Professional Documents
Culture Documents
Much concerted efforts are needed to control the tuberculosis epidemic. The first priority
of tuberculosis control is the appropriate management and cure of tuberculosis patients,
especially the infectious cases who are the source of transmission of infection in the
community. It is the only way to break the chain of transmission of the disease.
The fight against Tuberculosis is best conducted within the setting of a National
Tuberculosis Programme (NTP) integrated with the general health services of the country.
For effective control of tuberculosis and to prevent emergence of drug resistance, it is
important to have a uniform treatment policy for all patients. Close co-operation of all
health care providers with the NTP is essential at all levels, for successful implementation
of the control programme. Participation of community health workers, religious groups,
political leaders, and voluntary organizations is essential to achieve success in
tuberculosis control. It is important that the community is made aware of the nature and
extent of the problem of tuberculosis as well as its prevention and cure. It must be
1
stressed that the disease is curable and preventable and there is no reason for
discrimination or stigma.
The key in controlling tuberculosis is to ensure that patients take their medicines regularly
until they are cured. Non-compliance of patients to treatment is one of the major
problems faced by all national tuberculosis programmes. To overcome this, the strategy
of Directly Observed Treatment, Short-course (DOTS) has been recommended by the
WHO and accepted internationally. DOTS has been recognised as the only proven costeffective method which can ensure cure. Under the DOTS strategy, a trained health
worker actually watches the patient swallow his/her medicines, and ensure cure. This is
the key to stopping tuberculosis at the source.
PART I
BASIC INFORMATION ON TUBERCULOSIS
AND
TECHNICAL GUIDELINES
FOR
TUBERCULOSIS CONTROL
TUBERCULOSIS
Risk of infection
An individuals risk of infection depends on the extent of exposure to an infectious source
and susceptibility of the individual to infection. The risk of infection is therefore high in a
person who has close, prolonged exposure to a person with sputum smear positive
pulmonary TB. The risk of transmission of infection from sputum smear-negative
pulmonary TB is low and with extrapulmonary TB, still lower.
Pathogenesis
Primary infection
Primary infection occurs on first exposure of a person to tubercle bacilli. Once the
tubercle bacilli enter the respiratory tract through inhalation, the organisms reach the
alveoli of the lungs and start multiplying to form the Ghons focus. The bacilli spread
through the lymphatics to the hilar lymph nodes causing enlargement of the nodes. The
Ghons focus and the hilar lymphadenopathy form the Primary Complex. Bacilli from the
primary complex may spread via the blood stream and lymphatics to other parts of the
body .The immune response (delayed hypersensitivity and cellular immunity) develops
about 4-6 weeks after the primary infection. In most cases the immune response is
sufficient to stop the multiplication of bacilli and prevent development of disease. The
primary lesion may heal by fibrosis or by calcification. A positive tuberculin skin test
may be the only evidence of infection.
In few cases (e.g. the newborn, malnutrition, HIV) the immune response may not be
sufficient to prevent the multiplication of bacilli and the tuberculous infection may
progress to tuberculous disease within a few months.
Post-primary tuberculosis
Post primary tuberculosis occurs after a latent period of months or years after the primary
infection. It may occur either by endogenous reactivation of the latent primary infection
or by exogenous re-infection with TB bacilli.
Who is a TB suspect?
A TB suspect is a person who presents with symptoms or signs suggestive of TB,
particularly cough of three weeks or more.
Definite case of TB
A definite case of TB is a patient with positive culture for the Mycobacterium
tuberculosis complex. (In countries where culture is not routinely available, a patient with
two sputum smears positive for acid-fast bacilli (AFB) is considered a definite case)
Constitutional symptoms:
Fever and night sweats
Loss of appetite
Loss of weight
Tiredness (fatigue)
Symptoms of Extrapulmonary TB
The symptoms depend on the organ involved. Patients may present with constitutional
features of the disease fever, night sweats, loss of weight, and loss of appetite or local
symptoms related to the site of the disease.
CLASSIFICATION OF TUBERCULOSIS
Site of TB disease
A patient with at least two sputum smears positive for AFB by direct
smear microscopy
OR
A patient with at least one sputum smear positive for AFB by microscopy
and chest X-ray abnormalities consistent with active pulmonary TB as
determined by a clinician
OR
A patient with at least one sputum smear positive for AFB by microscopy
and sputum culture positive for M. tuberculosis.
A patient whose initial sputum smears were negative for AFB, but whose
sputum culture is positive for M. tuberculosis.
This group also includes cases without smear result, which should be
exceptional in adults but are relatively more frequent in children, because
children rarely produce a positive sputum smear.
