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TOPIC :

TB

GROUP MEMBERS :

SHAISTA PERVEEN
HAJRA SOHAIL
KIRAN JAMIL
MOBEEN ARSHAD
QURATUL AIN

TB
Definition
Types
Epidemiology

triad
Dynamics of transmission

National

case management
Diagnosis
Treatment
Co-morbidities
Levels of prevention

DEFINITION

Tuberculosis or TB (short for tubercle


bacillus) is an infectious bacterial disease
caused by various species of
mycobacterium, usually Mycobacterium
Tuberculosis in humans.

TYPES OF TB

When the infection affects the lung parenchyma, it is


called pulmonary tuberculosis.
When the infection affects other parts of the body, it is
called extra-pulmonary tuberculosis.
Examples of extra pulmonary TB includes
i. lymphadenopathy (glandular tuberculosis),
ii. pleural effusion (pleural TB),
iii. pericardial disease (pericardial TB),
iv. miliary TB,
v. genito-urinary TB
vi. tuberculous meningitis.

WORLDWIDE PREVALENCE:

Largest number of new TB cases occurred in: South-East


Asia and Western Pacific Regions, accounting for 58% of
new cases globally. However, Africa carried the most severe
burden, with 281 cases per 100 000 population in 2014.
The 6 countries that stand out as having the largest number
of incident cases in 2014 were India, Indonesia, Nigeria,
Pakistan, Peoples Republic of China and South Africa.
In 2014 1.5 million people died of TB.
There were an estimated 9.6 million new cases of TB in
2014.
There were also an estimated 1.0 million cases of
TB in childrenand 140,000 deaths.

PREVALENCE IN PAKISTAN :

Pakistan currently ranks fifth amongst 22


countries with highest burden of TB.
Pakistan is also estimated to have thefourth
highest prevalence of multidrug-resistant TB
(MDR-TB) globally.
Pakistan produces about 420,000 new cases
annually

host

Epidemiological
Triad

environment

agent

AGENT:

Agent for the casing TB is Mycobacterium


tuberculosis, which is an acid-fast, grampositive, aerobic, non-motile, rod-shaped
organism.
Two of its forms cause disease in humans
Human variety
Bovine variety

Host
Man is the host for TB. Host factors that makes him
susceptible for the disease are as follows:
Age

more than 75% of active TB cases belong to the


productive age group (15-59 yrs).
Gender
Heredity

HLA DR 2 has been associated with the


susceptibility to TB in Asian population

Nutrition
Education
Occupation

ENVIRONMENT

1- Overcrowding:

poor hygienic conditions,


poor ventilation and
contact of infectious case with more people

2- Economic status:

Crowding

Malnutrition

poor air ventilation

poor sanitation

The association between TB and poverty


is well established. Poverty can increase person's vulnerability to
TB.

DYNAMICS OF TRANSMISSION OF TUBERCULOSIS

Source of infection:

sputum is positive for Mycobacterium tuberculosis (who has received no


treatment or incomplete/irregular treatment)
excreta of such patient
milk obtained from cows suffering from TB
material from slaughtered tuberculosis animal

Mode of transmission:

o
o

o droplet nuclei
o

fomites,
dishes or other articles used by the patient.

Point of entry:

Nose and throat (by inhalation)


Mouth (by ingestion)

NATIONAL CASE
MANAGEMENT
GUIDELINES
1.Case detection
2. Treatment
3. Follow-up
4. Recording and reporting system

1)CASE DETECTION

1. CASE DETECTION
MAKING THE DIAGNOSIS OF TB FOLLOWS THE BASIC PRINCIPLES OF
DETAILED HISTORY, EXAMINATION AND INVESTIGATIONS.
HISTORY: THE FOLLOWING SYMPTOMS HAVE TO BE ASKED ABOUT:
1-COUGH: DURATION, WHETHER MORE OR LESS THAN TWO WEEKS.
2-SPUTUM: ITS COLOUR AND WHETHER BLOOD STAINED.
3- FEVER: ITS INTENSITY, DURATION, TIMING, I.E IN DAY OR NIGHT.
WHETHER ASSOCIATED WITH NIGHT SWEATS.

4-Weight: Any weight reduction/loss and change in appetite.


5-Smoking: Duration and frequency.
6-Family history: Does any close contact or family members suffers (or
has suffered) from TB.
7- History of medication: Inquire if the patient has taken:
TB treatment, if yes, for how long? (also verify records if possible)
Streptomycin (powder/dry) injections, if yes, for what? for how long?
Tablets which make urine color red (show if possible), if yes, for what? &
for how long?

