Primary Level Care of

Tuberculosis
Presenters: Solomon Asiyo
Emanuel Hans
 Objectives
• Definition and Classification of TB
• Distribution
• Risk Factors For TB
• Magnitude of Morbidity and Mortality from TB
• Control measures including
• The DOTs Strategy
• STOP TB Strategy
• TB/HIV Co-infection
• Prevention – Immunization, Contact Tracing, Case
Detection Rates, Cure Rates
 Definition of Terms
• The following are accepted definitions used by many international organizations,
including WHO.
• There may be differences in specific definitions according to definitions of
individual countries
Tuberculosis (TB)- Infectious Disease caused by tuberculosis complex bacteria (M.
tuberculosis, M. bovis, M. africanum) which is transmitted through the air (although in
extremely rare cases TB can be contracted congenitally or by drinking milk infected
with M. bovis.).

TB Infection- when a person carries the Mycobacterium tuberculosis bacteria inside

the body. Many people have TB infection but are well. A positive tuberculin test
indicates infection- but a negative tuberculin skin test dose not exclude the possibility.

Acid- Fast Bacilli (AFB) – Mycobacteria that remain aniline-dyed after they have been
stained and washed in an acid solution; include TB and non-TB mycobacteria

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 Definitions
• Pulmonary TB- any bacteriologically confirmed or clinically diagnosed cases
involving lung parenchyma or tracheobronchial tree. Also a combination of
pulmonary and extrapulmonary TB (WHO)

• Extrapulmonary TB- TB involving any organ other than lung parenchyma,

including tuberculosis pleuritic, upper respiratory TB ,intrathoracic lymph node TB,
abdomen, genitourinary tract, joints, bones and skin. A combination of pulmonary
and extrapulmonary TB is classified as pulmonary TB

• Miliary TB- TB that is characterised by severe acute progression with development

of shallow foci in many organs; develops due to haematogenous dissemination of
the bacteria especially in patients with immunity weakened by HIV, other disease,
malnutrition or old age.
• Multidrug Resistant TB (MDR-TB)- Strains of Mycobacterium tuberculosis
resistant to at least Isoniazid and Rifampicin, the two most efficacious anti-TB
drugs
 Definition of Terms
Basic (First-line) TB drugs- Drugs most effective against the tubercle bacilli and are
used in standardized chemotherapy regimens recommended by WHO. They include;
Isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E) and streptomycin (S)

Bacille Calmette-Guerin (BCG)- Active vaccine with live attenuated Mycobacterium

bovis

Close contact- defined as living in the same household as, or in frequent contact with
a source case with pulmonary TB.
Chemoprophylaxis – Regimen of anti-TB drugs used to prevent TB in persons not
infected with Tb but who have high risk of developing TB (i.e. children or persons with
HIV/AIDS living with sputum smear-positive patients)

Chemotherapy of TB- Use of an anti-TB combination able to kill or prevent

replication of TB mycobacterium in the patient’s body.

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 Definition of Terms
Immunocompromised- State in which he immune system is not working properly;
secondary to several causes

Monitoring of Treatment- System of uninterrupted follow-up on the process of and

responses to treatment. It includes description of the therapy, treatment changes,
adherence details, clinical changes, and adverse effects of drugs as well as laboratory
tests including sputum microscopy and other tests to assess treatment outcomes.

Mycobacterium tuberculosis- Tubercle bacillus; bacteria that causes tuberculosis in

humans

Notification rate- Number of new annually registered case of disease per 100 000

Prevalence- Total number of persons with disease per 100 000 population
Preventive Chemotherapy- Regimen of anti-TB drugs for infected persons with a
high risk of developing TB who have no signs and symptoms of active disease, in order
to prevent them from developing TB

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 Definition of Terms
Primary Health Care- The first level of contact of individuals, the family and
community with the national health system- constitutes the first component of a
continuing health care process.
.

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 Definition of Terms
Risk Factor for TB- An aspect of personal behaviour or lifestyle, an environmental
exposure , or an inborn or inherited characteristic which, on the basis of
epidemiological evidence is known to be associated with TB.

Sputum smear conversion- Negative result of sputum smear microscopy at the end of
the intensive phase of treatment in patients who were initially diagnosed with sputum
smear-positive TB.

Standard Chemotherapy- Chemotherapy for an average of 6-8 months based on the

combination of at least four major drugs (isoniazid, rifampicin, pyrazinamide and
ethambutol [streptomycin]) given for 2-3 months followed by a combination of at least
2 drugs given 4-6 months during the continuation phase of treatment.

TB burden- Indicator used by WHO; number of years of healthy life that will be lost
due to TB as result of both illnesses and premature death, in a population with given
standard life expectancy by age.

