TUBERCULOSIS Community health nursing ppt

Communicable diseases

1. TUBERCULOSIS

2. INTRODUCTION Globally,10.0 million people were infected with TB, in the year 2018 which accounted to 132 cases per 100,000 population. TB is one of the top 10 causes of death.world wide, 1.7 billion people are infected with M.tuberculosis and are at risk of developing the disease. Tuberculosis affects both sexes,but men has highest burden of the disease that accounted 57% of all TB cases in 2018, adult women accounted for 32% and children 11% among all TB cases, 8.6% were people living with HIV. In 2018, south-east Asia (44%), Africa (24%)and the western Pacific (18%) regions of WHO showed higher percentages of cases Eastern Mediterranean(8%),the Americas(3%)and

3. Europe(3%) showed lesser percentages of cases.Eight countries accounted for two thirds of the global burden of TB: India(27%),China(9%), Indonesia (8%) Philipines (6%), Pakistan (6%),Nigeria(4%), Bangladesh (3%),and South Africa (3%). World TB incidence showed a decline of 1.6% from the years 2000 to 2018 and 2.0% between 2017 and 2018. The global cumulative case reduction rate was 6.3% and decline in TB death rate was 11% for the years from 2015 to 2018. SDG 3 aims to end the global TB epidemic by 2030. The goal aims to attain a 90% reduction in TB incidence rate between 2015 and 2030.

4. DEFINITION Tuberculosis is a contagious infection that usually attacks your lungs. It can also spread to other parts of your body, like your brain and spine. A type of bacteria called Mycobacterium tuberculie causes it.

5. AGENT M.tuberculosis Source of infection -case Infective material - sputum Infectious cases- communicable disease ENVIRONMENT Housing Quality of life Overcrowding illiteracy Large family HOST Age Sex Genetic Nutrition Acquired immunity

6. CAUSATIVE AGENT The causative organism of tuberculosis is M. tuberculosis (Mycobacterium tuberculosis) is a facultative intracellular parasite. There are two strains: Human strain responsible for vast majority of cases occuring among human beings and bovine strain is responsible for infecting cattle and other animals. The source of infection is human cases whose sputum is positive for tubercle bacilli and milk from infected animal. Patients are infected as long as they remain untreated.

7. HOST FACTORS Tuberculosis affects all ages and more prevalent in males than in females. Though it is not a hereditary disease, twin studies indicate that inherited susceptibility is an important risk factor. Malnutrition predisposes tuberculosis due to poor resistance. Immunity is acquired as a result of natural infection or BCG vaccination. With the initiation of chemotherapy host factors are considered less relevant in the epidemiology of tuberculosis.

8. Poor quality of life Poor housing condition Overcrowding Population explosion Malnutrition Lack of education Lack of awareness Large families Early marriage ENVIRONMENTAL FACTORS

9. MODE OF TRANSMISSION Tuberculosis is transmitted mainly by droplet infection and droplet nuclei generated by sputum of positive patients with pulmonary tuberculosis. Droplets are generated by coughing. Tuberculosis is transmitted by fomites, such as dishes and other articles used by patient.

10. INCUBATION PERIOD The incubation period ranges between 3 and 6 weeks. The development of disease depends on closeness of contact, extent of disease, extent of infection and host parasite relation

11. CLINICAL MANIFESTATIONS Persistent cough Weight loss Fever Night sweats Hemoptysis Chest pain Fatigue

12. LAB INVESTIGATION MANTOUX TEST The tuberculosis is screening test is conducted by injecting tuberculin purified protein derivative of 0.1 mL into the inner surface of the forearm. A tuberculin syringe is used to administer this intradermal injection. The injection will produce a pale elevation of the skin as a wheal 6-10 mm diameter. The reaction of the skin test should be read within 48-72 hours of administration.

