Training on tuberculosis for counselors 2012


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Training PPT for counselors for TB Helpline

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Training on tuberculosis for counselors 2012

  2. 2. Why helpline for TB?Tuberculosis (TB) remains a major global health problem.It causes ill-health among millions of people each yearTB ranks as the second leading cause of death from an infectious disease worldwide, after HIV1Tuberculosis is a treatable and preventable disease.What is needed is knowledge about the disease.Stigma, discrimination and fear : TB has all as HIVStrong referral services availableSo helpline for TB makes sense 2
  3. 3. What is tuberculosis?• TB is a chronic bacterial infection.• The great majority of infections in people are caused by Mycobacterium tuberculosis (M. Tuberculosis or tubercle bacilli).• M. tuberculosis and seven very closely related mycobacterial species like M. bovis and others together comprise what is known as the M. tuberculosis complex.• M. Bovis can cause TB in people who drink unpasteurised milk from infected cows. 3
  4. 4. TB: Global Scenario • About 1 in 3 of the world’s population is infected with tubercle bacilli. • There were an estimated 12 million prevalent cases in 2011 • 170 cases per 100 000 population • Incidence: 90 lakh new cases • Someone is newly infected every second • Mortality: Nearly 14 lakh TB deaths every year 4
  5. 5. • About 95% of the world’s cases of TB occur in South East Asia, sub-Saharan Africa and the Western Pacific.• The five countries with the largest number of incident cases in 2011 were India (approx 2.0 million), China (approx–1 million), South Africa (approx 0.5 million), Indonesia (approx 0.5 million) and Pakistan (approx 0.4 million).• India and China alone accounted for 26% and 12% of global cases, respectively. 5
  6. 6. TB in IndiaNearly 40% of the Indian population is infected with the MTB bacillusApprox 30 million people in India are infected with TBIn 2011, with 2 million cases of TB, India alone accounted for 26% of global cases.4 lakh deaths occur from TB every year.Everyday 5000 develop TB disease and 1000 people die of TBTB kills more adults in India than any other infectious disease. (2 deaths every 3 minutes). 6
  7. 7. Who are getting infected?Of the 9 million incident cases in 2011  1 million (13%) were among people living with HIV  0.5 million were children  3 million were women.TB affects mostly adults in the economically productive age groups. 7
  8. 8. Drug resistant TBGlobally, 3.7% of new cases and 20% of previously treated cases are estimated to have MDR-TB.Estimated 310 000 of MDR-TB cases in 2011.Almost 60% of these cases were in India, China and the Russian FederationOf MDR-TB cases, Extensively drug-resistant XDR-TB is 9.0%Treatment success rate of MDR TB is 50% 8
  9. 9. MicrobiologyRod-shaped bacterium of 2-4 x 0.2-0.5 μm.Obligate aerobe found in the well-aeratedlungs.Slow growing (dividing only every 16-20hours)Lives within tissue macrophages.Humans are the only reservoir of M.Tuberculosis 9
  10. 10. Microbiology• Peculiar cell wall that consists of peptidoglycan and complex lipids.• The cell wall is a major factor in the virulence of the organism.• Once stained (e.g. with carbol fuchsin: Z N Staining), it retain dyes when treated by acidified organic compounds.• Therefore, it is classified as an “acid–fast” bacterium. 10
  11. 11. How is TB transmitted? Nearly all TB infection is acquired by inhalation of respiratory droplets from people with TB in the lungs or throat. Air droplets 3-5 μm diameter are coughed, sneezed or spat-out by an “open” case of TB. 11
  12. 12. Other modes of transmissionIngestion of the organisms leads to development of tonsillar or intestinal tuberculosis. This mode of infection of human tubercle bacilli is from self-swallowing of infected sputum of an open case of pulmonary tuberculosis, or ingestion of bovine tubercle bacilli from milk of diseased cows.Inoculation of the organisms into the skin may rarely occur from infected pus tissue.Transplacental route results in development of congenital tuberculosis in foetus from infected mother and is a rare mode of transmission. 12
  13. 13. How is TB not transmitted?People cannot get infected with TB bacteria throughHandshakesSitting on toilet seatsSharing dishes , mattresses with someone who has TB.From insect bitesFrom touching surfaces that are contaminated with M. tuberculosis. 13
  14. 14. Factors that determine transmission risk 14
  15. 15. Characteristics of a Patient with TB Disease thatAre Associated with Infectiousness 15
  16. 16. Environmental Factors that Enhance theProbability that M. tuberculosis Will BeTransmitted 16
