TUBERCULOSIS

Daniel Tekie, MD University of Gezira Department of Community Medicine 13th Feb., 2012

TABLE OF CONTENTS

DEFINITION AETIOLOGY EPIDEMIOLOGY CLASSIFICATION TRANSMISSION PATHOGENESIS CLINICAL PRESENTATION DIAGNOSIS/EVALUATION TREATMENT , CONTROL AND PREVENTION

DEFINITION

What is Tuberculosis? TB is a disease caused by the bacteria known as Mycobacterium (pronounced "my-ko-bakTEER-E-um") tuberculosis and transmitted

by airborne droplet nuclei(containing tubercle bacilli )

Rarely , M.bovis It was isolated by Robert Koch in 1882

Etiology

The tubercle bacillus (M.Tuberculosis) is aerobie, nonmotile,non-sporeforming, high in lipid content, and acid and alcohol-fast It grows slowly It cant tolerate heat, but It can live in humid or dry or cold surroundings

CLASSIFICATION

SITE Pulmonary TB(85%)

Disease involves the lung parenchyma Smear-positive: visible TB bacilli in sputum Smear-negative: no visible TB bacilli in sputum Disease involving an organ other than the lung parenchyma Includes pleural/pericardial TB, bone TB, GI TB, Lymphadenits, TB meningitis,Kidney

Extra-pulmonary TB

Cont,
STAGE TB infection/latent

TB bacilli live inside the person, but the bacilli do not cause pathological destruction of organs No signs or symptoms of disease

TB disease/active
TB bacilli progressively invade an organ(s) Signs and symptoms of disease appear AGE Adult /paediatric TB

Tuberculosis: Global epidemiology

Tuberculosis remains the leading infectious disease in the world

Top infectious killing diseases. Each year,

HIV/AIDS 3 million Tuberculosis kills 2 million Malaria kills 1 million

Someone is infected with TB every second; 33% of the world population is already infected; 10% develop disease 25% of all avoidable deaths in economically productive age groups are due to TB

The Incidence of tuberculosis (per 100;000 people) in Sudan was last reported at 119.00 in 2010 Tuberculosis mortality rate among HIV-negative people (per 100 000 population), 2010 Eritrea 9.0 United Republic of Tanzania 13 Benin 15 Cameroon 16 Zambia 18 Kenya 19 Malawi 23 Angola 25

Descriptive epidemiology

More common in developing countries. In developed countries is more frequent among immigrants, drug users, HIV, homeless, and those living in inner cities. HIV alone does not explain the increase of TB. In developed countries more frequent in old age (shift in age)

Descriptive Epidemiology Socioeconomic Status

Poverty
Crowding living conditions Reduce access to health care

Migration Population density (rural vs. urban) Substance abuse/alcoholism Nutritional status

Descriptive epidemiology

Age-specific incidence varies over countries and socioeconomic conditions:

Elders in Developed countries Young adults in developing countries*

Higher among males than females

Changing TB mortality

In the West, decline in TB mortality due to

elimination

of poverty improved nutrition medical care

Epidemiological triad

Environmental: (nutrition, wealth, housing, hygiene, sociopolitical). Host changes: susceptibility (e.g. HIV/AIDS infection), travel, migration, sociodemographics. The annual risk of TB in HIV infected approximates the lifetime risk of HIV uninfected Agent changes: Development of drug resistant strains of TB

SOCIAL FACTORS

TB is a social disease with medical aspect & described as a barometer of social welfare Social factors include many non medical factors such as poor quality of life, poor housing, & overcrowding, undernutrition , lack of education and awareness All these factors are interrelated and contribute to the occurrences and spread of TB

Transmission

Tuberculosis is transmitted by airborne droplet nuclei(containing tubercle bacilli )

The transmission is determined

The probability of contact with a case of TB The intimacy and duration of contact The degree of infectiousness of case The shared environment of the contact

Pathophysiology

Tubercle bacilli reach the alveoli ingested by alveolar Macrophages Infection occurs if the inoculums escapes alveolar macrophage microbiocidal activity Once infection occur,lymphatic and hematogenous dissemination typically occurs before an effective immune response take place Primary TB is typically silent If cell medited and macrophages are intact, they surround the organisms in granulomas limiting their multiplication and spread The organism is contained but not eradicated Viable organisms may remain dormant within the granuoloma for years decades , such people do not have active disease, they do not transmit the infection to others Latent TB infection 10% of those people will be reactivation later in their life if they do not receive prophylaxis therapy 50% of these occur in the next 2 years after the primary infection

Not Everyone Exposed Becomes Infected

Probability of transmission depends
on:
Infectiousness Type of environment Length of exposure

10% of infected persons will develop TB disease at some point in their lives
5% within 1-2 years 5% at some point in their lives
21

Persons at Risk for Developing TB Disease

22

Persons at high risk for developing TB disease fall into 2 categories

Those

who have been recently infected Those with clinical conditions that increase their risk of progressing from LTBI to TB disease

Recent Infection as a Risk Factor

23

Persons more likely to have been recently infected include Close contacts to persons with infectious TB Skin test converters (within past 2 years) Recent immigrants from TB-endemic areas Children 5 years with a positive TST Residents and employees of high-risk congregate settings (e.g. correctional facilities, homeless shelters, healthcare facilities)

