Tuberculosis

informa

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

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

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 1/5 th 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 5 th 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…