  17. 17. Proximity and Length of Exposure Factors thatCan Affect Transmission of M. tuberculosis 17
  18. 18. What happens when TB bacilli isinhaled? Between 70-90% of individuals exposed to TB will not develop the infection. This is because • inhale too few organisms to cause infection • have sufficient immunity to prevent an infection becoming established Any factor associated with impaired immunity, such as extremes of age, malnutrition and HIV/AIDS will increase the risk of developing infection. No infection in 70 to 90 % exposed people 18
  19. 19. What happens when TB bacilli is inhaled?In those 10-30% who develop infection, TB infection begins when the mycobacterium reach the lung alveoli.In the alveoli, TB enters macrophages and with other cells form a shell called granuloma. The granuloma prevents dissemination of the mycobacteria.Bacteria inside the granuloma can become dormant, resulting in a latent infection.It may remain latent lifelong or may reactivate to active TB when immunity fails. Of the 10 to 30% of the exposed who develop infection, 90% people have latent infection 19
  20. 20. What happens when TB bacilli isinhaled? Active TB InfectionActive TB disease occurs if the immune system cannot keep the tubercle bacilli under control.Bacilli begin to multiply rapidly and break free from the shell of granuloma.Active clinical disease can be pulmonary or may be systemic ( Brain Larynx Lymph node Lung Spine Kidney , etc) 20
  21. 21. What are the likely outcomesPathogenesis5 following exposure to open TB? Exposure to TB No infection Infection (70-90%) (10-30%) Dormant TB (90%) Active TB (10%) • well • ill and likely to die if • no TB disease untreated • not infectious to • infectious others Activation of infection results in disease 21
  22. 22. Clinical stages or states ofMycobacterium tuberculosis infection 22
  23. 23. 23
  24. 24. Who is at risk of TB infection?Contacts Low body weightChildren  Certain medical treatmentsElderly (such as corticosteroid treatmentAll household PrisonsWorkplace Urban slumHIV Poor areasPrevious TB MigrantsMalnourished Drug abusersSmokers Diabetics 24
  25. 25. Distribution of tuberculosis cases byanatomical site in HIV-negative patients. 25
  26. 26. Distribution of tuberculosis cases byanatomical site in HIV-positive patients 26
  27. 27. Clinical features of lung TBCough That Last For More Than Two WeeksChest painBreathlessnessCoughing up blood 27
  28. 28. HIV AND TB 28
  29. 29. Miliary TBExtensive TBMay present only as fever and weight loss 29
  30. 30. Common symptoms with TB at anysiteWeight LossLoss Of AppetiteFeverNight SweatsWeakness 30
  31. 31. TB lymphadenitisPainless nodes in neck commonlyNon-tender, matted together and rubberyMay ulcerate and discharge. 31
  32. 32. Abdominal TBWeight lossDiarrhoea or constipationAbdominal distension (from ascites) or chronic intestinal obstructionEnlarged abd lymph nodes may be palpable as multiple intra- 32
  33. 33. Pleural effusionExtrapulmonaryPain, breathlessness, cough 33
  34. 34. Brain TBMeningitis or intracranial tuberculomasHeadache, neck stiffness, altered mental status, and cranial nerve abnormalities, convulsions. 34
  35. 35. TB spineEspecially seen in young childrenPresents as a pain and/or swelling on the back or neckLoss of limb function 35
  36. 36. Pericardial TBPatient presents with breathlessness and chest pain.Chest x-ray shows cardio- megaly and pleural effusion Changes on ECG are common. 36
  37. 37. Diagnosis of TB: Latent andActive 37
  38. 38. Diagnosis of active TBSputum Examination for pulmonary TBExamination of ascitic fluid, pleural fluid, CSF, joint fluid, pus, etc for type of cells and AFBCulture for AFBNAAT for TBADA testUrine test: LAMAntibody testsBreath tests 38
  39. 39. Sputum Smear Examination forpulmonary TBSputum is a thick fluid that is produced in the lungsSample of sputum is usually collected by the person coughing.Earlier 3 morning sputum samples were recommended, but now two spot specimens are collected on the same day.To do the test a very thin layer of the sample is placed on a glass slide, and this is called a smear.A series of special stains ( Zeihl Neelson or ZN stain) are then applied to the sample, and the stained slide is examined under a microscope for signs of the TB bacteria.Ziehl-Nielsen stain demonstrates the presence of the acid and alcohol fast bacilli (AFB). 39
