Tuberkulosis Pada Anak - Prof Heda

HEDA MELINDA N.
Education
• General Physician: Universitas Padjadjaran, 1982
• Pediatrician: Universitas Padjadjaran, April 1993
• Pediatrics Pulmonologist: June 2002
• Magister: Universitas Padjadjaran, April 2003
• Doctor: Universitas Padjadjaran, August 2008
Recent Position
Professor of Pediatrics
Department of Child Health
Universitas Padjadjaran / Hasan Sadikin General Hospital Bandung
Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
Bandung, November 26 – 27 2016
Heda Melinda Nataprawira
Departement of Child Health Dr. Hasan Sadikin General Hospital
Universitas Padjadjaran
Presented in Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

NO CONFLICT OF INTEREST

Global Strategies to Control TB
Childhood TB
STOP
Diagnosis Definitive and Classification
New Diagnosis Investigations

TB
New Dosages and Regimens Treatment
DOTS STRATEGY (1995) VISION
1. Political
Robert
END
Koch commitment withMid
TB
increased
80’s
STRATEGY
& DOTS
MILESTONE SDG EndTB
Discovered of END TB
discovered
sustained financing
2020
Streptomycin (2016 – 2035)
Unexpected 2025
A WORLD 2030
Strategy FREE OF TB
Strategy
2035
M. tuberculosis
1. Pursue high-quality rise in TB case
Reduction in number of TB DOTS expansion
Zero &
deaths, disease, and suffering due to TB
2. Case detection through quality-
enhancement 35% 75% 90% 95%
deaths
assured
compared 1.
(%) Integrated,
bacteriology
with 2015 patient-centered care &
2. Address TBprevention & HIV, MDR TB, & other
3. Standardized
challenges treatment, with
Reduction in TB incidence rate
with 2015 2.
supervision
Compared (%)&Bold
patientpolicies support 20%
& supportive 50%
systems 80% 90%
3. Contribute to health system strengthening
4. An1920 effective
– 1940 3. drug
Intensified 1943 –research
supply & 1952 & innovation GOAL SDGs were
4.Used
Engage all care providers Global TB STOP TB
of
management
TB-affected attenuated
familiessystemfacingDiscovered of adopted by
Emergency Strategy
M.5.
bovis BCG as TB vaccine
Empower persons INH & TB
with PAS &0% communities 0% 0% 0%
The UN
catastrophic cost due
5. Monitoring & evaluation system to TB (%) END & THE GLOBAL TB EPIDEMIC
6.effect
World
Enable & Introducing
measurement
Health Organization.
promote research
the End TB Strategy: Gear Up to End TB. 2015
100 Current global trend: -1.5%/year
Rate per 100,000/year
75
Optimize use of current &
-10% /year by 2025
new tools emerging from
pipeline, pursue universal
50 health coverage & social
protection
Introduce new tools: -5% /year
25 A vaccine, new drugs & treatment
regimens, and a point-of-care test
-17% /year
for treatment of active TB disease &
10 latent TB infection
2015 2020 2025 2030 2035
Source: WHO;2015
Global The six countries that
Distribution of stood out as having the
Estimated TB
largest number of incident
Incidence 2015
cases in 2015 were (in
(source: WHO;2016)
descending order) India,

Estimating the burden of TB in children (aged less than 15) is difficultChina, Nigeria,
Indonesia,
• 2011: 0.5 million cases and 64.000 deaths among children