Brief Guide on Tuberculosis Control for Primary Health Care Providers

•
Classification of TB
TB is classified as pulmonary (PTB) or extra-pulmonary tuberculosis (EPTB)
based on disease site.
It is also classified according to severity, treatment history, and drug resistance as
• Non Severe TB
• Pulmonary TB without extensive parenchymal lung disease
• TB lymphadenitis
• TB pleural effusion
• Severe TB
• PTB with extensive parenchymal lung disease
• Miliary TB
• All other forms of extra-pulmonary TB including:
• TB bone or joint
• TB meningitis
• Pericardial TB
• Abdominal TB etc.
• Retreatment
• Multi-drug resistant TB
 Risk Factors for TB
For TB Infection
• Contact with source case For TB disease
• Closeness of contact • Young age
• Duration of contact • <5 years of age, esp 0-2 years
• Source case characteristics • Immunosuppression
• Smear positivity • HIV
• Cavities on CXR • Malnutrition
• Increased Exposure • Post-measles
• Living in high TB endemic • Not BCG vaccinated
communities • Risk of disseminated disease
• Children of families living with
HIV
 CHILD CONTACTS IN AFRICAN
COMMUNITIES
• One-third to two-thirds of child household contacts of TB cases have evidence of
TB infection i.e. TST positive
• Incidence of TB disease among household contacts is very high – reported as
>1,000 cases/100,000 population
• Likelihood of infection is related to closeness/proximity of contact to and sputum
smear positivity of index case
• Risk of infection greatest when the index case is the child’s carer e.g. mother,
grandmother
• HIV-infected children are at increased risk of exposure to TB

Kenyon TA et al, Int J Tuberc Lung Dis 2002; Sinfield R, et al Ann Trop Paediatr 2006; Jackson-Sillah D, et al Trans R Soc Trop Med Hyg 2007;
Morrison J, et al Lancet Infect Dis 2008
 Magnitude of TB Morbidity and Mortality
• Tuberculosis (TB) in children is common wherever TB is common in adults i.e. TB
endemic settings
• TB is an important cause of illness and death in children in many TB endemic
countries
• At least 550 000 children become ill with tuberculosis (TB) each year.
• Up to 80 000 HIV-uninfected children die of TB every year*.
• 70–80% of children with TB, have the disease in their lungs (pulmonary TB). The
rest are affected by TB disease in other parts of the body (extrapulmonary TB).
• There were over ten million orphans due to parental TB deaths in 2010.
• An understanding of the risks for infection and disease due to TB in children is
critical for improved diagnosis and preventive management
• The HIV epidemic has increased the burden of childhood TB and the clinical
challenges
• The main benefit of neonatal BCG is protection against severe disseminated TB in
children
Child TB Training Toolkit, WHO
Estimated TB Incidence Rate, 2013
 TB disease in children

• Most cases occur in young children ( <5years)

• Most disease occurs within 2 years after exposure/infection
• The majority within 1 year
• Most cases in children are pulmonary TB
• Smear negative or smear not done are the majority
• Extrapulmonary TB is also common and the type depends on age
• Smear positive disease is usually older children
Risk of TB disease following Infection by Age

Childhood TB Training Toolkit

 WHO Strategy for Controlling
Tuberculosis
• Combination of five technical and managerial components ensuring availability of a
diagnostic and treatment network easily accessible to the population and
emphasizing good programme management based on accountability, supervision
and quarterly evaluation of case finding and cohort analysis of treatment outcomes.

• Directly Observed Treatment Strategy (DOTS)- A strategy of treatment in which

a specifically trained health care worker observes the patient swallowing his or her
anti-TB drugs

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 The DOTs Strategy- Components
1. Government Commitment to sustained TB control activities at the national and
regional level.
2. Case detection by sputum smear microscopy among symptomatic patients self-
reporting to health services. Final diagnosis may be made based on sputum culture
in the countries where resources are available.
3. Standardized short course chemotherapy treatment regimen of an average of
6-8 months under proper case management conditions for all TB patients. This
incorporates direct observation of treatment and technically sound, socially
supportive treatment services.
4. A regular quality-assured uninterrupted supply of all essential anti-TB drugs
5. A standardized recording and reporting system based on quarterly cohort
analysis that allows assessment of treatment results for each patient and of the TB
control programme overall.

• These represent the minimum measures necessary to control TB. Individual

countries are to use it to establish their own national TB control programme,
consistent with local circumstances and resources.
Brief Guide on Tuberculosis Control for Primary Health Care Providers
 Directly Observed Treatment
• Directly observed standard treatment is an important element of the WHO strategy.
• A healthcare worker watches the patient swallow his or her anti-TB drugs, ensuring
that the patient is taking drugs correctly.
• Can be administered in hospitals or outpatient settings.
• Can be observed by TB specialists, Primary Health Care providers (Physician,
Nurse, CHW) or representatives from humanitarian organizations such as the red
cross.
• DOT by a family member is not encouraged- interpersonal relationships may
affect acceptance or adherence (however family support and encouragement in
emphasizing the importance of completing treatment is very significant)
• May include incentives (such as food or transportation) for the adherent patient
and/or health care worker who supervises DOT, increasing motivation for both the
patient and supervisor

