TB Huminis et bovis | Jindal Chest Clinic

Overview on the topic "Tuberculosis Huminis et bovis"

1. Dr. S. K. Jindal
www.jindalchest.com

2. TUBERCULOSIS –a global emergency
H. Nakajima
World Health (ed) 1993

3. Tuberculosis
A Global Emergency
TBkills5,000peopleaday–2millioneachyear
Onethirdoftheworld’spopulationisinfectedwithTB
Morethan100,000childrenwilldieneedlesslyfromTBthisyear
HundredsofthousandsofchildrenwillbecomeTBorphansthis
year
HIVandMDRTBwillmaketheTBepidemicmuchmoresevere
unlessurgentactionistaken

4. India is the highest TB burden country globally
accounting for one fifth of the global incidence Non-HBCs
20%
Ethiopia
3%
Philippines
3%
South Africa
4%
Bangladesh
4%
Pakistan
3%
Nigeria
4%
Indonesia
6%
China
15%
India
20%
Other 13 HBCs
18%
Source: WHO Geneva; WHO Report 2006: Global Tuberculosis Control; Surveillance, Planning and Financing
Globally ~9
million new TB
cases occur
annually

5. TB is the leading single infectious cause
of death in India

6. The National Problem
1.Largepoolofpatients
2.Renewedandperpetuated
3.Difficulttoapproach
4.Difficulttofind,holdandtreat
5.Shortageofbeds

7. TB in India
Per year Per
Day
Infection > 7 million >
20000
Disease > 2 million > 5000
Death > 4 lacs > 1000
Children forced 3 lacs -
to leave school
Women losing 1 lac -
status

8. TB research in India
Indian contribution
1.Supremeimportanceofbacteriologyindiagnosisandcontrol
2.Hospitalization–notessential
3.Principlesofchemotherapy–intermittentisasgood

9. All countries benefit from the fruits of Indian research –
all countries except India.
H. Maher, D.G. WHO
(Quoted by Grzybowski. TubercLung Dis, Ed, 1993)

10. HIV Infection & TB Risk
Annualrisk–about10%
LifeTimeRiskofTB
w.r.t.HIVstatus
-Negative 5-10%
-Positive 50%

11. ECONOMIC BURDEN: Per Year
Totalcosts Rs.12000crores
(US$3b)
Lossofworkdays 17crores
Atacostof 700crores

12. Classification of mycobacteria
Group 1
Obligate pathogens
Mycobacterium tuberculosis
Mycobacterium leprae
Mycobacterium bovis
Group 2
Skin pathogens
Mycobacterium marinum
Mycobacterium ulcerans
Group 3
Opportunistic pathogens
Mycobacterium kansasii
Mycobacterium avium
intracellulare(MAIC)
Group 4
Non-or rarely pathogenic
Mycobacterium gordonae
Mycobacterium smegmatis
Group 5
Animal pathogens
Mycobacterium paratuberculosis
Mycobacterium lepraemurium

13. Mycobacterium bovis
Subsetofmycobacteria
Include:M.tuberculosis
M.africanum
M.microti
(LiveattenuatedstrainsofM.bovisisusedinBCG)

14. M.bovisTB in Humans
Transmissionfromanimals/human
Inhalationroute
Unpasteurizedmilk
Karlsonetal(AnnIntMed1970)
Labprimates
Renneretal(ARRD,1974)
Commercialelkherds
Fanning(Lancet1991)
PersistenceofM.bovisinUS
Dankneretal(Med1993)

15. The public health importance of animal
TB
WHOReportoftheExpertCommitteeonTuberculosis1950
"Thecommitteerecognizestheseriousnessofhumaninfectionwith
bovinetuberculosisincountrieswherethediseaseincattleis
prevalent.Thereisthedangeroftransmissionofinfectionbydirect
contactbetweendiseasedcattleandfarmworkersandtheirfamilies,
aswellasfrominfectedfoodproducts."