Examination:

Look and listen for these signs:

1-Count the pulse


2-Take the temperature
3- Listen with a stethoscope, asking the patient to breathe deeply
Suspect TB if any of these present:
Cough more than 2 weeks, or
Cough less than 2 weeks or of uncertain duration, PLUS either
o Blood stained sputum or fever at night or weight loss, or
o Previous TB in the patient, family or other close contact

Investigations:
1-Sputum smear examination:
It is the first line test for the diagnosis of TB. Sputum
examination is the most specific, cost effective and
reliable test for diagnosis of pulmonary TB. Sputum
microscopy is available in BMUs (hospitals and RHCs). The
National TB Control Program has recommended training
laboratory technicians in all the diagnostic centres.

Suspects should submit at least two sputum specimens for microscopic


examination. When possible, at least one early morning specimen should be
obtained, as sputum collected at this time has the highest yield.

These two specimens are collected at the following times:


(a)Spot: This is collected on first consultation
(b)Early morning: This is collected at home and this is the early morning
sputum sample collected the day after consultation.

2-Chest X-ray:
The chest X-ray is no longer the best first line investigation for Pulmonary TB
and most patients with TB who are diagnosed by sputum smears do not need
a chest X-ray.
The chest X-ray appearances are not specific to TB. Chest X-ray is only
indicated if a patient is found to be sputum smear negative, and we need to
rule out smear negative pulmonary TB.

MANTOUX TUBERCULIN TEST:


injecting 0.1 ml (5 i.u). of Purified Protein Derivative (PPD)
solution intra-dermally forearm below the elbow.
reaction is measured after 48-72 hours
Positive reaction : a wheal is raised measuring 5 mm or more
surrounded by the zone of erythema.
Induration: The specificity of Mantoux test for pulmonary as well
as extra-pulmonary TB increases as the size of induration
increases reaching 86% at induration of more than 15 mm.

INTERFERON GAMMA RELEASE


ASSAY:
An IGRA is a blood test that can determine if a person has
been infected with TB bacteria. An IGRA measures how
strong a persons immune system reacts to TB bacteria by
testing the persons blood in a laboratory.
Positive IGRA: This means that the person has been
infected with TB bacteria. Additional tests are needed to
determine if the person has latent TB infection or TB
disease. A health care worker will then provide treatment
as needed.
Negative IGRA: This means that the persons blood did not
react to the test and that latent TB infection or TB disease
is not likely.

CULTURE TEST:
This test uses your sputum or tissue sample to grow any TB
bacteria that may be there.
It tells whether you are infectious and also whether your
TB is resistant to any antibiotics.
This helps ensure they put you on a combination of drugs
that will cure you. As TB culture grows slowly, it may take
up to eight weeks to get some of the results.

PCR:
Other mycobacteria are also acid-fast.
If the smear is positive,PCRor gene probe tests can
distinguishM. tuberculosisfrom other mycobacteria.
Even if sputum smear is negative, tuberculosis must be
considered and is only excluded after negative cultures.

FIGURE 1: MANAGEMENT OF TB SUSPECT

TB Suspect

Two Sputum Smear microscopy


(Spot-morning)

One or 2 Sputum
Smear positive

Declare Sputum positive


pulmonary TB & Start
Treatment

Both Sputum Smear negative

Give broad-spectrum
antibiotic for 7 10
days and re-assess

If responds to antibiotics
then re-assure

If no response to antibiotics, do
chest X-Ray (CXR).

CXR consistent with


active pulmonary TB

CXR not consistent with


active pulmonary TB

Declare smear negative


pulmonary TB & start
treatment

Refer to pulmonary specialist/


District physician

*History of drug intake

Smear result now

Type of patient

Never taken TB drugs in past


Taken TB drugs for less than 4 weeks in
past and not registered with the
Program.

Smear positive
Smear negative

New case

Taken full course of TB treatment in


past and declared Cured or treatment
completed.
Register

Smear positive

Relapse

Taken TB drugs and transferred from


another TB rejister
Smear positive patient taken TB drugs
for 5 months or more
patient taken drugs for 2 months

Transferred-in
Smear positive
Smear negative

Treatment After
Failure

Taken drugs for a certain period then


interrupted for 2/or more consecutive
months

Smear positive

Treatment after default

Taken drugs for a certain period then


interrupted for 2/or more consecutive
months

Smear Negative

Others

Taken drug for more than 4 weeks from


outside Program, pulmonary or extrapulmonary TB patient, Previous
treatment outcome unknown.

Smear positive
Smear negative

Others Positive
Others Negative

DURATION OF THERAPY:

6 months for Cat-1 and 8 months for Cat-II.

