THE KENYA MEDICAL TRAINING COLLEGE

FACULTY OF DIAGNOSTIC SCIENCES

DEPARTMENT OF LABORATORY SCIENCES

DIPLOMA IN MEDICAL LABORATORY SCIENCES

A RESEARCH ON PREVALENCE OF MYCOBACTERIUM TUBERCULOSIS

AMONG PATIENTS ATTENDING COAST COUNTY REFERRAL HOSPITAL.

ADMISSION NUMBER: D/MLS/16019/041

THIS RESEARCH IS SUBMITTED IN PARTIAL FULFILLMENT FOR THE

AWARD OF A DIPLOMA IN MEDICAL LABORATORY SCIENCES

2017

1
DECLARATION.

I hereby declare that this research project is my own work and has never been submitted by any

other person in any other institution for the award of the diploma, certificate or degree for the

best of my knowledge.

NAME: KAMBUA MULWA

REGISTRATION NUMBER: D/MLS/16019/041

SIGNATURE: ________________

DATE: ________________

I confirm that this research project was prepared under my supervision and has my approval to

be presented for the examination as per the KMTC Kisii examination regulations.

NAME: MR. ONCHIRI

SIGNATURE: ________________

DATE: ________________

2
Acknowledgment
I take this occasion to thank God, Almighty for blessing me with his grace and taking my
endeavor to a successful culmination. I extend my sincere and heartfelt thanks to my esteemed
project supervisor Mr. Onchiri for providing me with the right guidance and advice at the crucial
junctures while writing this proposal.

3
ABSTRACT
The research was conducted coast general hospital. The study aimed to determine the
prevalence of TB among patients and also trying to get the relationship between TB and HIV.
It will be done between January and April. The main proposed deliverable is to clearly
understand and document the preventive measures to curb the increase in TB infections and
also to give a prerequisite in research of one vaccine which can be used by patients suffering
from both TB and HIV. This study was a hospital-based descriptive cross-sectional (a type of
observational study that analyses cross-sectional data collected from patients).The research was
done from a specimen collected from patients which is mainly blood and sputum. It was taken
to the laboratory for diagnosis.

4
Table of Contents
Acknowledgment.........................................................................................................................................3
ABSTRACT................................................................................................................................................4
List of tables................................................................................................................................................7
List of figures..............................................................................................................................................7
CHAPTER ONE..........................................................................................................................................8
1.0 INTRODUCTION.................................................................................................................................8
1.1Background information.....................................................................................................................8
1.2 Statement of problem.........................................................................................................................8
1.3Research questions.............................................................................................................................9
1.4Justification of the study.....................................................................................................................9
1.5 Objective.........................................................................................................................................10
1.5.1 Broad objective................................................................................................................................................................................................................................................10

1.5.2 Specific objective............................................................................................................................................................................................................................................10

CHAPTER TWO.......................................................................................................................................10
2.0 LITERATURE REVIEW....................................................................................................................10
2.1 BACKGROUND.............................................................................................................................10
2.3 Predisposing factors OF tuberculosis...............................................................................................11
2.4 PATHOGENESIS OF TUBERCULOSIS.......................................................................................12
2.4 PREVENTION AND CONTROL OF TUBERCULOSIS...............................................................12
2.4.1 Administrative controls...................................................................................................................................................................................................................................12

2.4.2 Environmental (engineering) controls.............................................................................................................................................................................................................13

2.4.3 Personal protection control..............................................................................................................................................................................................................................13

2.4 DIAGNOSIS OF TUBERCULOSIS...............................................................................................13

2.4.1 Monteux tuberculin skin test ((MTST)/TB skin test........................................................................................................................................................................................13

2.4.2 Sputum smear microscopy...............................................................................................................................................................................................................................13

2.4.3 Gene Expert.....................................................................................................................................................................................................................................................13

2.5 TREATMENT OF TUBERCULOSIS.............................................................................................14

CHAPTER THREE...................................................................................................................................14
MATERIALS AND METHODOLOGY...................................................................................................14
3.0 Introduction.........................................................................................................................................14
3.1 Study area........................................................................................................................................15
3.2 Study design....................................................................................................................................16

5
 3.3 Study Population..............................................................................................................................16
3.3.1 Inclusion criteria..............................................................................................................................................................................................................................................16

3.3.2 Exclusion criteria.............................................................................................................................................................................................................................................16

3.4 Sample size determination...............................................................................................................16

3.5 Sample collection, storage, and transportation.................................................................................17
3.6 laboratory diagnosis of tuberculosis.................................................................................................17
3.6.1 Mantoux tuberculin skin test ((MTST)............................................................................................................................................................................................................17