  40. 40. How to collect sputum?Patient is instructed to inhale deeply two to three times with his/her mouth open, cough out deeply from the chest, open the container, spit out the sputum into it and close the container tightlyThe health worker or the laboratory technician should stand behind the patient. If a patient coughs out only saliva, (s)he should be asked to try again to bring out sputum.If a specimen cannot be sent to laboratory immediately, it should be stored in a refrigerator or in another cool place.Sputum specimens should be examined immediately whenever possible and not late than a week after collection. 40
  41. 41. Sputum Smear Examination forpulmonary TB Simple, inexpensive, requires minimum training High specificity High reliability with low inter-reader variation Can be used for diagnosis, monitoring and defining cure Results are available quickly Feasible at peripheral health institutions Correlates with infectivity in pulmonary TB casesBut the sensitivity though is only about 50-60%. I.e. the test is often falsely negative in patients with TB.When positive, the patient is “smear-positive” or “open TB” and the risk of transmission of infection to others is very high.The yield of the test is higher in patients with lung 41
  42. 42. Sputum-smear microscopy withLED=light-emitting diode Instead of simple microscope, benefits of low cost, durability, faster and ability to use without a darkroom.WHO issued a policy statement recommending that conventional microscopy should be replaced by LED microscopy 42
  43. 43. How is sputum smear testinterpreted? 43
  44. 44. 44
  45. 45. Sputum cultureCulturing is a method of studying bacteria by growing them on media containing nutrients.It provides a definitive diagnosis of TB and can significantly increase the number of cases found.Culture can also provide drug susceptibility testing, showing which TB drugs a persons bacteria is resistant to. 45
  46. 46. Sputum cultureSolid culture medium Egg-based Lowenstein Jensen (LJ medium) or Agar-based mediumDiagnosis can take 4 weeks to get a conclusive result with another 4-6 weeks to produce drug susceptibility results. 46
  47. 47. Liquid culture medium BACTEC MGIT 960.This can detect growth of mycobacteria as early as 4 days from inoculation and drug susceptibility will be available in 21-28 days. 47
  48. 48. Microscopic observation of drugsusceptibility assay (MODS)MODS has been described for the early detection of M. tuberculosis growth in liquid medium, allowing a more timely diagnosis and drug susceptibility testing.The method is based on the observation of the characteristic cord formation of M.tuberculosis visualized microscopically in liquid medium with the use of an inverted MicroscopeSensitivity of MODS (92 %)Turnaround time of nine days. 48
  49. 49. NAATs=nucleic acidamplification tests (MTB PCR)Currently available NAA tests are not sufficiently sensitive (detecting 50%--80% of AFB smear-negative, culture-positive pulmonary TB cases) to exclude the diagnosis of TB in AFB smear-negative patients suspected to have TBNAATs have high specificity.Cannot be used for treatment monitoring. Culture, supported by microscopy, still remains the gold standard 49
  50. 50. Xpert MTB/RIFIt is rapid NAAT testUses PCR technique for diagnosis of Mycobacterium tuberculosis and rifampicin resistanceXpert MTB/RIF has the advantage of detecting TB with equivalent sensitivity to culture on solid media and of simultaneously detecting rifampicin resistance with high sensitivity (95%) and specificity (98%)Turnover time less than 2 hours Another advantage is that it performs equally well among HIV-negative and HIV-positive individuals.It is therefore a useful tool to improve early case detection of MDR-TB and HIV-associated TB. 50
  51. 51. CDC recommendations ForNAAT 51
  52. 52. Serological (antibody) detection tests forpulmonary and extrapulmonary tuberculosis Commercial serological tests (Ig G, Ig M tests) for both pulmonary and extrapulmonary tuberculosis produce highly inconsistent estimates of sensitivity and specificity None of the assays do well enough to replace microscopy. 52
  53. 53. ADA for tuberculosis pleuritis,pericarditis, peritonitisMeasurement of ADA concentrations in pleural, pericardial, and ascitic fluid has highSensitivity and specificity for extrapulmonary tuberculosis. 53
  54. 54. Diagnosis of latenttuberculosis 54
  55. 55. Mantoux or tuberculin skin test (TST)or TT or PPD TEST0.1 ml PPD is injected intradermally and the injection site is inspected 48-72 hours later.Erythema and induration at the site signify an immune response and, therefore, previous exposure to mycobacteria. 55
  56. 56. Mantoux or tuberculin skintest (TST) or TT or PPD TESTFalse positive: a skin reaction in people who do not have TB because of exposure to non- pathogenic mycobacteria and also due to the immune response following BCG immunisationFalse negative: a negative result in a person with TB in early primary infection or because they are immunocompromised – for example, due to HIV/AIDS, malnutrition or people who develop disseminated TB. 56