13. In case if the patient does not visit the clinic within 72 hours he/she has to be called for another skin test. The reaction is measured in milimeters of the induration, the reader should be measured across the forearm. If the induration is more than 10 mm the test is said to be positive .

14. SKIN TEST INTERPRETATION DEPENDS ON TWO FACTORS Measurement of induration in millimetres Person's level of risk of being infected with TB and of development to disease if infected. PREVENTION AND CONTROL The control measures consists of : case finding and TB treatments as curative measures BCG vaccination as preventive measure. .

15. CASE FINDING Early detection of all cases means finding people whose sputum is positive for TB bacilli Finding the suspects means whose sputum is negative but x-ray shows suggestive shadows of TB. The patients seeking medical advice voluntarily with chest symptoms like persistent cough and fever are the most appropriate target group for case findings.

16. SPUTUM EXAMINATION Sputum examination is the cheapest and most suited tool for finding the cases. Sputum smears collected from suspected person's should be collected early in the morning on three successive days.The presence of at least 10,000 organisms per ml of sputum is considered "TB positive ". As per "Revised national tuberculosis control program" priority for sputum smear examination should be given to patient who come on their own to hospital or health center with following symptoms:

17. Persistent cough of 3-4 weeks duration Continuous fever Chest pain Hemoptysis SPUTUM CULTURE It is a long process needs trained people to perform. It is delivered only as centralized service in district hospitals. Advised for the patients whose sputum smear is negative but has chest symptoms.

18. MASS MINIATURE RADIOGRAPHY This is abandoned as a case finding measure because of its poor yields with high cost. CHEST X-RAY Chest x-ray is recommended as additional method to diagnose pulmonary tuberculosis when only one smear is positive. TUBERCULIN TEST This test does not have much value as a case finding tool. TB

19. CHEMOTHERAPY Effective treatment is available to treat tuberculosis. The main aim is to eliminate fast and slowly multiplying bacilli from a case and provide cure. Chemotherapy is readily available, free of cost to every detected case. Patient or the case is the core component of the success of the treatment because it requires strict compliance from the patient. Most often tuberculosis patients default since they start to feel good and active only by completing with 2 weeks of medicine at start. ANTI-TB DRUGS ARE GROUPED INTO TWO First-line drugs Second - line drugs

20. FIRST LINE DRUGS ARE FURTHER GROUPED INTO Bactericidal drugs: INH, Rifampicin, Pyrazinamide and Streptomycin Bacteriostatic drugs: Ethambutol and thik acetazone. A combination of these are used to treat TB patients FIRST LINE OF DRUGS Bactericidal drugs Rifampicin This is able to prevade all tissue membranes including blood brain and placental barriers.

21. This is the only drug which is active against dormant bacilli found in solid lesion. can be used only as oral drugs Total daily dose: 10-12 mg/kg body weight Administer 1hour before or 2 hours after food because absorption is reduced by food. Patient should be told that the drug will turn the urine red. Toxic effects of rifampicin -hepatoxicity, gastritis, influenza, thrombocytopenia and nephrotoxicity. Administered as single daily dose of 4-5 mg/kg body weight. For intermittent therapy the dose is 600 mg.

22. Side effects: peripheral neuritis, gastrointestinal irritation and hepatitis. Addition of 10-20 mg of pyridoxine prevent peripheral neuropathy. STREPTOMYCIN Given as daily dose of 0.75-1 g in a single injection. Side effects: vestibular damage giddiness and ataxia. PYRAZINAMIDE Dose: 30 mg/kg body weight divided into two or three doses per day or 45-50 mg/kg body weight twice weekly. Side effects: hepatitis, arthralgia and rarely gout.

23. BACTERIOSTATIC DRUGS Ethambutol -15mg/kg body weight (800mg/day) given in 2-3 doses and 1200mg for intermittent therapy. Side effects: Blurring of vision and retrobulbar neuritis THIOACETAZONE 2 mg/ kg body weight (150mg/day) Side effects: Gastrointestinal disturbances and Blurring of vision.