3.6.2 Sputum smear microscopy............................................................................................................17

3.6.3 Gene expert......................................................................................................................................................................................................................................................17

3.7 Benefit and Risks of the study.........................................................................................................18

3.7.1 Risks................................................................................................................................................................................................................................................................18

3.7.2 Benefits............................................................................................................................................................................................................................................................18

3.8 Data analysis and presentation.......................................................................................................18

3.9 Ethical Considerations.....................................................................................................................19
CHAPTER 4..............................................................................................................................................20
4.0 Research Findings................................................................................................................................20
4.1 Results.............................................................................................................................................20
CHAPTER FIVE:......................................................................................................................................28
5.0 DISCUSSION......................................................................................................................................28
5.1 Introduction.....................................................................................................................................28
5.2 Study findings..................................................................................................................................28
CHAPTER SIX:........................................................................................................................................30
6.0 CONCLUSIONS AND RECOMMENDATIONS...............................................................................30
6.1 Degree of success/Learning experience...........................................................................................30
6.2 Conclusion.......................................................................................................................................30
6.3 Research Contribution.....................................................................................................................30
6.4 Limitations.......................................................................................................................................31
6.5 Recommendations and future work.................................................................................................31
REFERENCES..........................................................................................................................................32
APPENDICES...........................................................................................................................................34
APPENDIX 1: WORK PLAN...............................................................................................................34
APPENDIX II: BUDGET..........................................................................................................................35

6
List of tables
Table 1: Prevalence of positive cases

Table 2: Mortality rate

Table 3: Drug used

Table 4: Predisposing factors

List of figures
Figure 1: Showing percentage of TB between sexes

Figure 2: The current drugs used in the management of tuberculosis

Figure 3: budget

7
 CHAPTER ONE
1.0 INTRODUCTION
1.1Background information
Tuberculosis being an infectious disease caused by Mycobacterium tuberculosis is now a major
problem globally. In 2006(WHO) estimated that there were 9.2million incidences cases and
among this 0.7million cases were HIV-positive. The risk of developing TB is estimated to be
between 26-31 times greater in people living with HIV than among those without HIV
infection.2014, there were 9.6million new cases of TB of which 12million were among people
living with HIV as per world health organization statistics. WHO (world health organization)
estimates that one-third of world's population is infected with m.tuberculosis resulting in an
estimated nearly 9million cases of active TB in 2010.worldwide 14.8% of TB patients have
HIV co-infection and as many as 50-80% have HIV co-infection in parts of sub-Saharan
Africa. The incidence of TB associated with HIV is believed to have peaked at 1.39million in
2005 but now it is decreasing, however, globally TB remains the most common cause of death
among patients with AIDS, killing 1of 3patients.TB can develop through the progression of
recently acquired infections(primary diseases), reactivation of latent infections or exogenous
re-infections. Infection with M.tuberculosis can occur when an individual is exposed to an
infectious TB particle (5um in size) containing the tubercle bacilli. Upon reaching pulmonary
alveoli they may be ingested by alveolar macrophage and later develop into an m.tuberculae to
cause TB. Several studies of HIV infected patient with TB, the median CD4 count was less
than 300cells/um. However, in patients with extra-pulmonary involvement or disseminated
diseases, a CD4 count may be much lower.

1.2 Statement of problem

In order for the people to live well and reduce their mortality rates, they should be educated and equipped
with knowledge on preventive measures to curb the increase in HIV and TB.

However, TB prevalence is increasing in many countries and being the leading cause of death
worldwide. In 2014 1.5million people died of TB, Of these people 0.4million people were
HIV positive, TB now annually causes more deaths worldwide than HIV (“GTC-2015",

8
WHO, Geneva,2015).In 2014 HIV claimed 400000 compared to TB which caused 1.1 million
deaths in the same year.

Likewise, infection with HIV increasing has posed as a major predisposing factor to develop
TB in people co-infected with M.tuberculosis. In Kenya, HIV, a major predisposing factor for
TB is prevalent in all counties with Mombasa county being almost at the top and leading in TB
prevalence due to; urbanization, high poverty and low literacy levels among the individuals.
These have affected human resource and directly lowered annual economic growth. (CAK-
2013)

If the government will not put in place the preventive measures on time, both HIV and TB will
become a pandemic and it will lead to a dearth of more people. This will not only lead to the
reduced population but also the workforce will reduce. A lot of revenue set aside for the
growth of the economy will be channeled to treating patients. Most of the breadwinners will
become liabilities in their homes and thus increased poverty which will in return hider the
dream of achieving vision 2030.

