system)

10-16

(dischargeplanner)

(dischargeplanner)

113 .. 2556 2 ()

8.1.6 (supervision, monitoring and evaluation)

(on the job training)

2

(mentor)

3 5

(TB prevalence survey)

(TBdrugresistantsurveillance)

(migrantworker)

(cross - border population)

carrier

8.2

114 .. 2556 2 ()

..2539431,451372,242

390100,0005-6

1.

2.

3. (referralsystem)

4.

1. (registeredmigrant worker)

()

115 .. 2556 2 ()

2. ()

3. (illegalmigrantworker)

4. crossborderpopulation

8.2.1

1.

2.

3.

4. (screening pathway)

8.2.2

(NTP)

()

8.2.3 (monitoring and evaluation)

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9-11

2547.

2. ..:

.2546.

2-42546

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:

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4. .

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.

5. .

..2545.

:

9 - 11 2547

.

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119 .. 2556 2 ()

9

121 .. 2556 2 ()

10

particle droplet nuclei

1-5

(alveoli)

alveolarmacrophages

(dormantbacilli)(latentTBinfection)

(5-10)

9

9.1

122 .. 2556 2 ()

(recentinfection)

10

silicosis

3

1.

2.

3.

9.2.1

(expose)

9.2

123 .. 2556 2 ()

1)

2)

3)

7

3.1

3.2

3.3

3.4

3.5

3.6

3.7

4)

(TB suspect)

2

5)

124 .. 2556 2 ()

6)

2-3

7)

8)

MDR-TB

surgicalmask

2

9)

9.2.2

125 .. 2556 2 ()

1)

(naturalventilation)

()

(mechanicalventilation)

)

)

)

high-efficiency particulate air (HEPA) filter

(ultravioletgermicidalirradiationUVGI)

)

2)

(directultravioletgermicidalirradiation

fixture)

126 .. 2556 2 ()

(upperroomorshielded

ultravioletgermicidalirradiationfixture)

3)HEPA

9.2.3

MDR-TBbronchoscopy

1.surgicalmask

mask

surgical mask (

)

127 .. 2556 2 ()

2.

1HEPAmask,N95bronchoscopy

1.

2.

(tuberculinskintest)

2.1

61

2.21-3(two-steptest)2

boosted reaction 2.1 2

tuberculin1-2

(tuberculin conversion) 1-2

1

6

(riskassessment,developmentoftheTBinfection-controlplanandperiodicreassessment)

9.3

9.4

128 .. 2556 2 ()

129 .. 2556 2 ()

(drug

susceptibilitytesting)

1. .

.,2529:17:131-6.

2. 2540-2549..

3. ..

.:

2550.

130 .. 2556 2 ()

4. . .

..2554.:

.

5. .

...2553,:

.

6. .

...2549.

7. .

.:2552.

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(Public-PrivateMix:PPM)

(ISTC)

()

/

DOTS

10

134 .. 2556 2 ()

()

10.1.1

(3)

10.1.2

(11)

10.1.3

(NTP)

10.1

135 .. 2556 2 ()

10.1.4

10.1.5

DOT

(Multidrug-Resistant Tuberculosis: MDR-TB)

DOT

10.1.6

6- 8

2(refer)(transfer)

1.

/

13

2. (hospital TB coordinator)

(infectious

controlnurse:ICnurse)

10.2

136 .. 2556 2 ()

/ (public private mix: PPM)10.3

3. /

3.1/

/

/

/

3.2

./

3.3/

4. /

5.

/

6.

/

137 .. 2556 2 ()

1.

/

2.

3.

4. (TB

networkmeeting/DOTSmeeting)

34/

5.

6.

3

138 .. 2556 2 ()

1. DOTS (Public-Private

PartnershipforTBcontrol):

.9-11

2547.

2. :

.

2546.2-42546

.

3. DOTS

:

. 9-11 2547

.

4.

:

.9-11

2547.

5.

..2545

:

9-112547

.

6. .2553.:

.

7. .

2551.5:2552:ISBN974-297-547-7.

8. .

2558.2:

2554.

139 .. 2556 2 ()

9. .

..2550.1:.2550.

10. AmericanThoracicSociety/CentersforDiseaseControlandPrevention/InfectiousDiseases

SocietyofAmerica:Treatmentoftuberculosis.AmJRespirCritCareMed2003:67:603

662.

11. CentersforDiseaseControlandPrevention.TreatmentofTuberculosis,AmericanThoracic

Society,CDC,andInfectiousDiseasesSocietyofAmerica.MMWR2003:52(No.RR-11):177.

12. Drug Information handbookhwith International Trade names index 2008-2009. 17th

edition.AmericanPharmacistAssociation.SeniorEditor:CharlesFLacy,LoraLArmstrong,

MortonPGoldman,LoonardLLance.

13. TheSanfordGuidetoAntimicrobialTherapy2009.39thedition.Editors:DavidNGilbert,

RobertCMoolleringJr,GeorgeMEliopoulos,HenryF(Chip)Chambers,MichaelSSaag.

14. UpToDate.Availableathttp://www.uptodate.com/indexMicromedex.

15. World HealthOrganization 2003. Treatment of Tuberculosis: Guidelines for National

Programmes. 3rd Edition. WHO, Geneva, 2003. WHO/CDS/TB/2003.313WHOModel

Formulary2008.

16. TreatmentofTuberculosis:GuidelinesforNationalProgrammes.3rdEdition.WHO2003,

Geneva.WHO/CDS/TB/2003.313WHOModelFormulary2008.

17. WHOModelFormulary2008.

18. WorldHealthOrganization2010.Treatmentoftuberculosis:Guidelines.4thedition.WHO/

HTM/TB/2009.420

141 .. 2556 2 ()

11

143 .. 2556 2 ()

(supervision)(monitoring)(evaluation)

(supervision)

3

(evaluation)

1

interimevaluation

11.1.1

1

(quality)(reliability)

(verification)

11

11.1

144 .. 2556 2 ()

11.1.2 (.)

.13

.

(on the job training)

1.

2.

3. ()

16

RTC 4

PTC+RTC 4

.. DTC/TBclinic 4

:

1. RTC(RegionalTBCoordinator:)

PTC(ProvincialTBCoordinator:)

DTC(DistrictTBCoordinator:)

TBClinic:

2. RTC PTC ()

..

3. ..DTCTBclinic

DTCTBclinic..

145 .. 2556 2 ()

3

)

)

11.2

11.3

146 .. 2556 2 ()

17

1.

(casedetection

rateforallformofTB)

2.

(sputum

conversionrate)

(

)

(

)

3.

(treatmentsuc-

cessrate)

(

)

(

)

4.

(defaultedrate)

(

)

2

(

)

5.

(failurerate)

(

)

(

)

6. (deathrate) (

)

(

)

died

7.

(transferredoutrate)

(

)

(

)

8.

(HIVtesting

rate)

()

(

)

()

147 .. 2556 2 ()

17 ()

9.

(HIVposi-

tiverate)

10.

(ARTrate)

()

(

)

()

(

)

11.

co-trimoxazole

(CPTrate)

()

co-tri-

moxazole

(

)

CD4