24. SECOND LINE OF DRUGS The second line of drugs is used where first line drugs can't be used for patient s reasons. The second -line drugs are ethionamide, prothionamide, cycloserine, kanamycin, viomycin, ofloxacin and capremycin. DOMICILIARY TREATMENT It is the method of self-consumption of prescribed anti-TB drugs by the patients without getting admitted to the hospital. Domiciliary treatment includes only oral drugs.

25. TREATMENT REGIMENS Conventional long course chemotherapy. This is outdated and not practiced now. SHORT COURSE CHEMOTHERAPY Wallace Fox and his colleagues from British medical research council added (1972) rifampicin and Pyrazinamide to anti TB regimen and reduced the duration of treatment from 18 months to 6-8 months. In short course chemotherapy the drugs are given in two phases.

26. INTENSIVE PHASE This is the initial phase lasts for 2 months; a combination of 3 or 4 drugs are given: During this phase a combination of three or more drugs are used to kill off as many bacilli as possible. CONTINUOUS PHASE This is the maintenance phase lasts for 4-6 months under short course chemotherapy in which a combination of 2 or 3 Durga are given.

27. DRUG ADMINISTRATION IN DIRECTLY OBSERVED TREATMENT SHORT COURSE CHEMOTHERAPY (DOTS) In intensive phase of treatment a health worker or trained person closely watches the patient swallowing the drug in his presence. During continuation phase the patient is issued 1 week medicine in a multiblister combipack. The first dose is swallowed by the patient in front of health worker The drug consumption in the continuation phase is counter-checked by retrun of empty multiblister combipack while collecting the drugs for next week.

28. The drugs are provided in patient wise boxes with sufficient shelf life. Tuberculosis cases are divided in to three categories for the sake of putting them under different regimens based on specific criteria INTERPRETATION OF THE NUMBERS AND LETTERS PLACED IN THE REGIMENS Prefix number indicates the number of months for that regimen Suffix number indicates the frequency of administration in a week No suffix means given daily R- Rifampicin I- Isoniazid

29. S- Streptomycin Z- Pyrazinamide BCG VACCINATION BCG vaccination was invented by calmette and Guirin, French scientists. BCG stands for Bacilli of Calmette and Guerin. It is a widely used live bacterial vaccine. It is a widely used live bacterial vaccine. There are two types of BCG vaccine: Liquid and freeze dried. Freeze dried is more stable. The vaccine is stored below 10°c. The vaccine must be protected from exposure to sunlight. It comes in freeze-dried powder from in ampoule. It is reconstituted with 1mL normal saline (Distilled water is not

30. used since it causes irritation ) strength is 0.1 mg in 0.1 mL The dose for newborns aged below 4 weeks in 0.05 mL It is advised to clean the site using saline swab before administering the vaccine Using tuberculin syringe BCG is administered intradermally in left upper arm just above the insertion of deltiod muscle. When properly Administered, the injection should produce a wheal measuring 5 mm in diameter .

31. CHEMOTHERAPY This preventive treatment is administered to contacts: INH for 1 year or INH and Ethambutol are given for 9 months. SURVEILLANCE This focuses on the continuous monitoring and measurement. It closely monitors and measures the rates of incidence, prevalence and other rates like TB death rates. It helps the epidemiologist to have current knowledge about what is happening and what he has to do to control the diseases.

32. REVISED NATIONAL TUBERCULOSIS PROGRAM In the year 1992 Govt. Of India, WHO and world bank together reviewed the national Tuberculosis program (NTP). After the revision it is revision it is referred to " Revised national Tuberculosis program (RNTCP) The main objectives of RNTCP: To achieve the cure rate of not less than 85% through short course chemotherapy.

33. CONCLUSION Tuberculosis infection and disease remain common in populations characterized by poor housing condition,drug use,and HIV infection.

34. THANK YOU