1.3Research questions
1. What are the relationships existing between TB and HIV?
2. What are some of the preventive measure to be put in place to reverse TB burden among
people?

1.4Justification of the study

A lot of research has been done by different organizations on HIV and TB separately. But they
have not done a research to show how HIV and TB are related. The outcome of the research will
be aimed to break the big data and come up with a universal way to prevent and also to control
the spread of both HIV and TB. This knowledge will be very useful to research institutes who are
trying to find the cure for HIV/AIDS. Since the cure of TB is known, the relationship between it
and HIV can be used to extend the research on HIV vaccine.

9
1.5 Objective
1.5.1 Broad objective
 To determine the rate of Co-infection between Mycobacterium tuberculosis and HIV
among patients attending Coast General Hospital.

1.5.2 Specific objective

1. To determine the incidences of TB in Coast General Hospital.
2. To evaluate the relationship existing between TB and HIV
3. To determine the measures to prevent HIV and TB.

10
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 BACKGROUND
TB, the oldest and multisystem diseases with myriad representation and manifestation is the
most common cause of infectious disease-related mortality worldwide. WHO has estimated the
2billion people have latent TB. Although the disease is decreasing in the United States, the
disease is becoming more common in many parts of the world. Also, the prevalence of drug-
resistance TB is also increasing worldwide.Kenya is ranked number 15 out of 22 high TB
burden countries in the world and fourth in Africa after South Africa, Nigeria, and Ethiopia
( International Medical Corps, IMC, 2012-2015).

HIV/TB co-infection in Kenya is approximately 48% of new TB patients (IMC-2010). The

causative agent is Mycobacterium tuberculosis belonging to a group of organisms including
m.microti, m.bovi, m.Africanum. The registered number of new cases of TB worldwide
roughly correlates with economics: Highest incidence is seen in the countries of Africa, Asia,
and Latin America with the lowest gross national product. WHO estimates that 9million people
get TB every year which 95% live in developing countries? An estimated 2-3 million people
die from TB every year. A great influence on the rising TB trend is HIV infection. In 2014,
400000 people who had both HIV and TB are estimated to have died, in addition to 1.1million
people who died from TB alone (“GTC-2015”,WHO,Geneva, 2015).

Chances are that one out of ten immunocompromised people infected with m. tuberculosis will
fall sick in their lifetime with active TB, but among those with HIV, one in ten per year will
develop active TB, while one in two or three tuberculin test positive AIDs patients will develop
active TB. In developing countries, the impact of HIV infection on the TB situation, especially
in the 20-35 years age group is of great and increasing concern. TB is much more increasing in
Kenya especially in Mombasa County. Estimated population being about 1,008,485 consisting
of 100% of urban population with a population density of 4605 persons per square KM. In
2013 Tb cases were 4726 giving the case notification rate as 469 per 100,000 compared to

11
national average of 261 per 100,000.TB/HIV co-infection rate was 32% in 2013 according to
(CHAK-2013-2014)

2.3 Predisposing factors OF tuberculosis

Among the many predisposing factors to TB HIV is the leading since it suppresses the
immunity. Mostly it is a major problem in sub-Saharan countries due to the high incidence of
HIV cases. Smoking more than 20 cigarettes per day also increases the risk of TB by two or
four times while silicosis increases the risk of 30 fold. Diabetic Mellitus is also an important
factor that is growing in importance in developing countries. Other diseases the increase the
risk include Hodgkin's lymphoma, end-stage renal disease, chronic lung disease, malnutrition,
and alcoholism. Also, persons, genetic may also be a factor. Overcrowding also plays a major
role in TB spread among people.(WHO-2006:Global tuberculosis, control, surveillance,
planning, and financing).

2.4 PATHOGENESIS OF TUBERCULOSIS

Infection with M.tuberculosis results most commonly through exposure of the lungs or
mucous membrane to infected aerosols droplets in these aerosols are 1.5um in diameter, person
with active pulmonary TB, a single cough can generate 3000 infective droplets of which 10
bacilli are enough to initiate infection upon inhalation , droplet nuclei are deposited within the
terminal airspaces of the lungs .The organism grows for 2-12 weeks until it reaches 1000-
10,000 sufficient to elicit a cellular immune response. After infection, host either develops
primary infection immediately or no initial infection occurs and disease remains latent within
the body.Upon inhalation, tuberculosis bacteria travel to the lungs and end up in the alveoli
where they are recognized in the immunocompromised host as foreign and attacked by body's
macrophages. Bacteria hare multiplies until they bust macrophages leading to further infection.
Infected areas gradually transform into granuloma. This allows the mycobacterium to continue
growing and overwhelm the cell it has infected till it dies .centers of these granulomas
Necrotize, leading to a mixture of blood and sputum in lungs. This then can heal with time and
remain dormant for a long time while one can infect others. After reemergence, tuberculosis
infection and symptoms proceed similarly. Host's immune attempts to contain the growing
infected areas by killing off the tissue around them to contain the spread and developing T-
cells. This leads to inflammation and some of the other symptoms common to tuberculosis.