New
A patient who has never taken treatment for TB
OR
Who has taken anti-tuberculosis drugs for less than one month
10
Relapse
A patient previously treated for TB who has been declared cured or treatment
completed, and is diagnosed with bacteriologically positive (smear or culture)
tuberculosis
Transfer in
A patient already registered in one district and transferred to another district for
continuation of treatment
Other
A patient who does not fit into anyone of the above definitions: e.g.
- A patient who has been taking treatment for TB for more than four weeks
without being registered with the NTP.
- A patient with smear-negative pulmonary TB or extrapulmonary TB who may
have relapsed (but without any bacteriological evidence) although this may be
rare.
Chronic
Patient remaining sputum smear positive after completing a fully supervised
re-treatment regimen
11
Figure I
CLASSIFICATION OF TUBERCULOSIS
BACTERIOLOGY
SITE OF
DISEASE
PREVIOUS
TREATMENT
NO
SMEAR
POSITIVE
NEW CASE
PULMONARY
RELAPSE
SMEAR
NEGATIVE
TB CASES
EXTRA
PULMONARY
YES
TREATMENT
AFTER
FAILURE
TREATMENT
AFTER
DEFAULT
OTHERS
CHRONIC
12
DIAGNOSIS OF TUBERCULOSIS
The highest priority for tuberculosis control is the identification and cure of the infectious
cases of tuberculosis. Therefore any person with symptoms suggestive of tuberculosis,
particularly cough for more than three weeks should be investigated.
Investigations
Sputum Smear microscopy
Sputum smear microscopy is the most reliable and cost effective method of diagnosing
infectious cases of pulmonary tuberculosis cases. Whenever tuberculosis is suspected in a
patient who has had a cough of three weeks or more, three sputum samples should be
collected and examined by microscopy for Acid-Fast Bacilli (AFB).
Early morning specimen - Patient is given a sputum container to collect early morning
specimen on the following day.
Second spot specimen - Second supervised spot specimen is collected when the patient
returns with the early morning specimen, on the following day.
Chest X-ray
The chest X-ray has a limited role in confirming the diagnosis of pulmonary tuberculosis.
Diagnosis of tuberculosis by means of X-ray alone is unreliable. Abnormalities seen on a
chest X-ray may be mimicked by a variety of other conditions. However chest X-ray is
helpful particularly in the following instances:
13
Diagnosis of PTB in a suspect, whose sputum smears are negative for AFB
The decision to start on anti-TB treatment on patients should not be based solely on
abnormal chest X-ray findings and all efforts should be made to perform sputum
microscopy.
If there is likely to be a delay of more than 3 days in transporting the specimen, add a
preservative (cetyl pyridinium chloride) to the bottle. The central laboratory will provide
universal containers with CPC to the District Chest Clinics.
14
The Tuberculin skin test is of limited value in clinical work, especially in countries with
a high prevalence of TB
A positive test only indicates infection and not the presence or extent of
tuberculous disease.
There are several methods of doing the Tuberculin skin test- Mantoux, Heaf and Tine
methods. In Sri-Lanka, the Mantoux test is the method used.
However this should be interpreted in the context of clinical picture and other
investigations.
A positive tuberculin test is only one piece of evidence in favour of a diagnosis of
tuberculosis
A Tuberculin test has no value in diagnosis of re-activation. Repeat Mantoux testing is
not recommended in the diagnosis of TB because repeat test is known to have a booster
effect and may give a false positive result.
15
HIV infection
Malnutrition
Cancer
Unexplained fever
Focal lesions such as enlarged lymph nodes, abdominal mass, ascites, CNS signs.
16
TREATMENT OF TUBERCULOSIS
Treatment of tuberculosis is the cornerstone of any NTP. The modern treatment strategy
is based on standardized short course chemotherapy regimens and proper case
management to ensure completion of treatment and cure.
To prevent relapse of TB
Short Course Chemotherapy (SCC) is now the recommended treatment for tuberculosis
and when properly applied, fulfills the above aims of anti-TB drug treatment.
It is essential for the patients to receive and to adhere to the recommended course of
treatment (usually 6-8 months) in order to be cured. If patients fail to take their
combination of drugs regularly, the bacilli may become resistant to the drugs. The best
way to ensure patient adherence to treatment is Direct Observation of Treatment (DOT).
This means that the patient swallows the tablets under the direct observation of a health
worker or a trained person. The strategy of DOTS has been recommended by the WHO
and now internationally accepted as the standard method for TB control.
17
TB treatment regimens
Treatment regimens consist of two phases:
1.
2.