  57. 57. Mantoux or tuberculin skin test(TST) or TT or PPD TESTIndividuals who had received BCG vaccination are more likely to have a positive TSTThe effect of BCG on TST results is less after 15 yearsPositive TST with indurations of >15 mm are more likely to be the result of tuberculosis infection than of BCG vaccination.Non tuberculous mycobacterial infection can cause positive test, esp in areas where MTB is less. 57
  58. 58. IGRAs=interferon-γ releaseassays.T-SPOT.TB Test, QuantiFERON-TB Gold testIGRAs have excellent specificity (higher than the TST), and are unaffected by previous BCG vaccination.IGRA sensitivity varies across populations and tends to be lower in high-endemic countries and in HIV-infected individuals. 58
  59. 59. Diagnosis of drug-resistanttuberculosisThe INNO-LiPA Rif assayGenoType MTBDR assaysCRI=colorimetric redox indicator methodNRA=nitrate reductase assaysMODS=microscopically observed drug susceptibilityXpert MTB/RIF 59
  60. 60. Different tests for drugresistanceThe INNO-LiPA Rif assay is a highly sensitive and specific test for the detection of rifampicin resistance in culture isolates. The test has lower sensitivity when used directly on clinical specimens.GenoType MTBDR assays have excellent sensitivity and specificity for rifampicin resistance, even when directly used on clinical specimens. 60
  61. 61. CRI=colorimetric redoxindicator methodColorimetric methods are sensitive and specific for the detection of rifampicin and isoniazid resistance in culture isolates.CRIs use inexpensive non-commercial suppliesand equipment and have a rapid turnaround time (7 days). 61
  62. 62. NRA=nitrate reductase assaysNRA has high accuracy when used to detect rifampicin and isoniazid resistance in culture isolates.NRA is simple and inexpensiveTurnaround time 7–14 days 62
  63. 63. MODS=microscopically observed drugsusceptibilityMODS for rapid detection of rifampicin and isoniazid resistanceMODS has high accuracy when testing for rifampicin resistance, but shows slightly lower sensitivity when detecting isoniazid resistance. MODS seems to do equally well with use of direct patient specimens and culture isolates.MODS uses non-commercial supplies and equipment, and has a rapid turnaround time (10 days) compared with conventional methods. 63
  64. 64. Diagnosis using urine sampleUrine-Based Assay for Lipoarabinomannan (LAM)Urine LAM test detects a subset of TB patients who have severe TB, advanced AIDS, and are not detected by sputum smear microscopyThe combination of smear and LAM (either positive = TB) detects about 75% of TB casesUrine LAM test is promising for use in conjunction with smear microscopy in settings of HIV high prevalenceLacks infection control issues of blood, sputum 64
  65. 65. The tuberculosis diagnostics pipeline 65
  66. 66. Prevention of Tuberculosis 66
  67. 67. Patients are more likely to beinfectious if they:Have TB of the lungs or throatHave a cavity in the lungAre coughing or undergoing cough-inducing proceduresAre not covering their mouth when coughingHave acid-fast bacilli on the sputum smearAre not receiving adequate treatment 67
  68. 68. What care a TB case should take to prevent transmission of TB?The most important thing is to take REGULAR medicine.TB patients who may be infectious should be instructed to cover their mouth and nose with a tissue when coughing or sneezing. Put the tissue in a closed bag and throw it away.Adequate (ventilated and sunny) site for sputum collection, preferentially outdoorsAvoiding the use of ceiling fansUse of a standing fan either to direct the air flow towards the window (or door) or to produce an air "barrier" between the contacts and the patient 68
  69. 69. What care a TB case shouldtake to prevent transmissionof TB?Avoid going to work or school. Sleep in a bedroom away from other family members.If in a hospital and also in home if possible, TB patient must be given a separate room, with the door closed and windows that can be opened.This is to be followed for a period of 2 weeks after starting TB treatment after which infectiousness appears to decline very rapidly.Close contacts should wear N99 masks, if available. 69
  70. 70. BCG VaccineBacille Calmette-Guerin is an live vaccine available for TB.BCG appears to reduce the risk of serious childhood forms of TB, including miliary TB and extrapulmonary TBBCG does not seem to be highly effective as people move into adulthood. 70
