TB PPT 2022.pptx

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1. . INSTITUTE OF HEALTH SCIENCES SCHOOL OF NURSING AND MIDWIFERY DEPARTMENT OF ADULT HEALTH NURSING PRESENTATION ON TUBERCULOSIS By Demiso Geneti ( MSc fellow) Wollega, Oromia, Ethiopia 11/14/2022 TB B by Damee 1

2. Learning objectives At the end of this section the learners will be able to: Define tuberculosis Describe epidemiology of tuberculosis Listing pathophysiology of tuberculosis Define risk factors of tuberculosis Describe clinical features of tuberculosis List treatment guideline of tuberculosis List nursing intervention of tuberculosis 11/14/2022 TB B by Damee 2

3. Pulmonary Tuberculosis (PTB) Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma in which case it is called pulmonary TB. In addition to the lungs, any part of the body can be affected with this bacterium and in this case it is called extra pulmonary TB. TB affects individuals of all ages and both sexes , and estimated to infect 1/3 of world population leaving increased pool of vulnerability to develop active. 11/14/2022 TB B by Damee 3

4. TB…. Infectious agent M. tuberculosis :- human tubercle bacilli (commonest cause) M. bovis:- causes cattle and man infection M. avium:- causes infection in birds and man 11/14/2022 TB B by Damee 4

5. Epidemiology of TB TB affects an estimated 10 million people per year (range 8.9–11.0 million) and is one of the world’s leading infectious disease killers. Due to malnutrition, immunity, overcrowded, susceptible Of the estimated 10 million, approximately 70% are diagnosed and treated and also reported to the WHO, resulting in 7.1 million TB notifications by National TB Programme, Of the 7.1 million persons notified in 2019, 5.9 million (84%) had PTB (WHO consolidated guidelines on TB 2022) 11/14/2022 TB B by Damee 5

6. TB situations in Ethiopia TB remains a major public health problem worldwide and leading cause of morbidity and mortality. Currently , 1.7 billion (26%) of the world’s population are considered to be infected with MTB. In Ethiopia , TB is a major public health problem. The country is still among the 22 high TB burden countries with high number of missed and infectious TB cases in the community. TB is among the top ten causes of admission and deaths in adults. 11/14/2022 TB B by Damee 6

7. Epidemiology of TB… It is also estimated that Ethiopia had 191,000 new TB cases in 2015. This number ranks Ethiopia 10th globally and 4th in Africa , after Nigeria, South Africa and the DR Congo . Ethiopia is also one of the 27 countries with a high burden of multidrug-resistant TB. A study conducted in Addis Ababa, Ethiopia showed that t he prevalence of both PTB and EPTB was 46.0% ( Eshetu Temesgen , etl , A ddis Ababa, 2021) 11/14/2022 TB B by Damee 7

8. Epidemiology of TB… In Ethiopia, TB case detection is below the WHO target. In 2019 , 29.3% of cases were not notified to the national TB program The prevalence of pulmonary TB cases among people who sought health care with cough of any duration was 16.7 %, of which 95.5% PTB cases were diagnosed at OPDs. Of 16.7% of TB cases, 60% was confirmed by sputum and 40% was confirmed by CXR, history & clinical. 11/14/2022 TB B by Damee 8

9. Epidemiology of TB… The prevalence of confirmed PTB among routine outpatients was high , and this included those with a low duration of cough who can serve as a source of infection. Screening all patients at outpatient departments who passively report any cough irrespective of duration is important to increase TB case finding and reduce TB transmission and mortality ( Hussen M, etl , Ethiopia, 2020) 11/14/2022 TB B by Damee 9

10. CONT… TB related mortality is highlighted in the top ten reported causes of death among hospital admissions, with annual estimated death rate of 26 per 100,000 populations in 2015 . TB incidence 42 % of decline from annual 369 cases per 100,000 populations to 177 per 100,000 populations in 2016 Ethiopia remains to be among the 30 countries reported with high burden of TB, TB/HIV and DR-TB for 2015 to 2020. 11/14/2022 TB B by Damee 10

11. …. In 2016 , estimated 35 % of incident TB cases were missed TB remains to be the leading causes of death of people with HIV, accounting for around 40% of AIDS-related deaths. Both diseases together form a lethal combination, each speeding the other's progress. 11/14/2022 TB B by Damee 11