16. Bovine tuberculosis occurrence, in Asia

17. Control measures for bovine tuberculosis based on
test-and-slaughter policy and disease notification,
Asia

18. Risk Factors of Bovine TB
Unpasteurizedmilkofinfectedcattle
Sharingofthesamemicro-environmentanddwellingpremises
byhumansandanimals
Immuno-compromisedpatients
HIVinfection(BCGvaccinationinpatientswithAIDS)
Leukaemias,Malignancies
Ranchworkers,veterinarians
Commonwateringplace(forlivestock)

19. Currently,theBTBinhumansisbecomingincreasinglyimportant
indevelopingcountries,as,especiallyinruralareas.Atpresent,due
totheassociationofmycobacteriawiththeHIV/AIDSpandemicand
inviewofthehighprevalenceofHIV/AIDSinthedevelopingworld
andsusceptibilityofAIDSpatientstotuberculosisingeneral,the
situationchangeismostlikely(Amanfu,2006).Thisdisease’s
presenceinhumanshasbeenreducedasaresultofthe

20. ZoonoticTB -Elephants
AreportfromIndia(July5,2009)
(TBindomesticatedelephantsfromKerala,Karnataka,TN,Andaman
&Nicobar)
Templeelephants–16of63(25.4%)
Individualowners– 24of160(15.0%)
Forestdepartment– 10of164(6.1%)
Total: 50of387(12.9%)
(Transmissionfromhumans)

21. Relative Risk for Developing Active TB
by selected clinical conditions
Clinical Condition Relative Risk
Silicosis 30
Diabetes mellitus 2.0 –4.1
Chronic renal failure/hemodialysis 10.0 –25.3
Gastrectomy 2 –5
Jejunoilealbypass 27 –63
Solid organ transplantation
Renal 37
Cardiac 20-74
Carcinoma of head or neck 16
Note: Relative to Control Population, independent of tuberculin-
test status.

22. Clinical Features
IndistinguishablefromM.tuberculosishuminis
Accountsforabout3.1%ofallformsofTB:2.1%ofpulmonaryand
9.4%ofextra-pulmonaryforms.
Pulmonary
Extrapulmonary
Cervicaladenitis
AbdominalTB
Skin(Lupusvulgaris)
Disseminatedinfection
(esp.inchildren)

23. TB control efforts in India
1997 RNTCPstartedasanationalprogramme
1998 LargescaleRNTCPexpansionbegan
Early2000 135millionpopulationcovered
MonitoringMissionconducted
Sept2003 741millionpopulationcovered;
MonitoringMissionappreciatesrapid
expansion
andoverallquality
Mar2006 100%populationcovered;
Next5-yearplanapprovedwithadditional
activities,suchasDOTS-Plus

24. DOTS Strategy
Astrategytoensuretreatmentcompletioninwhich
Treatmentobserver(DOTprovider)mustbeaccessibleand
acceptabletothepatientandaccountabletothehealthsystem
DOTprovideradministersthedrugs
inintensivephase.
Ensuresthatthepatienttakesmedicines
correctlyincontinuationphase.
Providesthenecessaryinformation
andencouragementforcompletionoftreatment.

25. RNTCP treatment guidelines
CATEGORY I New smear +
Seriously ill smear
negative
Seriously ill extra-
pulmonary TB
2 H
3R
3Z
3E
3 /
4H
3R
3
CATEGORY II Previously treated
smear-positive
( relapse, failure,
treatment after
default)
2 H
3R
3Z
3E
3S
3/
1 H
3R
3Z
3E
3 /
5H
3R
3E
3
CATEGORY III New smear negative;
and extra pulmonary
TB, not seriously ill
2 H
3R
3Z
3 /
4H
3R
3
ALL TREATMENT THRICE WEEKLY. CAT I AND CAT II EXTENDED by ONE MONTH
IF SMEAR POSITIVE AT THE END OF INITIAL INTENSIVE PHASE

26. Impact of RNTCP
Curerate:Morethandoubledand85%globaltargetachieved
Casedetection:Almostatthetargetof70%(72%in2004,66%
in2005)
Casefatality:Reducedfrom29%to4%inNSPcases,anddeaths
duetoTBfrom500,000to<370,000ayear
Treatment:Over6millionpatientsinitiatedonDOTS
TBincidenceandprevalence:Earlysignsofstartofdecline.