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 STOP TB Strategy
Vision
• A TB FREE world
Goal
• To dramatically reduce the global burden of TB by 2015 in line with the MDGs and
Stop TB Partnership Targets
Targets
• MDG 6, Target : Halt and begin to reverse the incidence of TB by 2015
• Targets linked to the MDGs and endorsed by the Stop TB Partnership:
• By 2015: reduce prevalence and deaths due to TB by 50% compared with a
baseline of 1990
• By 2050: eliminate TB as a public health problem

www.who.int/tb/strategy/stop_tb_strategy/en/
 STOP TB Strategy
Components

1. Pursue High quality DOTS expansion and enhancement

2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations
3. Contribute to health system strengthening based on primary health care
4. Engage all care providers
5. Empower people with TB, and communities through partnership
6. Enable and promote research

www.who.int/tb/strategy/stop_tb_strategy/en/
 TB/HIV Co-infection
• TB is the most common cause of death in person with HIV infection throughout the
world.
• HIV infection accelerates development of TB disease due to a weakened immune
system and Active TB disease further suppresses the immune system of people
living with HIV/AIDS- thus both disease progress more rapidly in co-infection.
• Primary Health Care providers should be alert to the possibility of TB infection in
HIV-positive patients.
• Rate of TB in persons with HIV infection depends on prevalence of TB in the
region.
• Particular challenges can be expected in countries with a high TB burden where
HIV incidence is increasing.
• Increased caseload of child TB
• Greater difficulty with diagnosis
• Poorer response to TB treatment
• Drug interactions
• Implementation of the “three Is’
Brief Guide on Tuberculosis Control for Primary Health Care Providers
 TB/HIV Co-infection
PHC providers who do see HIV-positive patients or patients at risk for HIV should;
• Educate the patient about the symptoms of TB and HIV, the risks of infection and
how to prevent transmission
• Be aware of the common forms and presentation of TB/HIV patients, including
pulmonary, disseminated and extrapulmonary forms
• Ensure (or refer appropriately) AFB microscopy of three good quality sputum
smears at a designated lab when TB suspected and refer the patient to TB services
for differential diagnosis, if necessary (Distinguishing pulmonary TB from other
HIV related pulmonary disease is a common diagnostic problem)
• Refer patient for CITC (voluntary counselling and testing for HIV)

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 TB Prevention in Children
• Improved case-finding and management: Early identification and effective
treatment of infectious TB cases will reduce the burden of child TB
• BCG: Neonatal BCG immunisation is used widely but efficacy is variable The
main proven benefit of neonatal BCG is protection against severe disseminated
forms of TB in children
• Contact Screening and Management

Brief Guide on Tuberculosis Control for Primary Health Care Providers

 Immunization
Many countries use Immunization with BCG vaccine
• Consists of live attenuated strain of bovine TB bacilli that are non virulent (M.bovis
BCG)
• Is given by intradermal injection and stimulates immunity
• WHO recommends giving newborns at birth or at first contact with the health care
facility to prevent development of severe forms of TB
• Effectiveness of BCG is variable
• More protective against disseminated TB and TBM than pulmonary TB
• BCG has a role in prevention of leprosy
• BCG effectiveness to protect from TB also depends on BCG strain used, Age it
is given and region.
 Contact Tracing
Active contact tracing of all children who are household contacts of smear-positive
pulmonary TB cases is recommended.
• This has huge potential to reduce burden of TB in children
• Focus is on individuals infected with TB that have greatest likelihood of developing
active TB disease following infection- infants, young children and HIV-infected
children of any age.
Screening should include:
• Taking a thorough history
• Clinical Exam
• Tuberculin Skin test
• Chest X-ray
WHO recommends prophylaxis (isoniazid 5mg/kg) for six months in asymptomatic
children under five years who are household contacts of smear positive pulmonary TB
patients
Isoniazid preventive therapy (IPT) for young children with infection who have not
yet developed
 CHILD CONTACTS IN AFRICAN
COMMUNITIES
• One-third to two-thirds of child household contacts of TB cases have evidence of
TB infection i.e. TST positive
• Incidence of TB disease among household contacts is very high – reported as
>1,000 cases/100,000 population
• Likelihood of infection is related to closeness/proximity of contact to and sputum
smear positivity of index case
• Risk of infection greatest when the index case is the child’s carer e.g. mother,
grandmother
• HIV-infected children are at increased risk of exposure to TB

Kenyon TA et al, Int J Tuberc Lung Dis 2002; Sinfield R, et al Ann Trop Paediatr 2006;
Jackson-Sillah D, et al Trans R Soc Trop Med Hyg 2007; Morrison J, et al Lancet Infect Dis 2008
 References
• Brief Guide on Tuberculosis Control for Primary Health Care Providers. WHO
• Kenyon TA et al, Int J Tuberc Lung Dis 2002; Sinfield R, et al Ann Trop Paediatr
2006; Jackson-Sillah D, et al Trans R Soc Trop Med Hyg 2007; Morrison J, et al
Lancet Infect Dis 2008
• Child TB Training Toolkit, WHO
• Kenya National TB Guidelines 2013