12. …. In Ethiopia, 82% of notified TB patients in 2016 knew their HIV status while 82% of reported HIV-positive TB patients have accessed antiretroviral therapy. HIV infection and TB disease on same year leaving people at increased risk of suffering & mortality MDG achieved HIV prevalence in incident TB cases (TB/HIV co-infection rate) is about 11%, Global average 13 %, African average 34% 11/14/2022 TB B by Damee 12

13. …. Ethiopia adopted the DOTS strategy since 1997 after successful pilot program with the development of the first combined TB and Leprosy Prevention and Control Program manual . TB/HIV collaborative activities were piloted in 2004 and subsequently scaled up national ( Ethiopia National guideline for TB Leprosy and TB 6th edition Aug-2018) 11/14/2022 TB B by Damee 13

14. TB Control strategy Globally different control strategies were implemented for the past two decades to reduce morbidity and mortality due to TB all over the world. These strategies were, DOTS (directly observed treatment, short-course) strategy of 1995 . T he stop TB Strategy of 2006 that aided to reduce all forms of TB including HIV-associated and drug-resistant TB These strategies got remarkable achievement in that 37 million lives were saved between 2000 and 2013/15 11/14/2022 TB B by Damee 14

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17. TB Control strategy… Recently , WHO developed the end TB strategy with an overall goal of a 90% reduction in TB incidence and a 95% reduction in TB deaths from 2015 to 2035 by integrated patient-centered care and prevention, bold policies and supportive systems, intensified research and innovation ( Eshetu Temesgen , etl , Addis Ababa, 2021) 11/14/2022 TB B by Damee 17

18. TB Control strategy… The national TB program has strategic plan in the 5 -year towards achieving the END TB 90-(90)-90 targets set for 2020: Ensure 90% of all people with TB diagnosed and treated. Ensure 90% of the key populations in the country are diagnosed and treated Ensure 90% of people diagnosed successfully complete treatment ( FMOH. National TB strategic plan: 2017-2020) 11/14/2022 TB B by Damee 18

19. Ethiopia TB Roadmap Overview,2022-2026 Among the top 30 high TB burden countries, Ethiopia ranked 12 th ; and among the high multidrug-resistant TB ( MDR-TB) burden countries, Ethiopia ranked 24 th . While some gains have been made in decreasing TB incidence, from 421 (in 2000) to 132 (in 2020 ) per 100,000, of incidence and mortality from drug-susceptible TB remain high, while treatment coverage remains low. 11/14/2022 TB B by Damee 19

20. Ethiopia TB Roadmap Overview,2022-2026… Currently , the NTP revised its five-year TB and Leprosy National Strategic Plan , which will cover the period 2021-2026 The TBL-NSP aims to reduce TB incidence from151 cases per 100,000 and 22 deaths per 100,000 in 2018 to 91 cases per 100,000 and 7 deaths per 100,000 by 2026 respectively. 11/14/2022 TB B by Damee 20

21. By Prioritizing the following interventions Scaling-up the use of rapid diagnostics for routine screening Engaging all care providers in TB diagnosis and care; Prioritizing reaching vulnerable populations Decentralization of TB care and treatment; Mitigating the catastrophic cost of TB care on patients and HHS Increasing contact screening coverage and preventive treatment Mitigating TB-related stigma in the community and healthcare Proactively finding ways to manage other respiratory impacts (Ethiopia_Narrative_TBRM22_Version_Final) TB B by Damee 21

22. Transmission of TB TB spreads from person to person by airborne transmission . An infected person releases droplet nuclei (usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing, or singing. Larger droplets settle; smaller droplets remain suspended in the air and are inhaled by a susceptible person. 11/14/2022 TB B by Damee 22

23. L ists risk factors for TB Close contact with someone who has active TB Immunocompromised status Substance abuse (IV/injection drug users and alcoholics). Any person without adequate health care Preexisting medical conditions or special treatment Immigration from or recent travel to countries with a high prevalence of TB. Institutionalization Living in overcrowded, substandard housing. Being a health care worker performing high-risk activities (Adapted from CDC and Prevention Sep 1, 2012) 11/14/2022 TB B by Damee 23