Pakistan, and South Africa
(combined, 60% of the
• 2012: 530.000 TB cases among children and 74.000 TB death
global total). Of these,
• 2015: 1.0 million from 10.4 million new TB cases worldwide (10%)
China, India & Indonesia
happened to children alone accounted for 45%
(WHO;2012,WHO;2013,WHO;2014,WHO;2016)
of global cases in 2015.
Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII (source: WHO;2016)
ROADMAP FOR CHILDHOOD TUBERCULOSIS
Include the needs of children & adolescense in research,

policy development, & clinical practices
Collect & report better data, including on preventive

measures
Develop training & reference materials for health

care workers
Foster local expertise & leadership
Do not miss critical opportunities for intervention

source: WHO Roadmap;2013
ROADMAP FOR CHILDHOOD TUBERCULOSIS (cont.)
Engage key stakeholders
Develop integrated family-centered & community-

centered strategies
Address research gaps
Meet funding needs for childhood TB
Form coalitions & partnerships to improve tools for

diagnosis & treatment
source: WHO Roadmap;2013
DIAGNOSIS TB
IN CHILDREN

Aspect Adults Children
Epidemiology and Massive global disease burden that is Massive global disease burden that is
awareness well quantified; excellent awareness poorly quantified; minimal awareness
Health policy Main focus of NTPs Rarely recognized as a priority by NTPs
Pathogenesis of Usually adult-type lung disease Usually intrathoracic lymph node

lung lesions (previously referred to as post- disease (previously referred to as
primary TB) primary TB)
Bacterial load, Multibacillary Paucibacillary
transmission and
infection control High infection risk after close contact Low infection risk but can be infectious
if there is extensive lung involvement
(with or without cavities); epidemiologic
marker of transmission
Marais BJ. Update on childhood tuberculosis. Pulmão RJ. 2013;22(3);58–4.
Drug resistance Difficult to differentiate between Nearly always transmitted (primary) drug
acquired and transmitted (primary) resistance indicating recent transmission
drug resistance
Exposure history Important, but often neglected Absolutely essential part of work-up
Risk of Relatively low risk of progression to Highly variable risk of progression to

progression to disease following TB disease following TB exposure/infection -
disease exposure/infection greatest in the very young and/or
immunocompromised
Preventive Limited value, except in Definite value in young children (< 5 years
therapy immunocompromised adults of age) and immunocompromised
children
Imaging studies CXRs not routinely required, unless CXRs (with PA & lateral views, of good
sputum negative quality & competently read) are the most
informative studies
Disease Pulmonary vs extrapulmonary Intrathoracic lymph node disease best
classification classified as pulmonary TB
Post-primary TB is a confusing Diverse spectrum of pathology that
concept requires accurate classification
Microbiological Easy to collect adequate respiratory Difficult to collect adequate respiratory
studies specimens & confirm the presence specimens; smear microscopy has very
of mycobacteria low yield; cultures & NAATs have low-to-
moderate yield depending on disease
severity
Treatment With at least 4 drugs With 3 or 4 drugs depending on estimated
bacterial load and severity of disease
Prognosis Excellent outcomes achievable with Excellent outcomes achievable with

timely and appropriate treatment timely and appropriate treatment.
Delayed diagnosis resulting in potentially
severe outcomes.

Standards for diagnosis
Standards for treatment
Standards for addressing HIV infection

& other co-morbid conditions
Standards for public health & prevention
Tuberculosis care . International Standards for Tuberculosis Care.3rd ed.2014

Diagnostic Algorithm for TB in
Children

Child in close contact with a pulmonary TB source case
<5 years or HIV-infected > 5 years & HIV-uninfected
Well Symptomatic Symptomatic Well

INH
10 mg/kg
daily for 6 6H# Evaluate for TB No treatment
months
If becomes symptomatic If becomes symptomatic

