Community Health Nursing 2012

Tuberculosis (TB) Tuberculosis is an infectious chronic respiratory disease caused by the tubercle bacilli . It can also affect others organs of the human body. Tuberculosis is curable and preventable. It most common among malnourished people living in crowded places in developing countries like Philippines. CAUSATIVE AGENT Mycobacterium tuberculosis (humans) Mycobacterium Africanun Mycobacterium bovis (from cattles, cow, rarely in

1. 2. 3. humans)

CHARACTERISTICS OF THE MYCOBACTERIUM

Figure 1 Mycobacterium Tuberculosis

TUBERCULOSIS Large nonmotile rod-shaped bacterium

An obligate aerobe, always found in the well-aerated upper lobes of the lungs.

Facultative intracellular parasite, usually of macrophages Has a slow generation time, 15-20 hours

MODE OF TRANSMISSION Airborne droplet via coughing, sneezing, laughing

Direct invasion thru mucous membranes/ breaks in skin

Exposure to TB cattle via ingestion of unpasteurized milk/dairy products (only in Bovine TB)
Figure 2 Bangladeshi with TB

Just so you know.. TB is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent. In 2010, 8.8 million people fell ill with TB and 1.4 million died from TB. Multi-drug resistant TB (MDR-TB) is present in virtually all countries surveyed. The estimated number of people falling ill with tuberculosis each year is declining, although very slowly. The TB death rate dropped 40% between 1990 and 2010. Source: WHO

HOW TB IS NOT SPREAD Through quick, casual contact, like passing someone on the By sharing utensils or food By sharing cigarettes or drinking containers By exchanging saliva or other body fluids By shaking hands Using public telephones

street

PERIOD OF COMMUNICABILITY As long as viable tubercle bacilli are discharged in the sputum

SUSCEPTIBILITY AND RESISTANCE Most hazardous period first 6-12 months after infection Children under 3 yrs of age, adolescents, the very old Immunosupressed, underweight, undernourished Persons with diabetes, gastroctomies, substance abusers

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SIGNS AND SYMPTOMS OF TB Cough (2-3 weeks or more) Coughing up blood Chest pains Fever Night sweats Feeling weak and tired Losing weight without trying Decreased or no appetite If you have TB outside the lungs, you may have other symptoms

TB infection: TB germs stay in your lungs, but they do not multiply or make you sick. You cannot pass TB germs to others TB disease: TB germs stay in your lungs or move to other parts of your body, multiply, and make you sick. You can pass the TB germs to other people TB OF THE LUNGS A. Active TB 1. Active pulmonary and laryngeal TB means a person infected with the TB bacteria is sick and can infect others unless they are taking medicine prescribed by their physician to treat TB. 2. Persons with active TB disease usually have some of the following symptoms: cough ( 3 weeks or more), feel weak, have a fever, lose weight, experience night sweats, cough up blood, or have chest pain when coughing. 3. Persons with active TB need to take their medications as prescribed in order to treat the disease and prevent the spread to others.

B. Latent TB 1. Persons with latent TB are identified by a positive skin test (PPD). 2. Persons who are not infected with Mycobacterium tuberculosis have a negative skin test (PPD). 3. When a person with a previously negative PPD, converts to a positive PPD, the conversion indicates recent infection with M. tuberculosis. DIAGNOSIS A. Mantoux skin test (PPD) B. Chest x-ray C. Sputum cultures A. MANTOUX SKIN TEST 1. Mantoux tuberculin skin test (PPD) is a skin test for identifying exposure to the TB bacteria, Mycobacterium tuberculosis (latent infection)