12
This tubercle can break off and travel through the bloodstream, leading to extra-pulmonary
tuberculosis (development of tuberculosis by holiday D,hailuB Girma M 2003;7 ).

2.4 PREVENTION AND CONTROL OF TUBERCULOSIS

2.4.1 Administrative controls

Institutions policies or measures that aim to reduce the time the arrival of people with
respiratory TB diseases at a healthcare facility, diagnosis of their condition and placental in an
airborne infection isolation room(AIIR).The purpose of these policies is to provide
overcharging protection for all HCWs, patients, and visitors to the facility. Administrative
control measures include occupational health programs incorporating skin test of HCWs for
LTBI after exposure and at regular intervals. (ECDC2005-20016)

2.4.2 Environmental (engineering) controls

This reduces the likelihood of exposure of HCWs other patients and visitors to viable airborne
m.tuberculosis. These include mechanical ventilation systems to supply fresh air to patient use
of high-efficiency particular air (HEPA) filters. (ECDC2005-20016)

2.4.3 Personal protection control

Measures directed to individual HCWs either to prevent infection (such as the use of
respirators)or to prevent disease if infected (such as detection and treatment) (ECDC2005-
20016)

2.4 DIAGNOSIS OF TUBERCULOSIS

2.4.1 Monteux tuberculin skin test ((MTST)/TB skin test

Used with purified protein derivative(PPD) for active or latent infection (primary method) in
vitro blood test based on interferon-gamma release assay (IGRA)with antigens specific for
Mycobacterium tuberculosis for latent infection.

13
2.4.2 Sputum smear microscopy
It’s a primary method that is always used in TB test in countries with high rate of TB infection.
Sputum is stained using fluorescent acid-fast stain and used as a test for TB. It's a simple and
inexpensive method.

2.4.3 Gene Expert

This diagnoses TB directing presence of TB bacteria as well as testing for resistance to the
drug rifampicin.

2.5 TREATMENT OF TUBERCULOSIS

1. Recommended treatment of latent TB infection in adults infected with HIV is a daily dose of
isoniazid (INH) for 9 months.(Treatment of TB guidelines WHO, Geneva, 2011, 29)

2.Recommended treatment of TB disease in adult infected with HIV (when the disease is
caused by an organism that is known or presumed to be susceptible to first-line drugs) is 6-
month regimen consisting of.(European respiratory journal, may,1, 2012)

a) The initial phase of (INH) a rifampinand ethambutol (EMB) for first 2 months.

b) Continuation phase of (INH) and rifampin for the last 4 months

3 patients with advanced HIV (CD4 counts <100/um) should be treated with daily or three
times weekly therapy both the initial and the continuation phases. Twice weekly therapy may
be considered in patients with less advanced immunosuppressed. lamberts-van
Weizenbock,C.S (1995),76,455.

4. Treatment of drug-resistant TB in persons with HIV infections is the same as for patients
without HIV. However, management of HIV related TB requires expertise in the management
of both HIV and HIV.

14
Note interaction of rifampin (RIF) with certain antiretroviral agents (some protease inhibitors-
PIs-) are Non-nucleoside reverse transcriptase inhibitors (NRTI). Rifampinwhich has fewer
problematic drug interactions (British drug resistance journal 1995)

15
CHAPTER THREE
MATERIALS AND METHODOLOGY
3.0 Introduction

This is the descriptive study with the aim of establishing the major predisposing factor to the

widespread of TB in the region.

The research was intended to investigate the role of government, community and other

stakeholders in the region management and prevention of TB in the region as well as to verify

the prominent contributing factors for the high spread of the disease in Mombasa metropolitan.

3.1 Study area

The study was carried out in Coast County referral Hospitals which serves as the tertiary referral

center for entire coast region. It is situated along the National bank of the island of Mombasa in

Makadara district. The latitude and longitude of Coast County and referral hospital are 4.0435

and 39.6682 respectively. The county has a total population of 939,370 as per census 2009. It has

a counseling center, laboratory and treatment units. Patients receive formal pre-treatment

adherence, education and counseling sessions.