Tuberculosis care . International Standards for Tuberculosis Care.3rd ed.2014 Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
Test Site Major Finding/RE
Sputum smear Pulmonary Fluorescence microscopy is on average 10% more sensitive than
microscopy conventional microscopy. Specificity of both fluorescence and
conventional microscopy is similar. Fluorescence microscopy is
associated with improved time efficiency.
Same-day sputum smear microscopy is as accurate as standard smear
microscopy. Compared with the standard approach of examination of
two smears with light microscopy over 2 days, examination of two
smears taken on the same day had much the same sensitivity (64% for
standard microscopy vs 63% for same-day microscopy) and specificity
(98% vs 98%)
Nucleic acid Pulmonary Commercial, standardized NAATs have high specificity and positive
amplification tests and extra- predictive value, however, they have relatively lower (and highly
(NAATs) [other than pulmonary TB variable) sensitivity and negative predictive value for all forms of TB,
Xpert MTB/RIF] especially in smear-negative and extrapulmonary disease.
Test Site Major Finding/RE
Xpert MTB/RIF Pulmonary TB Xpert MTB/RIF used as an initial diagnostic test for detection of M.
and tuberculosis and rifampicin is sensitive and specific. Xpert MTB/RIF is also
extrapulmonary valuable as an add-on test following microscopy for patients who are smear-
TB and RIF negative. An Xpert MTB/RIF result that is positive for rifampicin resistance
resistance should be carefully interpreted and take into consideration the risk of MDR TB
in a given patient and the expected prevalence of MDR TB in a given setting.
When used as an initial test replacing smear microscopy Xpert MTB/RIF
achieved a pooled sensitivity of 88% and pooled specificity of 98%. The
pooled sensitivity was 98% for smear-positive, culture-positive cases & 68% for
smear-negative cases; the pooled sensitivity was 80% in people living with HIV.
For detection of rifampicin resistance Xpert MTB/RIF achieved a pooled
sensitivity of 94% and pooled specificity of 98%.
Automated liquid Pulmonary TB Automated liquid cultures are more sensitive than solid cultures; time to
cultures and rapid and detection is more rapid than solid cultures.
MPT64-based species extrapulmonary MPT64-based rapid immunochromatographic tests (ICT) for species
identification tests TB; speciation identification has high sensitivity and specificity.
Sputum Smears Microscopy
• Direct smears
• Fluorescence microscopy
Culture
• Solid media (LJ, Middlebrook 7H10, Ogawa)
• Liquid media (BACTEC, MGIT)
Xpert MTB/RIF
Interferon-Gamma Release Assays (IGRAs)
• Interferon-Gamma Release Assays (IGRAs) are whole-blood tests that can aid
in diagnosing M. tuberculosis infection.
• They do not help differentiate latent tuberculosis infection (LTBI) from
tuberculosis disease.
• Two IGRAs that have been approved by the U.S. Food and Drug Administration
Interferon-gamma release assays (IGRAs) should not replace the tuberculin
(FDA) are commercially available in the U.S. They are:
skin test (TST) in low- and–middle-income
 QuantiFERON® countries
TB Gold In-Tube test for the diagnosis of
(QFT–GIT);
latent TBinfection
SPOT® TBintest
children or for the diagnostic work-up of children
(T–Spot)
(irrespective of HIV status) suspected of TB disease in these setting
Source: WHO Interferon Gamma release assays (IGRAS) ;2011 Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
A new test that is revolutionizing TB control by contributing to the
rapid diagnosis of TB disease and drug resistance
Automated, real-time molecular diagnostic
• PCR technology
• The test is a molecular test which detects the DNA in TB bacteria
• Simultaneously detection of TB, MDR-TB, and TB-HIV in less than 2 hours
• Nucleid acid amplification (NAA) test that uses a disposable catridge
• In comparison, standard cultures can take 2 to 6 weeks for MTBC to grow and conventional
drug resistance can add 3 more weeks
Simple process depends on acquiring sputum

The information provided by the Xpert MTB/RIF assay aids in selecting treatment
regimens and reaching infection control decisions quickly
WHO Xpert MTB/RI ;2013 Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
Marc T et al. Ped Infect Dis;2015 Bandung, November 26 – 27 2016
Xpert MTB/Rif should be used rather than conventional microscopy, culture & DST as the
initial diagnostic test in adults suspected of having MDR-TB or HIV-associated TB
(strong recommendation, high-quality evidence)
Xpert MTB/Rif should be used rather than conventional microscopy, culture & DST as the
initial diagnostic test in children suspected of having MDR-TB or HIV-associated TB
(strong recommendation, very low-quality evidence)
Xpert MTB/Rif may be used rather than conventional microscopy & culture as the initial
diagnostic test in all adults suspected of having TB
(conditional recommendation acknowledging resource implications, high-quality
evidence)
Xpert MTB/Rif may be used rather than conventional microscopy & culture as the initial
diagnostic test in all children suspected of having TB
(conditional recommendation acknowledging resource implications, very low-quality
evidence)
Xpert MTB/Rif may be used as a follow-on test to microscopy in adults suspected of

