informa

1. TUBERCULOSIS
By
Sriloy Mohanty
B.N.Y.S,2nd year
S-VYASA

2. Contents…
• Introduction • Childhood TB
• Problem statement • BCG vaccination
• Epidemological indices • Chemoprophylaxis
• Natural history of TB • NTP
• Stop TB strategy
• Definition of TB cases and
• TB and HIV
treatment
• Epidemiological impact
• Natural history of TB
• Modes Of Transmission
• Control of TB
• Chemotherapy

3. INTRODUCTION
 Specific infectious diseases
 Caused by-M. tuberculosis
 Primary effect on lungs-pulmonary tuberculosis
 Also affects
intestine,meninges,bones, joints,lymph nodes,etc.

4. Cont…
 It affects also animals like cattles
 Known as “Bovine tuberculosis”
 May communicated to man

5. Problem statement
 Distribution-worldwide
 WHO estimates that about 9.2 million new cases
of TB occurred in 2006
 Of these cases, 4.1 million were new smear
positive cases
 This includes 789,000 tuberculosis with HIV co-
infected cases
 There were 14.4 million prevalent cases
 An estimated 1.7 million people died from TB
which 231,000 were those co-infected with HIV

6.  31.8 million new and relapse cases and
15.5 million smear positive case were
notified by DOTS Programme between
1995-2006

7. India
 India is the first rank in incidence
 1/5th of global burden of TB
 1.8 million persons develop TB of which
0.8 million are new smear positive (highly
infectious)
 0.37 million people die every year
 DOTS program was launched in March
1997

8. TB estimates for India
Population 1151 million
Global rank (by estimated number of cases) 1
Incidence (all cases/1 lakh population/year) 168
Incidence (new smear +ve cases/lakh population/year) 75
Prevalence (smear +ve cases/lakh population) 299
TB mortality/1 lakh population/year 28
% of new TB cases HIV positive 1.2
% of new case multidrug resistance 2.8
Previously treated TB cases multidrug resistance (%) 17

9.  It is mainly a disease of the poor
 Majority of victims are migrant laborers, slum
dwellers, residents of backward areas and tribal
pockets

10. Epidemological indices
 Prevalence of infection
 Percentage of individual who are positive to
tuberculin test
 Incidence of new cases
 Percentage of new cases/1000people/1year
 Prevalance of suspect cases
 Based on X-ray examination of chast

11.  Mortality rate
 Number of death from TB
 Prevalance of drugs
 Prevalance of patient excreting tubercle
bacilli resistant to anti-tubercle drugs

12. Definition of TB cases
and
treatment
 Case of TB
 patient in whom TB is confirmed by tests
 Sputum smear examination
 Test for screening of TB (acid fast bacilli are stain
red by ziehl neelsen method)
 New case
 Person with smear positive test having pulmonary TB
who had never taken any treatment

13.  Relapse
 Person who returns smear +ve having previously
been treated and declared cured
 Failure case
 Person with smear +ve treated and again become +ve
at 5th month or later during treatment
 Return after default
 Person,returns to sputum positive ,after having left
treatment for atleast two months
 Transfer in
 A patient recorded in another administrative area
register and transferred into another area to continue
treatment

14.  Transfer out
 A patient who has been transferred to another
area register and treatment results are not
known
 Cured
 Negative smear after treatment
 Treatment completed
 Initially smear –ve or +ve and after receiving
full course of treatment becomes –ve
 Adherence
 Person takes appropriate drugs regimen for required
time

15. Natural history of TB
Agent factor
 M.tuberculosis is a intracellular parasite
 Ingested by phagocytes but resistant to
intracellular killing
 Indian tubercle bacillus is said to be less virulent
then the europian bacillus

16. Cont…
 Number of “atypical” myobacteria have been
isolated from man
 They are of 4 types
 Photochromogens
 Scotochromogens
 Non-photochromogens
 Rapid growers

17.  Source of infection
 Two source of infection
 Human source-person whose sputum is
positive for tubercle bacilli
 Discharge of bacilli in their sputum
 Bovine source-infection is usually by milk
 Not a problem in India because of the practice of
boiling milk before consuption

18. Communicability
 Patient are infective as long as they remain
untreated
 Infection can be reduced by 90% within 48 hours
by using anti-microbial treatment

19. Host Factor
 AGE
 Affects all ages
 In India under 5 age group-1%
 At the age of 15years-30%

20.  SEX
 More prevalent in male then female
 HEREDITY
 It is not a hereditary disease

21.  NUTRITION
 Malnutrition is believed to predispose to TB
 Diet had no effect on the recovery of patient
 IMMUNITY
 No inherited immunity against TB
 Acquired after natural infection or BCG
vaccination