24. Pathophysiology TB begins when a susceptible person inhales mycobacteria and becomes infected. The bacteria are transmitted through the airways to the alveoli, where they are deposited and begin to multiply. The bacilli also are transported via the lymph system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs. The body’s immune system responds by initiating an inflammatory reaction 11/14/2022 TB B by Damee 24

25. Pathophysiology…. Phagocytes (neutrophils and macrophages) engulf many of the bacteria, and TB-specific lymphocytes destroy the bacilli and normal tissue. This tissue reaction results in the accumulation of exudate in the alveoli , causing bronchopneumonia . The initial infection usually occurs 2 to 10 weeks after exposure. Granulomas , new tissue masses of live and dead bacilli, are surrounded by macrophages, which form a protective wall. 11/14/2022 TB B by Damee 25

26. Pathophysiology…. They are then transformed to a fibrous tissue mass, the central portion of which is called a Ghon tubercle . The material (bacteria and macrophages) becomes necrotic , forming a cheesy mass . This mass may become calcified and form a collagenous scar. At this point, the bacteria become dormant , and there is no further progression of active disease. After initial exposure and infection, active disease may develop because of a compromised or inadequate immune system response Active disease also may occur with reinfection & activation of dormant bacteria. 11/14/2022 TB B by Damee 26

27. Pathophysiology…. In this case, the Ghon tubercle ulcerates , releasing the cheesy material into the bronchi. The bacteria then become airborne, resulting in the further spread of the disease. THIS CAUSES the infected lung to become more inflamed, resulting in the further development of bronchopneumonia and TB formation . 11/14/2022 TB B by Damee 27

28. Evolution of TB infection and disease Latent TB infection: Individuals with latent TB infection do not have symptoms as there is no tissue destruction by the bacilli and are not infectious. In immunocompetent individuals, only 5-10% of infected persons develop active disease in their life time. 11/14/2022 TB B by Damee 28

29. CONT… 2. Active TB disease : may arise from progression of the primary lesion after infection (Primary TB), or from endogenous reactivation of latent foci, which remained dormant . The progression from LTBI to Active TB disease may occur at any time, from soon to many years later . Post primary/secondary TB usually affects the lungs (Pulmonary TB) and I f it disseminated, to all organs can be affected (MiliaryTB) 11/14/2022 TB B by Damee 29

30. CONT…. 3 . Prognosis of TB: I n the great majority (90-95%) of persons infected with MTB, the immune system either kills the bacilli or perhaps more often, keeps them suppressed (silent focus) resulting a latent TB infection 11/14/2022 TB B by Damee 30

31. Registration group for TB patient New TB: patients that have never been treated for TB or have taken anti-TB drugs for less than one month. Relapse : patients who were declared cured or treatment completed at the end of their most recent treatment course, and is now diagnosed with a recurrent episode of TB. Treatment after failure : refers to patients who were declared treatment failure in their most recent course of treatment as per national protocol. . 11/14/2022 TB B by Damee 31

32. Registration group for TB patient… Treatment after loss to follow-up : refers to patients who were declared lost to follow-up at the end of their most recent course of TB treatment and is now decided to be treated with full course of TB treatment . Transfer in : A patient who is transferred to continue treatment at a given reporting unit after starting treatment in another reporting unit. 11/14/2022 TB B by Damee 32

33. Clinical features The clinical features of TB depend on the specific organ affected. The clinical features can be grouped: General (non-specific) and Organ specific 11/14/2022 TB B by Damee 33

34. Clinical features…. Tuberculosis has two major clinical forms Pulmonary (80%) of the total TB cases. Primarily occurs during child hold & secondarily 15-45 years or later. Extra pulmonary (20%) affects all parts of the body. Most common sites are lymph nodes, pleura, GUT, bone and joints, meninges & peritoneum. 11/14/2022 TB B by Damee 34

35. Clinical features…. A. General symptoms of TB (PTB or EPT) Weight loss Fever Night sweats Loss of appetite Fatigue Malaise Malnourished and chronically sick appearance 11/14/2022 TB B by Damee 35