having TB who are not at risk of MDR-TB or HIV-associated TB, especially when further
testing of smear-negative specimens is necessary
(conditional recommendation acknowledging resource implications, high-quality
evidence)
“Xpert MTB/RIF performed better than
(smear) microscopy & generated
clinically relevant”
Presumptive TB
• A children who presents with symptoms or signs suggestive of TB
(previously TB suspect)
TB Case
• Bacteriologically confirmed TB case:
A biological specimen is positive by smear microscopy or culture
• Clinically diagnosed TB case:
Not bacteriologically confirmed, but diagnosed with active TB by a
clinician or other medical practitioner who has decided to give the
patient a full course of TB treatment
(previously a case of TB, not considered definite)
WHO TB definition revised; 2013 Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
WHO Guidelines for national TB; 2014 Bandung, November 26 – 27 2016
By Site of Disease
• Pulmonary tuberculosis (PTB):
Any TB case with involvement of the lung parenchyma or the
tracheobronchial tree, includes miliary and mixed PTB/extrapulmonary
(specific mention of the tracheobronchial tree)
• Extrapulmonary tuberculosis (EPTB):

Any TB case with involvement of organs other than the lungs, e.g.
pleura, lymph nodes, abdomen, genitourinary tract, skin, joints &
bones, meninges
WHO Guidelines for national TB; 2014 Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
By Previous TB Treatment History
• New:
Never been treated for TB or have taken anti-TB drugs for less than 1 month
• Previously Treated:
Have received 1 month or more of anti-TB drugs in the past
• Relapse:
Previously treated for TB, were declared cured or treatment completed at the
end of their most recent course of treatment, & are now diagnosed with a
recurrent episode of TB (either a true relapse or a new episode of TB caused
by reinfection)
• Treatment After Failure:
Previously treated for TB & whose treatment failed at the end of their most
recent course of treatment
By Previous TB Treatment History (cont.)
• Treatment after loss to follow-up:
Any previously treated for TB and were lost to follow-up at the end of
their most recent course of treatment (previously known as treatment
after default)
• Other previously treated:
Previously treated for TB but whose outcome after their most recent
course of treatment is unknown or undocumented (cases with unknown
previous TB treatment history classified separately)
• Unknown previous TB treatment history:
Do not fit into any of the other categories (new group)
Based on Drug Resistance
Main change: inclusion of rifampicin-resistant TB (RR-TB). RR-TB includes any
resistance to rifampicin, whether monoresistance, multidrug resistance,
polydrug resistance or extensive drug resistance. Category is not mutually
exclusive with the others
• Rifampicin resistance:
Resistance to rifampicin detected using phenotypic or genotypic
methods, with or without resistance to other anti-TB drugs
• Monoresistance:
Resistance to one first-line anti-TB drug only
Based on Drug Resistance (cont.)
• Polydrug resistance:
Resistance to more than one first-line anti-TB drug (other than both
isoniazid and rifampicin)
• Multidrug resistance:
Resistance to at least both Isoniazid & Rifampicin
• Extensive drug resistance:
Resistance to any fluoroquinolone and to at least one of three second-
line injectable drugs (capreomycin, kanamycin and amikacin), in
addition to multidrug resistance
Diagnostic Algorithm for Drug-
Resistant TB in Children

TB TREATMENT
REGIMENS IN CHILDREN

Recommended daily doses of first line anti-TB
drugs for children
Anti-TB Drug Dose & Range Maximum Dose