22. Social factor
 TB is a disease with both social and
medical aspects
 Social factors includes
 Poor quality of life
 Poor housing
 Population explosion
 Early marriages
 Lack of awareness of causes of disease

23. TUBERCULIN TEST
 Discovered by Von Pirquet(1907)
 Three main test are currently in use
 Mantoux intradermal test
 Heaf test
 Tine multiple puncture test

24. Modes Of
Transmission
 Mainly by droplate infection and droplate nuclei
generated by sputum positive patient
 Particle should be fresh enough to carry
 Coughing generates all size of droplates
 Notes-not transmitted by fomites

25. Incubation period
 Ranges from 3-6 week

26. Control of TB
 Reduction in prevalence and incidence
 WHO defines control as prevalance of natural
infection in the age 0-14yrs is of the order of 1%
 In india it is about 40%
 Control measure consists of
 Curative component-case finding and treatment
 Preventive component-BCG vaccination

27. Case finding
 THE CASE
 Detection of sputum positive case
 Case is defined by WHO as patient with
sputum positive for tubercle bacilli
 Target group
 Pulmonary TB has one or more of the
symptoms like
 Cough and Fever
 Chest problems

28.  Case finding tools
 Sputum examination
 Sputum smear examination
 Who also have problems like
 persistant cough of about 3-4weeks
 Continous fever
 Chest pain
 haemoptysis

29. Chemotherapy
 Indicated for every case of active BT
 Objectives are
 Elimination of both the fast and slow multiplying
bacilli
 Mainly elimination of bacilli from patients sputum
 Available for free of charge

30. Anti-tuberculosis
drugs
 An anti-tuberculosis drug should follow some
criteria's like
 Free from side effects
 Highly effective
 Easy to administrate
 Reasonably cheap

31. Classification of drugs
 Currently used drugs are classified in to
 Bactericidal drugs-kills the bacteria
 Bacteriostatic drugs-inhibits the multiplication of the
bacilli and leads to destruction by the immune
mechanism of the host

32. Bactericidal drugs
 Rifampicin(RMP)
 Powerful Bactericidal drugs
 Permeates all tissue membrane
 Only Bactericidal drugs active against the dormant
bacilli
 Only oral drug
 10-12mg/kg body weight
 May feel nausea,gastritis,purpra

33.  INH
 Most powerful drug
 Can penitrate the cell membrane
 Active against intracellular and extracellular bacilli
 It can also pass BBB,present in CSF
 4-5gm/kg body weight

34.  Streptomycin
 Act on rapidly multiplying bacilli
 Less active on slow multiplying bacilli
 No action on persisters
 Non-permeate cell wall
 0.75-1gm in a single injection

35.  Pyrazinamide
 Active against slow-multiplying intracellular
bacilli
 Drug given orally
 Usual dose 30gm/kg body weight
 Recommended in tuberculous meningitis

36. Bacteriostatic drugs
 Ethambutol
 Used in combination to prevent the
emergence to the drugs
 Given orally
 Side-effect-retro-bulbar neuritis
 15mg/kg body weight given in 2-3 doses

37.  Thioacetazone
 Companion drug to INH
 Adult dose-2mg/kg body weight
 Side-effect includes gastrointestinal
disturbances, blurring of vision, haemolytic
anaemia

38. Two-phase
chemotherapy
 Consist of two phase of effective treatment
 Short aggressive or intense phase
 Lasting 1-3months
 Three or more drugs are combined to kill initialy
 Continuation phase
 Aimed to sterilizing the smaller number of
dormant
 Not less then 18 months
 If rifampcin and pyrazinamide applied,then it can
reduced to 6-9 months

39. Treatment during
pregnancy
 Streptomycin can cause permanent deafness in
the baby
 So ethambutol should be used instead of
streptomycin,
 Isoniazid, rifampicin, pyrazinamide and
ethambutol are safe to use
 Second line drugs should not be used becouse
these are teratogenic
(flouroquinolomes,ethionamide)

40. Childhood TB
 TB in children present between 10-20% of all BT
 Sourse is usually adult
 Frequency of childhood TB depends
 Number of infectious case
 Closeness of contact with an infectious case
 Age of the child when exposed to TB

41.  Childhood TB is mainly due to failure in control
of TB in adult
 Under 5 age group-20%
 The commonest age-1-4years

42. BCG vaccination
 Calmette and guerin in 1919 discovered bacille
Calmette guerin(BCG)
 Avirulent for man while retaining its capacity to
induce an immune response
 During 1921-1925-given orally
 After 1927-intradermal technique
 1948-it is accepted by TB workers

43. AIM
 Induce benign artificial primary infection
 By stimulating an acquired resistance

44. Vaccine
 Widely used live bacterial vaccination
 Derived from an attenuated bovine stain of
tubercle bacilli
 WHO has recommended the “Danish 1331” stain
for production of BCG vaccination