36. Clinical features…. B. Organ specific Pulmonary tuberculosis Cough that lasts for more than 2weeks with or without sputum production Chest pain Hemoptysis Shortness of breath 11/14/2022 TB B by Damee 36

37. Clinical features…. Tuberculosis lymphadenitis Slowly growing painless lymph node enlargement Initially firm and discrete , later become matted and fluctuant Formation of abscesses and discharging sinuses, which heal with scarring 11/14/2022 TB B by Damee 37

38. Clinical features…. Tuberculous pleurisy Pleuritic chest pain ( pain while breathing /coughing /sneezing ) Intermittent cough Shortness of breath Signs of pleural effusion (dullness, decreased/absent air entry and decreased tactile fremitus) 11/14/2022 TB B by Damee 38

39. Clinical features…. TB of bones and or joints Localized pain and or swelling +/- discharge ,stiffness of joints Spine(TB spondylitis):localized swelling over the back ,back pain paralysis (weakness of the lower extremities) Abdominal TB Chronic non- specific abdominal pain with diarrhea or constipation Fluid in the abdominal cavity(ascites). Mass(inflammatory mass) in the abdomen 11/14/2022 TB B by Damee 39

40. Clinical features…. Tuberculous meningitis Head ache, fever, vomiting: insidious onset Neck stiffness, impaired level of consciousness. Tuberculous pericarditis Chest pain ( pleuritic) Shortness of breath Pericardial friction rub or distant t heart sound 11/14/2022 TB B by Damee 40

41. Diagnosis of Pulmonary Tuberculosis in Adult and Adolescents 11/14/2022 TB B by Damee 41

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43. Investigations and diagnosis The diagnosis of TB requires the following C linical suspicion, Physical examinations and Microbiologic identification of the bacilli . 11/14/2022 TB B by Damee 43

44. Investigations and diagnosis… Sputum direct microscopy : Acid F ast Bacilli(AFB) staining Three sputum specimens( Spot early morning-spot), need to be collected and examined in two consecutive days Result must be available on the second day. 11/14/2022 TB B by Damee 44

45. Investigations and diagnosis… Gene Xpert MTB/RIF A fully automated DNA/molecular diagnostic test to detect TB and Rifampicin resistance simultaneously . It is recommended as the initial diagnostic test for all persons being evaluated for TB 11/14/2022 TB B by Damee 45

46. Investigations and diagnosis… Sputum culture and drug susceptibility Culture is the gold standard It takes weeks to get the results. If sputum AFB and/or Gene Xpert are negative and there is a strong suspicion, sputum culture can be send to a referral laboratory. However , treatment for an alternative diagnosis or “clinical TB”should not be delayed 11/14/2022 TB B by Damee 46

47. Investigations and diagnosis… Tuberculin Skin Test The Mantoux method is used to determine whether a person has been infected with the TB bacillus I s used widely in screening for latent MTB infection . The Mantoux method is a standardized,intracutaneous injection procedure. P urified protein derivative ( PPD ) 0.1 ml is injected into the ID layer of the inner aspect of the forearm, approximately 4 inches below the elbow. 11/14/2022 TB B by Damee 47

48. Tuberculin Skin Test… The test result is read 48 to 72 hours after injection. Tests read after 72 hours tend to underestimate the true size of induration (raised hard area or swelling). A delayed localized reaction indicates that the person is sensitive to tuberculin 11/14/2022 TB B by Damee 48

49. Interpretations The size of the induration determines the significance of the rxn. A reaction of 0 to 4 mm is considered not significant or negative A reaction of 5 mm or greater may be significant in people who are considered to be at risk. An induration of 10 mm or greater is usually considered significant in people or positive In general, the more intense the reaction, the greater the likelihood of an active infection. A negative tuberculin skin test doesn’t exclude TB, so its no help in deciding that some one does not have TB. (2018.14edi.Brunner & Suddarth’s Textbook of.pdf ) 11/14/2022 TB B by Damee 49

50. CONT… The criterion for a significant or 'positive ' tuberculin test depends on whether a child has previously had BCG vaccination or not. This is because a reaction to tuberculin is usual after a previous BCG, for several years A significant reaction indicates past exposure to M. tuberculosis or vaccination with BCG. The BCG vaccine is given to produce a greater resistance to development of TB (60%-80% protect) A positive tuberculin test is only one piece of evidence in favor of the diagnosis of TB. 11/14/2022 TB B by Damee 50