(mg/kg BW) (mg)
Isoniazid 10 (7-15)a 300
Rifampicin 15 (10-20) 600
Pyrazinamide 35 (30-40) -
Ethambutol 20 (15-25) -
aThe higher end of the range for isoniazid dose applies to younger children; as the
children grow older the lower end of the dosing range becomes more appropriate
Remark: as children approach a body weight of 25 kg,

clinicians can use adult dosing recommendations 2014

“A daily isoniazid dose of 8 – 12 mg/kg
should be recommended” Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII
USE OF ETHAMBUTOL IN CHILDREN
“Ethambutol is no longer contraindicated for
use in young children of less than 5 years of
age and is safe to use at recommended
dosages in all age groups”

Recommended treatment regimens for new cases
of TB in children
Anti-TB Drug Regimens

TB Diagnostic Category Intensive Continuation
Phase Phase
Low HIV prevalence (and HIV-negative children) and low isoniazid resistence settings
Smear-negative pulmonary TB
Intrathoracic lymph node TB 2HRZ 4HR
Tuberculous peripheral lymphadenitis
Extensive pulmonary disease
Smear-positive pulmonary TB
2HRZE 4HR
Severe forms of extrapulmonary TB (other than
tuberculous meningitis/osteoerticular TB)
Recommended treatment regimens for new cases
of TB in children (cont.)
Anti-TB Drug Regimens
TB Diagnostic Category Intensive Continuation
Phase Phase
High HIV prevalence or high isoniazid resistence or both
Smear-positive PTB
Smear-negative PTB with or without extensive
parenchymal disease 2HRZE 4HR
All forms of EPTB except tuberculous meningitis &
osteoarticular TB
All regions
Tuberculous meningitis & osteoarticular TB 2HRZE 10HR
MDR-TB Individualized regimens
TB-MDR TERDIAGNOSIS Treatment regimens for MDR-TB cases
in children
Gunakan OAT Golongan I yang masih sensitif Pyrazinamide (Z), Etambutol (E), INH (H)
Tambahkan 1 OAT Golongan II

Kanamisin (Km), Kapreomisin (Cm)
(OAT Injeksi)
Tambahkan 1 OAT Golongan III Levofloksasin (Lfx)
Tambahkan OAT dari Golongan IV sampai

Etionamid (Eto), Sikloserin (Cs), Para Amino
didapatkan 4 OAT Lini II yg tdk terbukti
Salisilat (PAS), Sodium Para Amino Salisilat
resisten
INH dosis tinggi, Clofazimin (Cfz), Linezolid

Tambahkan OAT dari Golongan V sampai
(Lzd), Amoksilin/Asam Klavulanat
didapatkan 4 OAT Lini II yg tdk terbukti
(Amx/Clv), Imipenem/Cilastatin (Ipm/Cln),
resisten
Thioacetazone (Thz), Klaritromisin (Clr)
Drug groups used to treat drug-resistant TB

Drug groups used to treat drug-resistant TB (cont.)

Management of TB in Children Living With HIV
Approach to diagnosis
• Essentially the same as for diagnosis in HIV-negative children
• Approach can be challenging because of:
✓ Lack specificity for diagnosis of TB
✓ Difficult to confirm the cause of acute or chronic lung disease for its
peak age prevalence is in infants & young children
✓ TST is less sensitive
✓ High incidence of acute & chronic lung diseases other than TB
✓ Co-infection can mask the therapy response
✓ Overlapping radiographic findings
Management of TB in Children Living With HIV (cont.)
Prevention of TB
• BCG vaccination should not be given to infants or children with HIV
• Contact screening and case-finding
• Primary prophylaxis
Children living with HIV more than 12 mths of age & unlikely to have TB on symptom-based
screening & have no contact with a TB case:
o Should be offered 6 months of IPT* if living at high TB prevelence

o Might be offered 6 months of IPT* if living at medium or low TB
prevelance
IPT : Isoniazid Preventive Therapy, 10 mg/kg/day range 7-15 mg/kg, max. 300 mg/day,
as part of a comprehensive package of HIV prevention & care services
Prevention of TB
In high TB prevalence settings, a 6 months of IPT may have additional