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2. The Mantoux test is recommended because it provides the most consistent and reliable result. 3. The Mantoux test is read 48-72 hours after administration. Induration or knot-like swelling at the test site is significant and the reaction is measured in millimeter units. Redness at the test site is not measured. 4. Persons with HIV or diseases affecting the immune system may have no response to the skin test. B. CHEST XRAY 1. A chest x-ray is ordered when a person presents a recent skin test conversion and is suspected of having TB. 2. If a chest x-ray is normal, further diagnostic testing may not be necessary. 3. If the chest x-ray shows signs of disease, further diagnostic testing will be needed to confirm TB disease. C. SPUTUM CULTURES 1. A sputum specimen is necessary to confirm that the TB bacteria is present in the lung. 2. The sputum specimens should: -come from deep within the lungs; -be obtained from the first coughed up sputum of the day, for 3 consecutive days -may be obtained through special respiratory therapy procedures. TREATMENT AND MEDICATION Treatment for Latent TB 1. Medication is given to prevent the Latent TB from becoming Active TB disease. 2. Preventive treatment reduces the risk of getting active TB by more then 90%. 3. Medication, usually Isoniazid (INH) should be taken as prescribed by the physician. The duration of treatment is usually 6-12 months. 4. INH is an antibiotic that kills the TB bacteria. INH may cause side effects, such as nausea, vomiting, and liver function abnormalities. Therefore, patients will be seen frequently by their doctor until treatment is over. 5. Persons who do not take the medication as prescribed may develop active TB, and treatment may be prolonged. Treatment for Active TB 1. When a person with active TB is diagnosed, they should be isolated from other people until the medication begins to kill the bacteria-usually 2 weeks, but sometimes longer. 2. When a person with active TB is diagnosed, they should be isolated from other people until the medication begins to kill the bacteria-usually 2 weeks, but sometimes longer. 3. The CDC recommends that infections due to Mycobacterium tuberculosis be treated with several drugs in addition to INH: Rifampin, Ethambutol, Streptomycin, and Pyrazinamide.

MEDICATION DRUGS

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Table 1 Drugs Daily Dose of Anti-tuberculosis Medications mg / kg (Maximum Dose) Adults INH 5 (300 mg) RIF 10 (600 mg) PZA See table 4 Children 10-15 (300 mg) 10-20 (600 mg) 15-30 (2 g) EMB See table 4 15-20 (1.0 g) See table 4 15 (900 mg) 10 (600 mg) See table 4 Twice Weekly Dose of Anti-tuberculosis Medications mg / kg (Maximum Dose) Adults Children 20-30 (900 mg) 10-20 (600 mg) 50 (4 g) 50 (4.0 g)

Table 2 Initial Phase Drugs Interval and Duration (Total Number of Doses) Option 1 (preferred) INH RIF PZA EMB Option 2 INH 3 times weekly DOT for 8 weeks (24 doses) INH RIF
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Continuation Phase Drugs Interval and Duration (Total Number of Doses) INH RIF (62 total doses over 26 weeks) Twice weekly DOT for 18 weeks (36 doses)

Daily DOT for 2 weeks (14 doses), and then twice weekly DOT for six weeks (12 doses)

3 times weekly DOT for 18 weeks

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(54 doses) RIF PZA EMB Option 3 INH RIF PZA EMB Daily for 8 weeks (56 doses) (DOT should be used for the entire treatment period.) INH RIF Daily for 18 weeks (126 doses: 182 total over 26 weeks) (78 total doses over 26 weeks)

TREATMENT FOR ACTIVE TB MULTIDRUG-RESISTANT TB (MDR) Multidrug-resistant TB is on the rise. MDR TB means that some TB bacteria have developed resistance, so that traditional antibiotics, like INH, no longer kill the bacteria. This is due to people not taking their medication properly; new strains of the bacteria evolve.

METHODS OF CONTROL AND PREVENTION Prompt diagnosis and treatment of infectious cases BCG vaccination of NB, infants, grade 1students Health education for the public about TBs mode of transmission, control, and early diagnosis Improve social conditions (overcrowding of areas) Isolation of TB pts Provision of PHN services for home supervision Identify and evaluate persons and health care workers exposed to infectious TB. Screen health care workers for skin test conversions. Conduct surveillance for TB cases among patients and healthcare workers. PHN RESPONSIBILITIES Interview and Open Treatment cards for identified TB pts Perform tuberculin testing and reading to pts Maintain records (treatment card) Manage distribution of drugs Assist physician in supervising other health workers in RHS for proper implementation of the policies and guideline Assist in training other health care workers in tuberculin testing and reading

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