51. Investigations and diagnosis… Imaging : Chest X-ray:- patients who cannot produce sputum or who have negative Xpert results. But CXR is non-specific for TB Depending on the suspected extra pulmonary sites other imaging modalities may be needed. 11/14/2022 TB B by Damee 51

52. Investigations and diagnosis… Other investigation:- HIV test, CBC, ESR, CSF analysis Body fluid analysis and identification of pathogen Tissue biopsy and histopathology Fine needle aspiration and histopathology examination : enlarged lymph nodes 11/14/2022 TB B by Damee 52

53. Treatment of drug susceptible TB Objectives Cure Prevent death from active TB or its late complications Restore quality of life and productivity Decrease transmission Prevent relapse Prevent the development and transmission of medicine resistance 11/14/2022 TB B by Damee 53

54. Essential properties of TB treatment In order to achieve the designed aim of treatment, an anti-TB treatment regimen should be administered: In appropriate combination of drugs In the correct dosage Regularly taken by the patient, and F or a sufficient period of time 11/14/2022 TB B by Damee 54

55. Non pharmacologic  Counseling : adherence, the nature of treatment, contact screening Good nutrition Adequate rest  Admission for severely ill patients E .g. Tb meningitis, pericarditis 11/14/2022 TB B by Damee 55

56. Pharmacologic Standardized combination treatment: A ll patients in a defined group receive the same treatment regimen. A combination of 4 or more anti-TB medicines. Directly observed treatment (DOT) 11/14/2022 TB B by Damee 56

57. First line anti-TB Medicines The first line anti-TB treatment available in Ethiopia are: Rifampicin(R ):the most bactericidal and potent sterilizing agent Isoniazid(H ):highly bactericidal especially in the first few days Pyrazinamide (Z):only active in acidic environment and bacilli inside m acrophages Ethambutol(E ):bacteriostatic and effective to prevent drug resistance when administered with other potent drugs 11/14/2022 TB B by Damee 57

58. Table :- The essential anti-TB drugs and their dose Recommended adult dose and body weight Daily dose (mg/kg ) Maximum (mg) First line TB drugs 5 ( 4-6) 300 Isoniazid(H) 10 ( 8-12) 600 Rifampicin(R) 25 ( 20-30) 2,000 Pyrazinamide(Z) 15 ( 15-20) 1,600 Ethambutol(E) 11/14/2022 TB B by Damee 58

59. Phases of chemotherapy TB treatment is administered in two phases: Intensive (initial) phase : aims to reduce the patient non-infectious by rapidly reducing the bacillary load in the sputum and brings clinical improvement in most patients receiving effective treatment. Continuation phase: aims to sterilize the remaining semi-dormant bacilli and is important to ensure cure/completion of treatment and prevent relapse after completion of Rx. 11/14/2022 TB B by Damee 59

60. A. Standardized first line treatment regimen for new drug Susceptible or presumed to be drug susceptible TB 1 . New pulmonary TB patients presumed or known to have drug-susceptible TB 2 . New extra pulmonary patients Standardized regimen : 6 months total (2months intensive and 4months continuation phase) : 2RHZE/4RH Intensive phase: 2 months Rifampicin, Isoniazid, Pyrazinamide & Ethambutol (2RHZE) Continuation : 4months Rifampicin and Isoniazid (4RH) 11/14/2022 TB B by Damee 60

61. First line TB treatment adult dosing chart using patient’s body weight 11/14/2022 TB B by Damee 61

62. B . Previously treated TB patients presumed or known to have drug-susceptible TB In all previously treated TB patients who require re-treatment , specimen for rapid molecular-based drug susceptibility testing for first line TB drugs While awaiting the result , the standard first line treatment regimen is recommended:2(RHZE)/4(RH) R e- treatment regimen” with addition of streptomycin is not recommended. 11/14/2022 TB B by Damee 62