benefits to that of ART in protecting against TB
However, in settings with a medium to low prevalence of TB, IPT might
be offered considering resource implications
Treatment
• Children with suspected or confirmed pulmonary TB or tuberculous
peripheral lymphadenitis living in settings with a high HIV prevalence
should not be treated with intermittent regimens
• A four-drug regimen (HRZE) for 2 mths, followed by a two-drug regimen
(HR) for 4 months, same dose with non-HIV
• Should receive INH for an additional for 6 months, ones completed the
TB treatment
• Recommended additional therapy: Co-trimoxazole preventive therapy,
ART, & Pyridoxin supplementation
Vaccination
Prophylaxis pre & post TB exposure
Treatment of the latent TB infection
WHO Guidelines for national TB; 2014

Diagnostic confirmation based on molecular based
diagnostic test
Molecular based-diagnostic test may aid diagnostic

confirmation of TB, MDR-TB, & childhood TB-HIV cases
Changes (increasing) in dosage of anti-TB drugs
Principles of MDR-TB treatment regimens for children

are similar with adults
Administration of INH as a preventive measures of TB

transmission will lead to TB elimination

New update of recommended dosages & range for INH,
Rifampicin, Pyrazinamide, Ethambutol, & drugs for
childhood TB-HIV
Preventive measures of TB infection
Molecular based diagnostic test for pediatric TB

using Xpert MTB/RIF assay

THANK YOU..

Tuberkulosis Pada Anak - Prof Heda

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HEDA MELINDA N.

Presented in Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

New Diagnosis Investigations

descending order) India,

• 2011: 0.5 million cases and 64.000 deaths among children

Include the needs of children & adolescense in research,

Collect & report better data, including on preventive

Develop training & reference materials for health

Foster local expertise & leadership

Do not miss critical opportunities for intervention

Engage key stakeholders

Develop integrated family-centered & community-

Address research gaps

Meet funding needs for childhood TB

Form coalitions & partnerships to improve tools for

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Health policy Main focus of NTPs Rarely recognized as a priority by NTPs

Pathogenesis of Usually adult-type lung disease Usually intrathoracic lymph node

Risk of Relatively low risk of progression to Highly variable risk of progression to

Prognosis Excellent outcomes achievable with Excellent outcomes achievable with

Marais BJ. Update on childhood tuberculosis. Pulmão RJ. 2013;22(3);58–4.

Standards for treatment

Standards for addressing HIV infection

Standards for public health & prevention

Tuberculosis care . International Standards for Tuberculosis Care.3rd ed.2014

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

<5 years or HIV-infected > 5 years & HIV-uninfected

Well Symptomatic Symptomatic Well

If becomes symptomatic If becomes symptomatic

Simple process depends on acquiring sputum

Xpert MTB/Rif may be used as a follow-on test to microscopy in adults suspected of

• Extrapulmonary tuberculosis (EPTB):

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Anti-TB Drug Dose & Range Maximum Dose

Remark: as children approach a body weight of 25 kg,

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Anti-TB Drug Regimens

Tambahkan 1 OAT Golongan II

Tambahkan 1 OAT Golongan III Levofloksasin (Lfx)

Tambahkan OAT dari Golongan IV sampai

INH dosis tinggi, Clofazimin (Cfz), Linezolid

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

o Should be offered 6 months of IPT* if living at high TB prevelence

In high TB prevalence settings, a 6 months of IPT may have additional

Prophylaxis pre & post TB exposure

Treatment of the latent TB infection

WHO Guidelines for national TB; 2014

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Molecular based-diagnostic test may aid diagnostic

Changes (increasing) in dosage of anti-TB drugs

Principles of MDR-TB treatment regimens for children

Administration of INH as a preventive measures of TB

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

Preventive measures of TB infection

Molecular based diagnostic test for pediatric TB

Pendidikan Ilmu Kesehatan Anak Berkelanjutan (PIKAB) XIII

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