Data collection methods

a) Interviews.
The patients were asked some questions and their replies was used as the primary
data. This method is the best since it as a personal appeal.
b) Questionnaires.
Patients were expected to fill some questions and the information was used as the
primary data.
c) Sampling

16
 Population sampling was effective and easy since many patients in Mombasa
cosmopolitan attends coast general hospital for treatment.

3.2 Study design

This was a hospital-based descriptive cross-sectional study.

3.3 Study Population.

The study was carried out at coast county referral hospitals, Mombasa County. The study
population was 334 both inpatients and outpatients. The major economic activity here in
Mombasa is fishing, tourism, and local trading. The specimen of choice was sputum and blood

CRITERIA FOR PARTICIPANT’S SELECTION

3.3.1 Inclusion criteria

Any TB and HIV positive client who attended coast county and referral hospital and was able
and willing to give consent and participate voluntarily.

3.3.2 Exclusion criteria

Any TB and HIV positive client who attended coast county and referral hospital and was not
able and willing to give consent and participate voluntarily.

3.4 Sample size determination

Sample size was determined using standard statistical formula (Fishers et al., 1998):

n=Z2pq/d2

Where;

Z2=1.96,

p= 32% based on Mombasa TB prevalence (CHAK 2013),

q=1-p

d2=0.052

17
n=1.962 X ((0.32) X (1-0.32))/ (0.05)2 = 334

Approximately 334 samples

3.5 Sample collection, storage, and transportation

The samples (Sputum) was collected in sterile TB tubes and blood was collected in EDTA
tube. Samples was taken immediately to the laboratory to be tested. Sample collected will
depended on whether it's latent or active TB. Patients' type of specimen, name, and number
was used to record the results of the hospital record book. This was done at the coast county
and referral hospital.

3.6 laboratory diagnosis of tuberculosis

3.6.1 Mantoux tuberculin skin test ((MTST)

Used with purified protein derivative(PPD) for active or latent infection (primary method) in
vitro blood test based on interferon-gamma release assay(IGRA)with antigens specific for
Mycobacterium tuberculosis for latent infection.

3.6.2Auramine-phenol stains fluorescent microscopy.

Purpose; a staining technique used to stain Mycobacterium tuberculosis

Reagents

1. Auramine O-main stain.

2. 0.5% acid alcohol – Decolorizer

3. Potassium permanganate- Counterstain

Principle:

A smear is stained with fluorescent dye and examined by fluorescent microscopy using an ultra
Violet Light source. The acid –fast bacilli, then present appear glow with a yellow color once
stained. The acid-fast bacilli are resistant to subsequent treatment with acid alcohol due to
mycolic acid present in theircell wall hence maintaining the primary stain, where most other
bacteria are decolorized.

18
PROCEDURE

1. After drying in the air smears.

2. Arrange the slides on a staining rack without touching each other.

3. Always include negative and positive slides.

4. Flood slides completely with Auramine O and stain for 20mins.

5. Rinse gently with distilled water and drain excess water.

6. Apply 0.5% acid-alcohol for 2 mins

7. Wash with water.

8. Flood the smear with Potassium permanganate for 2 mins.

9. Wash with water

10. Allow to air dry and place stained smear in the dark.

RESULTS

AFB- White yellow rods glowing against dark background.

Reporting: If fluorescent AFB is seen, report the smear as no AFB seen.

(Microbiology Procedure by Clement CPGH).

3.6.3 PCR Gene expert

This diagnoses TB directing presence of TB bacteria as well as testing for resistance to the
drug rifampicin.

Principle

Intro-gene expert is a diagnostic system that includes automated and integrated sample
preparation, nucleic acid amplification and detection of the target sequence in sample or
complex sample using real time polymerase chain reaction (RT-PCR). The system is also able
to detect resistance of MTB to rifampicin.

19
 Advantages

 Most reliable compared to others.

 Speed in giving results.
 Identifies the rifampicin resistance hence the choice of medication is chosen.

Disadvantages

 The shelf life of the cartridge is only 18months

 It’s very stable
 It needs to recalibrated annually
 Test is costly
 Temperature ceiling is critical

3.7 Benefit and Risks of the study

3.7.1 Risks

During transportation of specimens, there is a risk of infection to the people around and to the person
carrying the specimen since Mycobacterium are highly infectious.

3.7.2 Benefits.
The findings of this study will aid the public health implementers in coming up with suitable
models that can further prevent and manage TB infection.

3.8 Data analysis and presentation

Statistical Package for social sciences (SPSS) will be used to analyze the result. Results will
be measured using central tendencies such as; mean median and mode and the presented using
Tables, figure, bar graph and charts.

