BY DR.

TAHMINA AZHAR

One-third of the worlds population is infected by tuberculosis. Each year, around 8 million of these people develop the clinical disease, known as active TB . Globally, TB is the second commonest cause of death, killing almost 2 million people annually. TB kills 4,700 people every day. One person is infected every second. One person with active TB might infect 10-15 people/year.

TUBERCULOSIS PROFILE
Pakistan ranks eighth among 22 high burden states. 1.6-2 million suffer from TB in Pakistan Est. number of new cases-410,000 Est. prevalence- 373 cases/100,000 pop. Est. Incidence- 231/100,000 pop. Est. Death rate due to TB- 38/100,000

TUBERCULOSIS-FACTS AND FIGURES

More than 150,000 deaths annually 26% avoidable deaths Only one in 5 cases is ever diagnosed/treated Prevalence of MDR cases is 8% Cost of treatment for 2 years of a MDR case is Rs.250,000 80% of patients first go to a private doctor Only one in 10 GP in Pakistan prescribe the correct anti-TB treatment

NATIONAL TUBERCULOSIS PROGRAMME (NTP)

NATIONAL TB CONTROL PROGRAMME (NTP)

267,451 cases were diagnosed in 2009-2010 More than 1.3 million TB patients have been treated free of cost. Case detection rate- improved from 70% to 75% under the DOTS programme. Treatment success rate- from 88% to 91% Free diagnosis and treatment at 5800 centres. Defaulters have reduced from 17% to 11%

TB an ever increasing Problem

Lack of awareness about seriousness of disease Poverty Delay in diagnosis, unsupervised, inappropriate and inadequate drug regimens. Malnutrition Non-compliance of treatment Lack of supervision and poor follow up Lack of social support programme Economic recession

EMERGENCE OF DRUG RESISTANCE TB

Multi-drug resistant TB (MDR-TB) 3.2%

Resistant to INH and Rifampicin

Extensively drug resistant TB (XDR-TB)

Resistant to INH and Rifampicin Resistant to a fluroquinolone Resistant to one or more of injectables

HIV- associated TB

TUBERCULOSIS

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. Those with pulmonary TB are most likely to spread the disease to others, each infecting between 10 and 15 people on an average every year.

99% percent of TB deaths occur in the developing world

95%percent of active TB cases occur in the SouthEast Asia Region (SEAR), Western Pacific and Sub-Saharan Africa.
Disease kills mostly adults in the economically productive age group, between 15-49 years.

It primarily affects lungs, but can also affect skin, intestines, meninges, bones & joints, lymph glands & other tissues of the body.
Bovine tuberculosis which mainly effects cattle, can also be transmitted to man.

TUBERCULOSIS OF SKIN

TUBERCULOSIS ADENITIS (SCROFULA )

GIBBUS DEFORMITY IN TB SPINE

TUBERCULOSIS OF LUMBAR SPINE ( POTTS DISEASE)

TB VERTEBRAE

EPIDEMIOLOGICAL INDICES
PREVALENCE OF INFECTION: It is the % of individuals testing positive to the tuberculin test. Age specific prevalence is a good indicator to recent & remote infections.

INCIDENCE OF INFECTION: It is the % of individuals likely to be newly infected by M.tuberculosis among the non-infected population during one year. It indicates the annual infection rate & risk of being infected in a given community.

PREVALENCE OF DISEASE OR CASE RATE: it is the % of sputum positive individuals. It estimates the number of infectious cases in a community. INCIDENCE OF NEW CASES: It is the % of newly confirmed cases per 1000 population per year. PREVALENCE OF SUSPECT CASES: based on X-ray chest examination but bacteriological examination is a must.

PREVALENCE OF DRUG-RESISTANT CASES: It is the % of patients excreting tubercle bacilli resistant to antituberculosis chemotherapy.

MORTALITY RATE:It is the number of deaths from tuberculosis every year per 1000 or 100,000 population. It indicates the need for a strong and effective national tuberculosis control programme.