27. Indiahas already
implementedmostofthe
additionalcomponentsof
theStopTBStrategy

28. VISION: A world free of TB
GOAL
-ToreducedramaticallytheglobalburdenofTBby2015inlinewiththe
MillenniumDevelopmentGoals(MDGs)andtheStopTBPartnershiptargets
OBJECTIVES
-Toachieveuniversalaccesstohigh-qualitydiagnosisandpatient-centred
treatment
-ToreducethesufferingandsocioeconomicburdenassociatedwithTB
-ToprotectpoorandvulnerablepopulationsfromTB,TB/HIVandMDR-TB
-Tosupportdevelopmentofnewtoolsandenabletheirtimelyandeffectiveuse
TARGETS
MDG6,Target8
-TBhaltedby2015andbeguntoreversetheincidence
-TargetslinkedtotheMDGsandendorsedbytheStopTBPartnership

29. Millennium Development Goal 6
MillenniumDevelopmentGoal(MDG)6,Target8:Haltandbegin
toreversetheincidenceofTBby2015
TargetslinkedtotheMDGsandendorsedbytheStopTB
Partnership:
i.by2005:detectatleast70%ofnewsputumsmear-positiveTB
casesandcureatleast85%ofthesecases
ii.by2015:reduceTBprevalenceanddeathratesby50%relative
to1990
iii.by2050:eliminateTBasapublichealthproblem(1caseper
millionpopulation)

30. Componentsofthestrategyandimplementation
approaches
1. Pursuehigh-qualityDOTSexpansionandenhancement
a.Politicalcommitmentwithincreasedandsustainedfinancing
b.Casedetectionthroughquality-assuredbacteriology
c.Standardizedtreatment,withsupervisionandpatientsupport
d.Aneffectivedrugsupplyandmanagementsystem
e.Monitoringandevaluationsystem,andimpactmeasurement
2. AddressTB/HIV,MDR-TBandotherchallenges
a.ImplementcollaborativeTB/HIVactivities
b.PreventandcontrolMDR-TB
c.Addressingissuesconcerningprisoners,refugeesandotherhigh-riskgroupsandsituations
3. Contributetohealthsystemstrengthening
a.Activelyparticipateineffortstoimprovesystem-widepolicy,humanresources,financing,
management,servicedeliveryandinformationsystems
b.Shareinnovationsthatstrengthensystems,includingthePracticalApproachtoLungHealth(PAL)

31. Componentsofthestrategyandimplementation
approaches(Contd.)
4.Engageallcareproviders
a.Public-PublicandPublic-Privatemix(PPM)approaches
b.InternationalStandardsforTuberculosisCare(ISTC)
5.EmpowerpeoplewithTBandcommunities
a.Advocacy,communicationandsocialmobilization
b.CommunityparticipationinTBcare
c.Patient’scharterfortuberculosiscare
6.Enableandpromoteresearch
a.Programme-basesoperationalresearch
b.Researchtodevelopnewdiagnostics,drugsandvaccines

32. Health sectors involved in RNTCP
Medicalcolleges
◦Taskforces,Corecommitteesincollegesestablished
◦~230medicalcollegesinvolved
OtherCentralgovernmentdepartments/PSUs
◦Railways,ESI,Mining,Shipping
NGOs
◦Morethan2000NGOsinvolved
PrivatePractitioners
◦Morethan12,000privatepractitionersinvolved
Corporatesector
◦Nearly120corporatehousesinvolved
◦CoalIndia,Teaindustry,Steel/Aluminiumplants