3.9 Ethical Considerations

Ethical clearance for this study was sought from the Ethical Review Committee (ERC) of
Coast County and referral. Permission to conduct this research was obtained from MTC Kisii.
Before participation, subjects was required to fill informed consent and assent forms. Sample

20
collection was done by a qualified laboratory technologist and the proper techniques was
followed to reduce any risk.

The samples acquired from the patients was coded to delink them from the identity of the
person.

21
CHAPTER 4
4.0 Research Findings
4.1 Results
Table 1

AGE GROUP IN NO OF NEGATIVE POSITIVE PREVALENCE OF

YEARS PATIENTS CASES CASES POSITIVE CASES

1-10 11 6 5 3.3
11-20 40 30 10 6.7
21-30 95 45 50 33.3
31-40 72 34 40 26.7
41-50 65 50 15 10
51-60 55 45 10 6.7
61-70 35 25 10 6.7
71-80 18 10 8 5.3
81-90 9 7 2 1.3

The table above shows the prevalence of positive cases in age groups.

The most affected age group is between 20-50 years.

Generally, the mortality rate was high between the ages of 21-50

This was because most of the infected cases were HIV positive and responded poorly to chemotherapy.

22
 Table 2

Age Group Positive Cases Negative Cases

1-10 5 2
11-20 10 3
21-30 50 8
31-40 40 10
41-50 5 5
51-60 10 2
61-70 10 1
71-80 8 1
81-90 2 1

The table above shows mortality rate between the age group

This table shows a prevalence rate of infection according to age and sexes of the patients whereby;

Males presented with the highest prevalence rate whereas children and elderly i.e. 1-10, 71-80,and 81-90
had the lowest cases.

23
 Table 3

Month No.of patients Percentage Drung used

0ctomber 48 32% Macox plus

(rifampicin and
isoniazid)
November 50 33% Rifin
(Ethambutol &
isoniazid)
December 52 35% Rifa
four<rifampicin
Isoniazid
Ethambutol

pyrazinamide

The table above shows the current drugs used in the management of pulmonary tuberculosis for 3 months
in the Hospital.

These drugs were used in combination.

24
 Table 4:

Age group No. of Predisposing factors

Patients

1-10 5 Malnutrition contact with an infected person

10-20 10 Overdosing
21-30 50 HIV infection
31-40 40 Male gender & heavy jobs
41-50 15 Diabetes
51-60 10 Poverty
61-70 10 Extreme of age
71-80 8 Extreme of age
81-90 2 Extreme of age and malnutrition

The table above shows the predisposing factors of tuberculosis among the age groups.

In the above table, HIV infection contributed to the highest numbers of infection followed by gender and
heavy jobs

25
 Age in years

Graph 1: showing the total number of positives.

According to the bar graph above 21-40 age group has the highest cases while 71-90 had the lowest cases.

26
 Age group

Bar graph 2: showing the common predisposing factors of tuberculosis among the age groups.

Key

1-10 malnutrition & contract with infected cases

11-20 overcrowding

21-30 HIV infection

31-40 male gender and heavy jobs

41-50 diabetes

51-60 poverty

27
 Tb between sexes

Female
Male

Fig 1: showing percentage of TB between sexes

Female 51/150x100 = 34%

51/100x100 =122.4%

Males 99/150x100 =66%

According to the figure above. Males have the highest percentage of infection compared to females.

DRUG USE
28
 Ethambutol and isonicised
(Rifin)
Rifambicin and isonicised
(Malox)
Rifambicin, isonicised,
ethambutol and pyrazinamide

Fig 2: shows the current drugs used in the management of tuberculosis in the four months
times.

CHAPTER FIVE:

29
5.0 DISCUSSION.
5.1 Introduction
With the data collected and analyzed well, it is clearly seen that HIV and TB are closely related.
This data will be useful to the government when making decisions on how to improve health
sector. This research can also be extended in future to come up with a vaccine which cures HIV.
This will reduce the mortality rate and thus ensure better living and thus increase the productivity
of people. High productivity means that the vision 2030 will be achieved.

5.2 Study findings

According to the data presentation and analysis in table 1, pulmonary tuberculosis was found to be more
prevalent between the ages 21-40 years.

This was the productive age and most active people in the society. Majority of the patients were
employed in firms where they worked and the environment was very dusty.

Other tuberculosis cases occurred as opportunistic infection since most patients were HIV positive.

Those infected between the ages of 1-10 years were children who had close contact with infected cases
such as mothers and other caretakers.

The reason was, tuberculosis was transmitted from infected cases to them through aerosol.

The infection between the ages 81-90 years was based on malnutrition and age factor.

Mortality rate was high between the ages 21-50 as it can be seen in table 2.