TREATMENT REGIMENS
The standard treatment regimen for all
patients is made up of
an intensive phase lasting 2 months in cat-1
patients three months in cat-2
and a continuation phase lasting 4 months

INTENSIVE PHASE
4 drugs are used to rapidly kill the tubercle
bacilli.
(isoniazid,
rifampicin,
pyrazinamide,
and ethambutol)
Infectious patients become less infectious within
approximately 10-14 days of starting treatment
and symptoms abate. However, the majority of
patients with sputum smear-positive TB will
become smear-negative within 2 months.

CONTINUATION PHASE
2 drugs are used, over a period of 4 months.
(isoniazid,
rifampicin)
The sterilizing effect of these drugs eliminates
the remaining bacilli and prevents
subsequent relapse.

Anti TB
drugs

Mode of
action

dosage

Common drug
preparation

isoniazid

bectericidal

5mg/kg

Tab:100mg

rifampicin

10mg/kg

Tab:150,300,
450

pyrazinamide

25mg/kg

Tab:500mg

streptomycin

15mg/kg

amp-:1000mg

ethambutol

becteriostatic

15mg/kg

Tab:400mg

DECIDE THE TREATMENT


CATEGORY:
Smear
result
Positive

Disease
classification
pulmonary

Patient type

new

category

CAT-1

retreatment:
relapse
Rx. After failure CAT 2
Rx. After default
other (s+ only)
Nagative

pulmonary or
extra pulmonary

new or other
(s- only)

CAT 1

category

Intensive phase

Continuation phase

Duration
in month

drugs

Duration
in months

drugs

CAT-1

HRZE

RH

CAT-2

HRZR +
( S**)

RHE

3)FOLLOW UP

FOLLOW-UP
TB patient is being followed up for the
following reasons: 23
1-Compliance of the patient:
Regularity of drug intake is ascertained. If
patient is not taking it regularly, then
reasons for it is enquired and the problem is
sorted out.

2-IDENTIFICATION AND MANAGEMENT OF SIDE EFFECTS:


If patient has an adverse effect:

Then Manage as follows:

Minor adverse effects;


Anorexia, nausea, abdominal pain

Continue anti-TB drugs and:


Give drugs last thing at night

Joint pains

Aspirin

Burning sensation in the feet

Pyridoxine 100 mg daily

Itching of skin

Anti histamine

Major adverse effects;


Skin rash
Deafness
Dizziness (vertigo & nystagmus)
Jaundice
Visual impairment (other causes
excluded)
Shock, purpura, acute renal failure

Stop anti-TB drugs.


Refer to a Specialist

3-CHECKING THE EFFECT OF TB


TREATMENT:
Category of
Patient

AFB smear
examination

CATEGORY I
(NEW SMEAR
POSITIVE
no history of
previous ATT

month

result

positive

START treatment intensive


phase (2RHEZ)

End of 2M

Negative

Continue treatment

Positive

Repeat sputum smear to


confirm the positive status
Declare treatment outcome as
CAT-1 TREATMENT FAILURE
For further management refer
protocol for cat-11

Negative

Stop treatment and declare


treatment outcome- CURE

Positive

Repeat sputum smear to


confirm positive status
Declare treatment outcome as

End of 6M

Management

Category I (smear
negative)

AFB smear examination management


Month

Result

0-month

Negative

Start intensive Phase 2RHEZ

End of 2M

Negative

Start continuation phase


treatment 4RH

Positive

Repeat sputum smear to confirm


positive status.
Declare treatment outcome as
TREATMENT FAILURE
For further management see
protocol for cat-11.

Category of Patient

Category II
All retreatment
cases after failure ,
default or relapse

AFB smear
examination

Management

Month

Result

0.Month*

Positive

Register Patient for Cat-11, and start


intensive phase

End of 3
Month#

Negative

Start continuation phase treatment


(5RHE)

Positive#

START continuation phase

Neg

Continue continuation phase

Positive

Declare Treatment outcome CAT-11


TREATMENT FAILURE
Declare MDR Suspect. Refer Patient to
DRTBMU

Negative

Declare treatment outcome CURE

Positive

Declare Treatment outcome CAT-11


TREATMENT FAILURE
Declare MDR Suspect. Refer Patient to

End of 5M

End of (8
Month)

TREATMENT OUTCOMES:

Cured: A patient registered as smear-positive,


has completed the duration of treatment,
becomes sputum smear negative in the last
month of treatment and on at least one
previous occasion.
Completed: A smear positive patient who has
completed the duration of treatment and have
follow up smear negative results but none at
the end of treatment due to any reason OR
Smear negative and extra pulmonary cases
complete six months of treatment successfully

Failure: A sputum smear positive patient who


remains or becomes sputum smear positive
at five months or later OR Also a patient who
was initially smear negative before starting
treatment and became smear positive after
completing the initial phase of treatment
Defaulted: A patient whose treatment was
interrupted for two consecutive months or
more after registration

Transferred out: A patient, who has been


transferred to another BMU and for whom,
the treatment outcome is not known.
Died: A patient who dies for any reason
during the course of treatment (based on
information gathered and recorded by a
responsible health worker)

4)RECORDING AND
REPORTING SYSTEMMONITORING OF TB
PATIENT:

PREVENTION OF TB

PREVENTION

PRIMARY PREVENTION
TB stigma ;focused health education
Specific protection: Certain measures can be taken to protect a
person from tuberculosis. These are:
(a)Vaccination:
()Bacille Calmette Geurin (BCG) is the vaccine used for the control
of TB.