EPIDEMIOLOGICAL FACTORS
AGENT FACTORS: Mycobacterium tuberculosis SOURCE OF INFECTION: Human source: cases whose sputum is positive for tubercle bacilli & who have received no treatment or incomplete treatment. Bovine source: infected milk COMMUNICABILITY: Patients remain infected unless treated. Effective chemotherapy reduces infectivity by 90% within 48 hours.

HOST FACTORS

AGE SEX HEREDITY NUTRITION IMMUNITY

A CARRIER

SOCIAL FACTORS

NON-MEDICAL FACTORS e.g.

Lower socio-economic status & a poor quality of life. Overcrowding & population explosion Lack of education & awareness Under nutrition & large families

INCUBATION PERIOD:
3-6 weeks, but depending on the closeness of contacts, extent of disease & sputum positivity it may be weeks, months or years.

MODE OF TRANSMISSION:

DROPLET TUBERCULOSIS
generated by sputum positive patients with pulmonary tuberculosis.

CONTROL OF TUBERCULOSIS
Control possible by reduction in the prevalence & incidence of disease in the community. Curative ComponentCase finding & treatment Preventive ComponentBCG vaccination

CASE FINDING

THE CASE: it is a patient whose sputum is positive for tubercle bacilli, whereas, sputum negative but doubtful shadows in chest X-rays are regarded as suspects. TARGET GROUP: majority of the patients seek medical help with one or more chest symptoms, e.g. persistent cough, fever, dyspnea, chest pain, haemoptysis.

CASE FINDING TOOLS

SPUTUM EXAMINATION:
DIRECT

SMEAR EXAMINATION SPUTUM CULTURE

MASS MINIATURE RADIOGRAPHY TUBERCULIN TEST To estimate the prevalence of infection in a population. Intradermal injection of 1TU of PPD in 0.1ml. Results read after 72 hours. Induration exceeding 10mm is considered positive.

POSITIVE TUBERCULIN TEST

MILIARY TUBERCULOSIS

PYOPNEUMOTHORAX IN TB

TB CAVITY

ACTIVE PULMONARY TUBERCULOSIS

TB WITH HILAR LYMPHEDENOPATHY

TB PERICARDITIS

TB WITH PLEURAL EFFUSION

TB PYOPNEUMOTHORAX

PULMONARY TB WITH CAVITY FORMATION

DOUBLE PNEUMONIA TB PLUS STREPTOCOCCUS PNEUMONIA

STOP TB STRATEGY
Principal indicators used to measure the implementation and impact of TB control: 1. Case detection 2. Treatment success 3. Incidence rates 4. Prevalence rates 5. Death rates

STOP TB Partnership Targets

By 2005-70% diagnosed & 85% cured By 2015- global burden of TB to be reduced by 50%

Prevalence 150/100,000 per year Deaths to 15/100,000 per year

By 2050 incidence 1 case/ million population/year.

CHEMOTHERAPY

ANTI-TUBERCULOUS DRUGS: should be Highly effective Free from side-effects Easy to administer Reasonably cheap,free or easily available BACTERICIDAL DRUGS: Rifampicin Isoniazid Streptomycin Pyrazinamide

BACTERIOSTATIC DRUGS

Ethambutol Thioacetazone

TWO-PHASE CHEMOTHERAPY: Short,aggressive & intense phase,1-3 months, (3 or more drugs are combined) Continuation phase of 6-9 months

DOMICILIARY TREATMENT
Self administration of oral drugs without hospitalization is referred to as domiciliary or ambulatory treatment.

The best cost effective strategy being used world-wide to ensure cure of tuberculosis. During intensive phase a health worker watches as patients swallow the drugs. In continuation phase, medicine is issued in multi blister pack weekly. Successful chemotherapy depends on adequate and regular drug intake. Through DOTS a cure can be assured.

DIRECTLY OBSERVED TREATMENT,SHORT COURSE(DOTS) CHEMOTHERAPY

The greatest development in TB control was WHO launching Directly Observed Treatment, Short Course or DOTS in 1994. DOTS has five key components:
1. Government commitment to sustained TB control activities.