24

Increased Risk for Progression to TB Disease

Persons more likely to progress from LTBI to TB disease include HIV infected persons Those with history of prior, untreated TB Underweight or malnourished persons Injection drug use Those receiving TNF- antagonists for treatment of rheumatoid arthritis or Crohns disease Certain medical conditions

Evaluation for TB
Medical history
Physical examination

Mantoux tuberculin skin test

Chest x-ray Bacteriologic exam (smear and culture)
25

Symptoms of TB
26

Productive prolonged cough* * Chest pain * Hemoptysis Fever and chills Night sweats Fatigue Loss of appetite Weight loss

*Commonly seen in cases of pulmonary TB

Chest x-Ray
27

Obtain chest x-ray for patients with positive TST results or with symptoms suggestive of TB
Abnormal chest x-ray, by itself, cannot confirm the diagnosis of TB but can be used in conjunction with other diagnostic indicators

Sputum Collection
28

Sputum specimens are essential to confirm TB

Specimens

should be from lung secretions, not

saliva

Collect 3 specimens on 3 different days Spontaneous morning sputum more desirable than induced specimens Collect sputum before treatment is initiated

Smear Examination
29

Strongly consider TB in patients with smears containing acid-fast bacilli (AFB) Use subsequent smear examinations to assess patients infectiousness and response to treatment

Culture
30

Used to confirm diagnosis of TB

Culture all specimens, even if smear is negative Initial drug isolate should be used to determine drug susceptibility

Treatment
31

Latent TB Infection Daily Isoniazid therapy for 9 months

Monitor

patients for signs and symptoms of hepatitis and peripheral neuropathy

Alternate regimen Rifampin for 4 months

Treatment of TB Disease

New pulmonary TB patients should receive a regimen with 6 months of rifampin: -2HRZE / 4HR* -Phase out 2HRZE / 6HE regimen

33

TB treatment for people living with HIV

Receive at least the same duration of TB treatment as HIV negative patients Includes new WHO recommendations* to Start antiretroviral treatment in all HIVinfected individuals with active TB, irrespective of CD4 cell count Start TB treatment first, followed by ART as soon as possible after starting TB treatment

Directly Observed Therapy (DOT)

34

Health care worker watches patient swallow each dose of medication DOT is the best way to ensure adherence Should be used with all intermittent regimens Reduces relapse of TB disease and acquired drug resistance

Clinical Monitoring
35

Instruct patients taking TB medications to immediately report the following:

Rash Nausea,

loss of appetite, vomiting, abdominal pain Persistently dark urine Fatigue or weakness Persistent numbness in hands or feet

Drug Resistance
36

Primary - infection with a strain of M. tuberculosis that is already resistant to one or more drugs

Acquired - infection with a strain of M. tuberculosis that becomes drug resistant due to inappropriate or inadequate treatment

Barriers to Adherence
37

Stigma Extensive duration of treatment Adverse reactions to medications Concerns of toxicity Lack of knowledge about TB and its treatment

Improving Adherence
38

Adherence is the responsibility of the provider, not the patient and can be ensured by:
Patient

education Directly observed therapy (DOT) Case management Incentives/enablers

Measures to Promote Adherence

39

Develop an individualized treatment plan for each patient Provide culturally and linguistically appropriate care to patient Educate patient about TB, medication dosage, and possible adverse reactions Use incentives and enablers to address barriers Facilitate access to health and social services

Completion of Therapy
40

Based on total number of doses administered, not duration of treatment Extend or re-start if there were frequent or prolonged interruptions

Who is responsible for infection control? Where?

41

Health facility management at facility level Health care providers (Health Care workers) at facility, community and household levels Patients at facility, community and home/household levels Visitors at facility, community and home/household levels

Multi Drug Resistant strains of TB (MDR-TB) MDR-TB is TB resistant to 2 or more main-line anti-TB drugs. MDR-TB is increasing worldwide More than 50 million people probably already infected Poor adherence to treatment

TB control

TB control means reduction in the prevalence and incidence of disease in community WHO defines TB control is achieved when the prevalence of natural infection in age group 0-14 years is of the order of 1%.

TB Control and Prevention

Main strategies include: BCG vaccination Case finding Effective chemotherapy Health Education Chemoprophylaxis

Summary- :
leading infectious cause of death infection rates and drug resistant rates increasing, travel and migration key risk factors poor, weak and elderly most vulnerable HIV positive people vulnerable and

References:
46

Oxford text book of public health 3rd edition, 2004 2. K.park. Park;s text book of preventive and social medicine.21st edition. 2011 3. Menzies D et al. Effect of duration and intermittency of rifampin on TB treatment outcomes A systematic review and meta-analysis. PLoS Med. 2009; 6(9): e1000146. doi:10.1371/journal.pmed.1000146.
1.

4. Menzies D et al. Standardized treatment patients with previous treatment and/or with mono-resistance to isoniazid a systematic review and meta-analysis. PLoS Med. 2009; 6(9): e1000150. doi:10.1371/journal.pmed.1000150 5.WHO treatment guide line, 4th edition

THANK YOU!!!