33. Factors influencing nosocomialtransmission of
tuberculosis among HCWs
Related to the health care facility
Level of exposure
High vslow exposure areas
Inadequate isolation of infected patients
Ennvironmetal
Inadequate sanitation
Inappropriate disposal of excreta
Overcrowding in the wards
Poor ventilation
Host factors related to HCWs
Immune status of an individual
Co-morbid illnesses
BCG vaccination status
General clinical factors
Delayed suspicion and diagnosis
Delayed initiation of treatment
Self-administration of drug
HCWs = health care workers; BCG = BacilleCalmette-Guerin

34. Measuresusedforcontroloftuberculosis
transmissioninhealthcareworkers
General infection control measures
Reduction of environmental load by reducing the release of mycobacteria
Use of masks for patients
Isolation rooms
Preventing environmental spread
Negative pressure rooms
Use of HEPA filters
Use of ultraviolet radiation
Individual protection measures
Inhalation prevention strategies
Use of simple masks
Use of respirators: HEPA filters/PAPR
BCG vaccination
Chemoprophylaxis
Early detection and treatment
(HEPA=highefficiencyparticulateair;PAPR=poweredairpurifying
respirator)

35. Suggested algorithm for early detection of tuberculosis
in HCWs in resource limited settings
Annual screening of HCWs with a symptom-questionnaire
TB Suspect (any HCW with respiratory and/or constitutional symptoms,
not explained by a definitive alternative cause)
Sputum smear for AFB [X3]
Positive Negative
Treatassmear-positiveTB ChestX-ray
SuggestiveofTB NotsuggestiveofTB
-Treatassmear-negativeTB TST/IGRAs
Considerbronchoscopy&BAL
fluidexaminationforAFB Positive Negative
BCGVaccination
Consideralternativediagnosisforsymptoms&
mangeaccordingly

36. Prevention of non-tuberculousmycobacteria
disease
Healthcare-associatedNTMdisease
Avoidexposureofinjectionsites,intravenouscathetersandsurgical
woundsandtapwaterderivedfluid
Avoidcleaningofendoscopeswithtapwater
Avoidcontaminationofclinicalspecimenswithtapwaterandice
DisseminatedMAICdisease
PatientswithAIDS(CD4+T-lymphocytecount<50cells/l)or
Clarithromycin100mg/dayorRifabutin300mg/day(lesswell
tolerated)

37. Control of Bovine TB
Control/Eradicationprograminanimals
Co-ordinationwithRNTCP
Treatmentwitheffectivedrugs
Pasteurizationofmilk
Advancesinsanitationandhygiene
Sustainedcooperationofnationalandprivateveterinary
services,meatinspectors,andfarmersforsuccessfulconductof
atest-and-slaughterpolicy,aswellasadequatecompensationfor
servicesetc.

38. Treatment of Bovine TB
InnateresistancetoPyrazinamide
Treatmentwith2or3drugs(H,R,EandS)for9-12months
StandardSCC:2HRZE,4RH
(O’Donahueetal(ARRD,1974)
DOTSstrategy:Notclearlydefined.Buttypeofmycobacteriaisnot
distinguishedinRNTCP.

39. Summary
IndiaisthehighestTB-burdencountry.
NationwideDOTS-coverageisachievedafteraphaseofunprecedentedrapid
expansionofDOTS.
Withreferencetotheglobaltargets,theTreatment-successhasexceededandcase-
detectionisclose.
AwiderangeofinitiativesbeyondbasicDOTSserviceshavebeenimplemented
Thechallengeaheadistosustaingoodqualityservicesoverthenextfewdecadesin
ordertoachieveTBcontrol
BovineTBisbeingrecognizedasanimportantcauseinhumansinspecificpatient
populations.
ControlprogramsforbovineandhumanTBshouldcoordinateforaneffective
implementation.