Continuation phase
Intensive phase
During the initial intensive phase, there is rapid killing of TB bacilli. Infectious patients
quickly become non-infectious (within about two weeks) and symptoms improve. Most
patients with sputum smear-positive pulmonary TB becomes smear negative within two
months. Directly Observed Therapy (DOT) is essential in the initial phase to ensure that
the patient takes every single dose. This prevents development of drug resistance. The
18
risk of development of drug resistance is higher during the early stages of anti-TB
treatment, when there are more bacilli.
Continuation Phase
During the continuation phase, fewer drugs are necessary, but for a longer period. The
sterilizing effect of the drugs eliminates the remaining bacilli, thus preventing subsequent
relapses.
Patients who have taken anti-tuberculosis drugs previously are much more likely to
develop drug resistance, which may have been acquired through inadequate prior
chemotherapy. Such patients require a stronger regimen consisting of more drugs and for
a longer period.
Therefore before starting treatment, it is essential to question all patients closely and
carefully to determine whether or not they have previously taken treatment for
tuberculosis, so that they can be given the proper treatment regimen.
A TB treatment regimen consists of two phases, the intensive phase and the continuation
phase. The number before a phase is the duration of that phase in months. A subscript
number (e.g. 3) after a letter indicates the number of doses of that drug per week. No
subscript number after a letter indicates that the treatment is daily.
E.g.: 4 HR means 4 months of Isoniazid and Rifampicin daily.
5 H3 R3 E3 means 5 months of Isoniazid, Rifampicin and Ethambutol three times a week.
19
Treatment
Category
Treatment Regimen
Intensive Phase
Continuation
Phase
2 HRZE
4 HR
New cases
- PTB smear-positive
- PTB smear-negative
- Extrapulmonary TB
CAT 1
Re-treatment cases
- Relapses
-Treatment after failure
-Treatment after default
(smear-positive)
Category 1 (CAT 1) -
CAT 2
2HRZES / 1 HRZE
5 HRE
New Extrapulmonary TB
Isoniazid
Rifampicin
Pyrazinamide
Ethambutol
20
In patients who cannot be given Ethambutol as in the case of small children who are
unable to communicate visual symptoms, Streptomycin may be given instead of
Ethambutol.
- If the smear is positive at the end of two months, continue the intensive
phase of four drugs for another one month.
Repeat the sputum smear examination at the end of the 3rd month.
If the smear is positive at the end of the 3rd month, stop drugs for three days; send
sputum for TB culture and ABST.
Continuation Phase
Isoniazid
Rifampicin
For patients with tuberculous meningitis, miliary TB, or spinal tuberculosis with
neurological complications, continuation phase can be extended up to 7 months.
Relapses
21
Intensive phase
Isoniazid
Rifampicin
Pyrazinamide
Ethambtol
Streptomycin
Isoniazid
Rifampicin
Pyrazinamide
Ethambutol
- If the sputum is positive, the four oral drugs are continued for another
month
Repeat the sputum smear, at the end of the 4th month (If found positive at the end
of the 3rd month).
-
If the sputum is still positive, further treatment will depend on the results
of pre-treatment culture and sensitivity test.
22
Continuation Phase
Isoniazid
Rifampicin
Ethambutol
Do the follow up sputum smear examinations at the end of the 5th month and end
of treatment.
- If the sputum is negative, do the chest X-ray (optional) and anti-TB drugs
are stopped.
- If the patient remains smear positive after the completion of a fully
supervised re-treatment regimen, he should be referred to the Chest
Physician for management. Such patients are defined as Chronic cases.
Advantages
The number of tablets to ingest is smaller and may thus encourage patient
adherence to treatment.
Disadvantages
23
Poor rifampicin bioavailability has been found for some FDCs, particularly in 3 or
4 drug combinations. Quality assurance is therefore essential.
Using FDCs does not obviate the need for separate drugs for a minority of patients
who develop drug toxicity.
Drug
Dose form
Strength
for
thrice- weekly
use
Isoniazid+ rifampicin
Tablet
75mg +150mg
150mg+ i50mg
150mg + 300mg
60mg + 60mg
of granules
Isoniazid+ethambutol
Tablet
150mg + 400mg
--
Isoniazid+thioacetazone
Tablet
100mg + 50 mg
--
300mg + 150mg
Isoniazid + rifampicin +
Tablet
pyrazinamide
150mg + 150mg+
500mg
--
of granules
Isoniazid+rifampicin+
pyrazinamide+ethambutol
Tablet
75mg+150mg+400mg+
---
275mg
24
Flow chart I
Positive
Negative
Examine sputum
(end of the 3rd month)
Positive
Stop ATT for 3 days
Send sputum for culture
and ABST
Examine sputum
(end of the 5th month and
end of treatment)
Negative
Positive
Negative
Examine sputum
(end of the 5th month and end of treatment)
Do a CXR**
and stop ATT
(Cured)
Positive
Negative
25