2. Case detection by sputum smear microscopy among symptomatic patients self-reporting to health services.
3. Standardized treatment regimen of six to eight months for at least all sputum smear- positive cases, with directly observed therapy (DOT) for at least the initial two months.

DOTS CHEMOTHERAPY
4. A regular, uninterrupted supply of all essential anti-TB drugs. 5. A standardized recording and reporting system that allows assessment of treatment results for each patient and of the TB control programme performance overall (WHO 2004).

HAS DOTS SUCCEEDED ??

The decision to implement DOTS was based on evidence which showed that detecting 70% of smear-positive patients and curing 85% of these could reduce TB incidence by 6% every year and thus halve TB prevalence in ten years. It persistently delivers better results,allows improved management and monitoring, and as a brand it has attracted increased attention and resources for TB.

Advantages of DOTS
Accuracy of TB diagnosis is doubled Treatment success rate is upto 95% Prevents spread of infection, thereby, reducing incidence and prevalence rates Improve quality of health Prevents failure of treatment & emergence of MDR-TB Helps alleviating poverty by saving lives

DOTS BEING IMPLEMENTED

DRUG RESISTANCE

PRIMARY OR PRETREATMENT RESISTANCE SECONDARY OR ACQUIRED RESISTANCE Multi-drug resistance strain MDR
( INH and Rifampicin )
Common

reasons being:

Incorrect

prescription Irregular supply of drugs Noncompliance of treatment Lack of supervision & follow-up

PREVENTION OF DRUG RESISTANCE:

Combination treatment with 1-2 drugs Using specific bacteria sensitive drugs Ensuring complete, adequate & regular treatment.

BCG VACCINATION
BACILLE-CALMETTE GUERIN AIM: to induce a benign, artificial primary infection which gives an acquired immunity against possible subsequent infection from tubercle bacilli. VACCINE:live attenuated bovine strain vaccine of tubercle bacilli. TYPES OF VACCINE:
Liquid

(fresh) vaccine Freeze dried vaccine

DOSAGE: for new born, below 4 weeks- .05ml usual strength is .1ml in normal saline ADMINISTRATION: intradermal injection AGE: at birth in most developing countries or at 06 weeks along with DPT and polio. in developing countries, it is only given to high-risk groups. PHENOMENA AFTER VACCINATION: in 2-3 weeks -development of a papule at site of vaccination-after 5 weeks a shallow ulcer develops which heals in 6-12 weeks.

COMPLICATIONS OF BCG
Prolonged severe ulceration at site of injection Suppurative lymphadenitis Osteomyelitis Disseminated BCG infection & death.

PROTECTIVE VALUE:
80% protection & immunity for 18-20 years or more. REVACCINATION: doubtful

CONTRAINDICATIONS:
Generalized eczema Infective dermatosis Hypogammaglobulinemia History of deficient immunity

REHABILITATION

SURVEILLANCE:
By

measuring the annual infection rates Application of control measures

HOSPITAL CARE:
Massive

Haemoptysis Spontaneous pneumothorax Surgical treatment Meningeal tuberculosis

TUBERCULOSIS AND HIV

Tuberculosis is the most frequent opportunistic infection which kills HIV positive patients. HIV virus damages the immune system & simultaneously accelerates tuberculosis progress from a curable infection to a life threatening condition. DOTS can be the best thing to control & cure such patients.

Immunosupression radically increases the risk of progressing to active TB, so the global HIV pandemic has had a huge impact on TB incidence and mortality.

BCG VACCINATION & HIV INFECTION

WHO recommends all asymptomatic HIV infected children should receive the BCG vaccine and those with AIDS Related Complex / AIDS should not be given BCG.

PULMONARY TUBERCULOSIS
A serious health problem all over the world. Highly effective vaccine and drugs available makes it a preventable and curable disease,yet most developing countries are still in its deadly grip. Improvements in the standard of living & quality of life along with advanced technology & good health resources has achieved spectacular results in the developed world.