()It

contains live attenuated strain of Mycobacterium bovis that uses


shared antigens to stimulate cross- immunity against Mycobacterium
tuberculosis and Mycobacterium leprea.
()It reduces the risk of all forms of TB by 50%
()It also reduces severe, non-pulmonary forms such as childhood
meningitis by 70% .
()In Pakistan it is a part of the Extended Program of Immunization (EPI)
and is administered at birth.
()Immunity induced by it lasts from 3-12 years and 5-8 years on an
average.

(b) Chemoprophylaxis:

It is recommended for those at risk of


tuberculosis such as malnourished
individuals and those in contact of
established tuberculosis case. Isoniazid
(INH) is used in as the chemo prophylactic
agent.

Early diagnosis:
As TB is an insidious disease by the time person identify of infected
by TB ,has already infected many others.
So in order to prevent its spread its early diagnosis is imperative.
Following investigations are performed to detect a case of TB:

Sputum examination

Sputum microscopy for AFB


Tuberclin test
X-ray examination
Prompt treatment:
most important preventive measure against TB.
to control TB, control the reservoir (infected TB patient). The only
quick way for it is to treat the infectious patient to render him
non-infectious.

Improving the ventilation in indoor spaces so there


are fewer bacteria in the air.
Using germicidal ultraviolet lamps to kill airborne
bacteria in buildings where people at high risk of
tuberculosis live or congregate.
Treating latent infection before it becomes active
Usingdirectly observed therapy(DOT) in people
with diagnosed tuberculosis (latent or active) to
raise the likelihood of the disease being cured.

PATIENT EDUCATION
AND LIFE STYLE
MODIFICATION

LIFESTYLE MODIFICATION
Components of lifestyle modification include;
Before the initiation of IVF, importance of
lifestyle modification should be stressed
particularly
Weight loss monitoring
Increase exercise
Smoking cessation
Reduced alcohol consumption

Increase sodium intake(less than 2.4 g daily)


Maintain adequate dietary potassium (more
than 120 mmol/day)
DASH diet i.e rich in fruits, vegetables, low
fat dairy products and reduced saturated and
total fats.

CASE STUDY

A 56 year old male presented in a medical


care facility with cough from last 4 weeks,
he also have blood in sputum.The physical
exam on admission revealed the following
findings: BP 130/80, PR 80, RR 24, Temp
98.Chief complaints including
,chills,weakness,sweating, fever,weight loss,
known case of pulmonary Kochs from 1
week,SOB from 9 days.He is also suffering
from hypertension & pulmonary edema.

CASE STUDY

History of medication:Regular use of panadol for fever

Lab examination:Sputum smear positive


Tuberculin test (Mantoux test) positive

Diagnosis:Pulmonary tuberculosis

MEDICATIONS:
Tab. Myrin P

: 705mg (3-OD)

Calan( verapamil):40mg
Tab. Vita 6
:1-OD
Tab. Leflox
:750mg -OD
Syp. Hydraline
:1 tbs -TD

QUERIES

What are possible interactions with


prescribed regimen?
What is the first line therapy for treatment
of TB?
What are contraindications in therapy?
What kind of tests are considered necessary
to be performed for diagnosis?
What is DOT therapy?

ANSWERS

Answer 1:
Possible Interactions:
1) INH+Verapamil= INH increase verapamil level
(both are hepatotoxic,so moniter these two drugs
closely)
2)Rifampin decreases verapamil level when both are
given at same time,so use alternative

Answer 2:
first line therapy include Myrin P
(ethambutol,pyrazinamide,INH,rifampin)
Answer 3:
Contraindications:
Verapamil
heart failure
INH
drug induced liver disease
Rifampin
acute jaundice
Pyrazinamide
nephrotoxcity

Answer 4:
1. X-ray (chest/sputum test)
2. Culture & sensitivity test(C & S)
3. Purified protein derivative test (PPD)
Answer 5:
DOT therapy: It is known as directly observed
therapy,it starts when patient compliance
decreases and drug resistance increases.In this
therapy Physician, Nurse or Clinical technician
directly moniter patient and hence improve
patient compliance.