45. Types of vaccination
 Two types of BCG vaccination
 Liquid vaccination(fresh)
 Freeze-dried vaccination(stable)

46.  BCG is stable for several weeks in a tropical
climate and for up to 1 year if kept away from
direct light and stored in cool environment
preferably refrigerator at a temperature below 10
deg C
 Normal saline is recommended for diluent for
reconstituting the vaccine

47. Dosage
 For vaccination the usual strength is 0.1 g in 0.1
ml volume
 For new born (below 4 weeks) 0.5 ml, because
the skin of the new born is thin

48. Administration
 Inject the vaccine intradermally using a
tuberculin syringe (recommended by WHO)
 If injected subcutaneously an abscess is likely to
develop
 The site of injection should be above the insertion
of deltoid

49. Phenomena after
vaccination
 After 2-3 weeks a papule develops at the site of
vaccination
 It increases slowly in the diameter about 4-8 mm
in 5 weeks
 Healing occurs within 6-12weeks
 Round scar is formed

50.  complication
 Prolonged severe ulceration
 Supractive lymphadenitis
 Osteomyelitis
 Death
 Protective value
 Protection from 15-20years

51. Revaccination
Even 80 years after the development of the vaccine, it is
not known whether booster doses are indicated or
advisable
Contraindication
Generalized eczema, infective dermatosis,
hypogammaglobulinaemia, to those with a history of
deficient immunity
Patient under immunosuppresent treatment and in
pregnancy

52.  Direct BCG vaccination
 Vaccination without a prior tuberculin test has been
adopted as a National policy in many developing
countries including India
 No adverse effects have been reported even if
BCG is given to tuberculin – positive reactors

53. Impact
 BCG is less effective than the chemotherapy
BCG vaccination and HIV infection
 A single dose of BCG vaccine should be given to
all healthy infants as soon as possible after birth
unless the child presented with symptomatic HIV
infection

54. Combined vaccination
 BCG may be given at the same time as OPV.
DPT vaccine may also be given at the same time
as BCG, but in different arm without reducing the
immune responses or increasing the rate of
complication

55. Chemoprophylaxis
 The case against INH chemoprophylaxis rests on
3 points:
 It is a costly exercise
 It is not strikingly effective
 It can induce hepatitis
 According to WHO mass treatment is not feasible
 In this context, BCG gets priority over
chemoprophylaxis

56.  Surveillance
 An integral part of any effective TB
 Concern with two distinct aspect
 Surveillance of TB situation
 Surveillance of control measures(BCG and chemotherapy)
 Role of hospital
 Inspite of effective domicilliary treatment service
there will be need for hospitalization for some person
 Indications are
 Emergencies
 Surgical treatment
 Management of serious type of TB(meningeal TB)
 Social indication

57.  Drugs resistance
 All drugs used in TB produce resistance
 Resistance may be of two types
 Pretreatment resistance
 Acquired resistance

58. National Tuberculosis
Programme (NTP)
 NTP has been under operation since 1962
 The long term goal of NTP is “to reduce the
problem of tuberculosis in the community
sufficiently quickly to the level where it ceases to
be a public health problem”.

59. Revised NTP
 The Govt. of India, WHO and World Bank
together reviewed the NTP in the year 1992
 The main pillars of the revised strategy are;
 Achievement of not less than 85% cure rate amongst
infectious cases of TB, through short course
chemotherapy involving peripheral health
functionary

60.  Detecting 70% of the estimated cases – through quality
sputum microscopy
 Involvement of NGOs
 Direct Observed Therapy Short – term (DOTS) – a
community based TB treatment and care strategy

61. Stop TB strategy
 2006- WHO launched
 Core of the strategy – DOTS
 Indicators used to measure implementation and
impact of TB control:
 Case detection
 Treatment success
 Incidence
 Prevalence
 Deaths

62. Stop TB partnership
target
 By 2005
 70% of people with sputum smear positive TB will
be diagnosed
 By 2015
 Global burden of TB will be reduced by 50% relative
to 1990 levels
 By 2050
 Global incidence of TB will be less then or equal to 1
case/million population/year

63. TB and HIV
 HIV virus damages the bodies natural defense
 Accelerates the speed at which TB progresses
from a harmful infection to life – threatening
condition

64. Epidemiological impact
 Reactivation of latent infection
 People who are infected with both TB and HIV are
25-30 times more likely to develop TB than the
people infected with only TB
 Recurring infection
 People having HIV who have been cured of TB may
be at more risk of developing TB again
 In the community
 Educate people that TB is curable and the people are
no longer infectious after the first few weeks of
treatment

65. Thank You…