  71. 71. BCG VaccineWHO recommends that BCG be given to infants and young children in countries where TB is common.It should not be given during pregnancy or to children with symptomatic HIV infection.If you were vaccinated with BCG, you may have a positive reaction to a TB skin test. This reaction may be due to the BCG vaccine itself or to a real TB infection. 71
  72. 72. Treatment of Active TB 72
  73. 73. Anti-Tuberculosis Therapy First-Line Drugs Isoniazid Rifampin Pyrazinamide Ethambutol Streptomycin 73
  74. 74. High INH А Continuous (RIF, SM) growth Special bacterial population hypothesis PZ RIF and action of theSpeed ofbacteria A specific drugs growth B C (From Mitchison, 1985) D Acid Spurts of Dormant inhibition metabolismLow (No cure) Mitchison, Tubercle 66: 219-226 74
  75. 75. Side effects of ATT drugsNo appetite, nausea, Easy bleeding vomiting Aching jointsYellowish skin or eyes DizzinessHepatitis Blurred or changed visionAbdominal pain Ringing in the earsSkin rash Tingling fingers or toesPatients on Rifampicin or around mouth can have red colored urine, saliva, or tears. 75
  76. 76. Principles of TherapyInsure that patient is taking medication properly (Directly Observed Therapy). TherapyAlways use at least 2 drugs to which the organism is susceptible.Never add a single drug to a failing regimen.Monitor clinical response to therapy. 76
  77. 77. What is MDR/XDR TB?MDR-TB occurs when the TB bacteria are resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs.Extensively drug-resistant tuberculosis XDR-TB is TB that is resistant to any fluoroquinolone, and at least one of three injectable second-line drugs, in addition to MDR-TB 77
  78. 78. Criteria to label a patient asMDR-TB suspect.A new smear-positive patient remaining smear- positive at the end of fifth month.A new smear-negative patient becoming smear- positive at the end of fifth month.A patient treated with regimen for previously treated remaining positive at fourth monthSmear-positive contacts of an established/confirmed MDR-TB case 78
  79. 79. MDR is more common inpeople whoHave spent time with someone with drug-resistant TB diseaseDo not take their medicine regularlyDo not take all of their prescribed medicineDevelop TB disease again, after having taken TB medicine in the past 79
  80. 80. Contributing Factors for MDRTBHigh prevalence of HIV.Delayed diagnosis.Delays in adequate therapy (in part due to unknown drug susceptibilities).Inadequate isolation procedures. 80
  81. 81. Deadly Mistakes Not knowing MTB drug susceptibilities. Inadequate therapy. Ineffective drug regimen. Inadequate length of treatment. Sub-therapeutic drug level. Lack of patient monitoring. DOT. Clinical Response. 81
  82. 82. ReasonMulti-Drug Resistant TB* Prevalence of for Alarm6 5.5 %54 *The W IUATLD Global Project on Anti- HO/3 TB Drug Resistance Surveillance % (1994-1997)2 1.61 Countries with good TB control = >33% DOTS coverage.0 With Good TB With Poor TB Control Control 82
  83. 83. Management of MDR/XDR TBFor MDR Intensive Phase (IP) of 6 drugs should be given at least 6 months. Continuation Phase, 4 drugs are given for 18 months.For XDR: At least three to four drugs to which the strain is sensitive need to be used for effective treatment Surgery of lung 83
  84. 84. Treatment for LatentTuberculosis Infection (TLTBI)Isoniazid preventive therapy (IPT), is given to people who have latent TB infection to prevent them from developing TB disease.The usual regimen for IPT is isoniazid given daily for 6 months for all patients.Patients she should be screened for activeTB (current cough, fever, weight loss or night sweats ) to rule out active TB before starting IPT. 84
  85. 85. Who should be offered IPT?ALL HIV patients should be given IPT irrespective of the degree of immunosuppression, and also to those on ART, those who have previously been treated for TB and pregnant women.IPT is administered to all the children aged 6 years , in risk groups such as household contacts, individuals with chronic renal or respiratory diseasePatients should be clinically evaluated every month for signs of hepatitis and other adverse reactions like tingling numbness in legs due to isoniazid. 85
  86. 86. References Revised National Tuberculosis Control Programme (RNTCP) Training Module for Medical Practitioners Extrapulmonary tuberculosis Indian J Med Res 120, October 2004, pp 316-353 The Situation of HIV/M. tuberculosis Co-Infection in India. The Open Infectious Diseases Journal, 2011, 5, (Suppl 1-M5) 51-59 WHO Policy on TB Infection Control in Health-Care Facilities, congregate Settings and Households Biomarkers and diagnostics for tuberculosis: progress, needs, and translation into practice( Lancet) Questions and Answers About Tuberculosis, CDC 2009 86
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