63. C . Patients who presented with active TB after known contact with patient documented to have drug-resistant TB Sample should be sent for rapid drug s usceptibility Test ( DST ) Treatment should be decided based on rapid DST result. While awaiting DST result , the patient may be initiated treatment with the regimen based on the DST of the presumed source case . 11/14/2022 TB B by Damee 63

64. D . Extended continuation phase EPTB forms of TB require prolonged continuation phase A.CNS (TB meningitis orTuberculoma) B. Bone or joint TB (Vertebral (TB spondylitis), joint & osteomyelitis. Regimen (a total of 12 months:2months intensive phase and10 months continuation phase); -2RHZE/10RH 11/14/2022 TB B by Damee 64

65. E . Adjuvant corticosteroid therapy Adjuvant corticosteroid therapy, dexamethasone or prednisolone tapered over 6- 8weeks should be used for patients with the following two extra pulmonary forms TB meningitis TB pericarditis 11/14/2022 TB B by Damee 65

66. Monitoring of patients on treatment 1. Clinical monitoring : During scheduled visit patient checked for: Persistence or reappearance of clinical feature of TB Weight monitoring: weight is a useful indicator of improvement Occurrence of Adverse drug reaction Development of TB complication Adherence: By reviewing the“ treatment supporter card” or Unit TB register Risk for drug resistance & need for drug susceptibility screen test TB B by Damee 66

67. 2. Bacteriologic monitoring for initially bacteriologically confirmed PTB Sputum AFB should be done at end of 2nd,5 th and 6 th month of therapy. Molecular technique like Gene Xpert, MTB cannot be used to monitor. WHY ? Treatment as the technique may give false positive result by identifying dead bacilli 11/14/2022 TB B by Damee 67

68. Bacteriologic monitoring… If AFB positive at the end of 2 nd month: send sputum sample for Xpert for DST. If at least Rifampicin sensitive: continue to the continuation phase. If Rifampicin resistance: Mark as Rifampicin-resistant Tb & the outcome is labeled as“ MDR TB”. Treatment will be started as MDR-TB. If AFB is positive at the end of 5th or 6th month: the outcome is treatment failure . DST testing and treatment will proceed as MDR-TB suspect 11/14/2022 TB B by Damee 68

69. Treatment of patients also infected with HIV All patients with HIV and active TB who are not on ART should be started on ART as described below: CD4<50cells/mm3 :Initiate ART within 2weeks of starting TB t/t CD4 counts ≥50cells/mm : Initiate ART with in 8weeks of starting TB treatment. During pregnancy, regardless of CD4 count: Initiate ART as early as feasible for to prevent HIV transmission to the infant. With TB meningitis : Initiate ART after 8weeks of TB treatment . 11/14/2022 TB B by Damee 69

70. Nursing Management Promoting airway clearance Increasing the fluid intake promotes systemic hydration Nurse instructs the patient about correct positioning Promoting adherence to treatment regimen Understanding of the medications, schedule, and side effects, avoiding alcohol consumption. Nurse educate the patient about regular drug taking, taking medication on empty stomach or 1 hr. before meals . 11/14/2022 TB B by Damee 70

71. Nursing Management… Promoting activity and adequate nutrition The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength. A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional supplements may assist in meeting basic caloric requirements 11/14/2022 TB B by Damee 71

72. Nursing Management… Preventing Transmission of TB Infection The nurse carefully instructs the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene. TB is a disease that must be reported to the health department so that people who have been in contact with the affected patient during the infectious stage ( Brunner textbook pdf 14th edition) 11/14/2022 TB B by Damee 72

73. THANK YOU 4 UR ATTENTION!!! 11/14/2022 TB B by Damee 73

74. Reference Ethiopia tuberculosis roadmap overview, fiscal year 2022 CDC U.S. TB Clinical Guidelines Update, 2022 Final draft TBL-NSP July 2021 – June 2026, August 2020 by MOH WHO Regional Office for Africa, 2017 Ethiopia-National-guideline-for-TB-Leprosy-and-DR TB-6th-ed-Aug-2018 WHO consolidated guidelines on drug-resistant TB treatment 2018.14 edi.Brunner & Suddarth’s Textbook of.pdf STG for general Hospitals in E thiopia 4thEdition,2021by MOH 11/14/2022 TB B by Damee 74