This was attributed to HIV whereby these characters responded poorly to anti-tubercular drugs. This was
because HIV infection weakened their body immunity lowering the body's ability to fight/protect against
diseases hence TB occurred as an opportunistic infection.

Mortality rates between the age 1-10 years and 60-90 years were because most of the patients responded
well to chemotherapy and completed the treatment.

Male showed the highest prevalence rate as it can be seen in table3, it was because males were more
prone to predisposing factors of tuberculosis such as heavy tasks in the community and more exposed to
the outside world where the majority of them suffered from HIV infections.

These factors that contributed to a high prevalence rate of infection in them (male) compared to female
patients.

Although tuberculosis is difficult to treat, many anti-tubercular drugs have shown some promises,
effectiveness in the treatment and management of tuberculosis.

Those drugs are used in combination (combination therapy) to avoid development of resistance when one
drug is used alone (see table 4)

30
Other reasons for using combination therapy are:

 To broaden the spectrum of the drugs.

 For synergistic purposes.

 For patients compliance i.e. lower the duration of administration.

The most commonly used combination is Rifa four i.e.
 rifampicin
 isoniazid
 ethambutol
 pyrazinamide

Those drugs have shown to be effective in the treatment and management of tuberculosis.
Although tuberculosis has been associated with Mycobacterium tuberculosis many factors have
led to the high increase of infection (predisposing factors) and fast spread of the same (refer to
table 5).

Among the factors, HIV infection has been a threat presenting the highest rate of the
predisposition of tuberculosis hence high rate.

Tuberculosis is also associated with the male gender whereby the majority of patients with TB
are males due to heavy jobs.

These factors and others have contributed in one way or the other in the rise and spread of
tuberculosis in the region and also worldwide.

CHAPTER SIX:

31
6.0 CONCLUSIONS AND RECOMMENDATIONS
6.1 Degree of success/Learning experience
The research has successively determined the rate of co-infection between Mycobacterium
tuberculosis and HIV. This has been clearly seen since most of TB cases among patients
attending Coast General Hospital were also diagnosed with HIV virus. Research also recorded
accurately the incidences of TB in the Hospital since we used mostly interview and observation
which gives primary data and is not prone to biases.

However, since the research was done only in 3 months, it could not extend to relate TB and HIV
to come up with a cure for HIV.

6.2Conclusion
According to the research and result, it was concluded that tuberculosis was an infectious disease.

In the region that affected all the age groups and all sexes. It was found to be more prevalent in males and
mortality rate was a bit high between the ages of 21-41. This was attributed to HIV/AIDs infection.

The following contributed to high infection rate in the region:-

 Lack of knowledge about the disease among the residence

 Poverty hence no money to buy/get the required prescribed drugs for the needed therapy.
 Ignorance and illiteracy of some people when by the majority of them did not go to the hospital
when sick.
 Air pollution due to dust since the region is most of the time dry.
 The high rate of HIV infection whereby tuberculosis occurred as an opportunistic infection.
 Overcrowding in public institutions and villages
 Malnutrition among the old and young children.
 Poor hygiene e.g. spitting anywhere, coughing directly to others etc.

6.3 Research Contribution

Since the research was done to both TB and HIV, it has shown there is a similarity between the two
diseases. From the research, it is seen most of TB cases were recorded among patients who are already
infected with HIV. The government can now use this similarity to have a joint fight against HIV and TB.
The research can also be extended to come up with a cure for HIV.

32
6.4 Limitations
I encountered a budget constraint since most of the money was used in commuting, food, and
stationaries. Some of the patients also requested some refreshment so as to give the information.
At the end of it all, I had to add more budget.

I also experienced a time constraint when trying to complete some of our objectives. Also while
covering as much of the scope as possible.

6.5 Recommendations and future work.

The government should launch a campaign to create awareness to people the dangers of HIV
infection and how to prevent its increase. The government should also start improving the
standard of living of the citizens to ensure that there is no malnutrition which is the catalyst for
TB infection.

I would also encourage the next year students of KMTC Kisii to extend my research. They
should take the advantage of this data on HIV/TB coexistence to try and come up with a research
on the vaccine which will cure HIV. Sounds crazy? Don’t worry, just give a try. Even the biggest
ideas started with a thought. All the best.

33
 REFERENCES
1. Elzinga G, Raviglione MC, Maher D. Scale up meeting targets in global tuberculosis control.
Lancet 2004; 363 :814-819.CrossRef Medline Web of Science Google Scholar
2. Corbett EL, Watt CJ, Walker N, et al. The growing burden of tuberculosis: global trend sand
interactions with the HIV epidemic. Arch Intern Med 2003; 163:1009-1021.CrossRef Medline
Web of Science Google Scholar
3. . Kochi A. The global tuberculosis situation and the new control strategy of the World Health
Organization. Tubercle 1991; 72:1-6.CrossRef Medline Web of Science Google Scholar
4. Joint United Nations Programme on HIV/AIDS. Report on the global AIDS epidemic.
Geneva: Joint United Nations Programme on HIV/ AIDS;2008.
5. Nunn P, Williams B, Floyd K, Dye C, Elzinga G, Raviglione M. Tuberculosis control in the
era of HIV. Nat Rev Immunol 2005; 5:819-826.CrossRef Medline Web of Science Google
Scholar
6. Peltzer K, Matseke G, Mzolo T, Majaja M. Determinants of knowledge of HIV status in
South Africa: results from a population-based HIV survey. BMC Public Health 2009; 9:174.
CrossRef Medline Google Scholar
7. . Raviglione MC, Harries AD, Msiska R, Wilkinson D, Nunn P. Tuberculosis, and HIV:
current status in Africa. AIDS 1997; 11 (Suppl):S115-S123. Medline Google Scholar
8. Reid A, Scano F, Getahun H, et al. Towards universal access to HIV prevention, treatment,
care, and support: the role of tuberculosis/HIV collaboration. Lancet Infect Dis2006; 6:483-
495. CrossRef Medline Web of Science Google Scholar
9. World Health Organization. First Meeting of Global Working Group on TB/HIV 9–11 April
2001, Geneva, Switzerland. Geneva: World Health Organization; 2001.
10. World Health Organization. The strategic framework to decrease the burden of TB/HIV.
Geneva: World Health Organization; 2002.
11. World Health Organization. Guidelines for implementing collaborative TB and HIV
programmed activities. Geneva: World Health\ Organization; 2003.
12. World Health Organization. Report of a "lesson learned" workshop on the six ProTEST pilot
projects in Malawi, South Africa, and Zambia. Geneva: World Health Organization; 2004.

34
13. World Health Organization. Interim policy on collaborative TB/HIV activities. Geneva: World
Health Organization; 2004.
14. World Health Organization. A guide to monitoring and evaluation for collaborative TB/ed.
Geneva: World Health Organization; 2004.
15. World Health Organization. Towards universal access scaling up priority HIV/AIDS
interventions in the health sector. Progress report 2008. Geneva: World Health Organization,
United Nations Joint Programme on HIV/AIDS; 2008.
16. World Health Organization. Global tuberculosis control: a short update to the 2009 report.
Geneva: World Health Organization; 2009.December 2009.
17. World Health Organization. Progress report2009. Geneva: World Health Organization,
UNICEF; 2009. Towards universal access: scaling up priority HIV/AIDS interventions in the
health sector.
18. World Health Organization. WHO Report 2009.Geneva: World Health Organization;
2009.Global tuberculosis control: surveillance, planning, financing.
19. Stop-TB-Partnership. The Global Plan to Stop TB (2006–2015). Geneva: World Health
Organization; 2006.

35
APPENDICES
APPENDIX 1: WORK PLAN
Table 1: The work plan for completion of the study.

The table below shows tasks perfumed during the entire research with the weight given to
research writing since it requires a lot of research and typing.

Duratio
Task Start Date End Date n
Proposal submission &
approval 12/1/2017 12/10/2017 9 days

Requirement Gathering 01/01/2017 01/21/2018 20days

Data gathering 01/22/2017 02/20/2018 27days

Research writing 02/21/2017 03/30/2018 37days

Research submission 04/05/2017 04/20/2018 15days

The grant chart below shows how the days were allocated in the entire research period. The
longer the cohort, the higher the number of days spent doing a certain task.

36
 9/22/2017 11/11/2017 12/31/2017 2/19/2018 4/10/2018 5/30/2018

Proposal submission & approval

Requirement Gathering

Data gathering

Research writing

Research submission

APPENDIX II: BUDGET

The table below shows the total amount of money set aside for the budget and how the money
will be used for different tasks during the research.

ITEM UNIT COST UNITS TOTAL(KSCH)

Typing 5 per page 80 400

Binding 40 2 80

Transport 100 per day 90 9000

Pens 10 4 40

Flash Disk 800 1 800

Foolscaps 2 per page 30 60

Printing 5 per page 80 400

Total 10780

37
Figure3

38
The pie chart below shows the how the total money of the budget will be allocated to different tasks with
transport consuming the highest amount of money.

Budget

Typing Binding Transport Pens Flash Disk Foolscaps Printing

39
 END

TO GOD BE THE GLORY

40