A General view about pulmonary TB and the global approach to stop TB and some data about incidence and prevalence in Saudi Arabia.

1. Tuberculosis
Done by: Jehad Alqurashi
Supervised by: Prof. Zaiden Abdu Zaiden

2. Background
 Tuberculosis (TB) is an infectious disease that is
caused by a bacterium called Mycobacterium
tuberculosis.
 TB primarily affects the lungs, but it can also affect
organs in the central nervous system, lymphatic
system, and circulatory system among others.

3.  There were an estimated 8.7 million cases of TB in
2011 and 1.4 million TB deaths.
 Most of the cases were reported from Asia (59%
 In Africa (26%).
 The Millennium Development Goals set a target
to halt and reverse the incidence of the disease
by 2015.
 Global incidence rates have been falling,
although slowly over the past few years in
various regions of the world.

4. Mode of Transmission :
 Transmission can only occur from people with active—not
latent—TB.
 The probability of transmission from one person to another
depends upon :
 The number of infectious droplets expelled by a carrier,
 The effectiveness of ventilation,
 The duration of exposure,
 And the virulence of the M. tuberculosis strain.
 The chain of transmission can be broken by isolating
people with active disease and starting effective anti-
tuberculosis therapy.

5. SIGNS AND SYMPTOMS:
 A bad cough that lasts 2 weeks or longer
 Weight loss
 Coughing up blood
 Weakness or fatigue
 Intermittent fever and chills
 Night sweats

6. How TB is Diagnosed:
 For diagnosing active “recent” TB infection in
addition to symptoms:
 AP chest X-ray should be taken appearances
suggestive of TB should lead to further
investigation.
 Chest Radiograph Abnormalities often seen in
apical or posterior segments of upper lobe or
superior segments of lower lobe.

7. Arrows points to cavity in patient’s
left upper lobe

8. Tuberculin test
 intradermal injection of PPD “M. tuberculosis
antigens (5 TU)
 The test is very sensitive for detecting
tuberculosis in healthy individuals if 5 mm
induration is used to define a positive reaction.
 Read it after 48-72 h
 Positive: induration≥ 10 mm

9. The left picture is the correct
way to measure Tuberculin skin
test

10. Acid- Fast Bacilli (AFB) smear &
Culture
 A PPD test is always done to show whether the
patient has been infected by the tubercle
bacillus.
 To verify the test results, the physician obtains a
sample of sputum or a tissue sample (biopsy) for
culture.
 Three to five sputum samples should be taken
early in the morning.
 Culturing M. tuberculosis is useful for diagnosis
because the bacillus has certain distinctive
characteristics. Unlike many other types of
bacteria, mycobacteria can retain certain dyes
even when exposed to acid.
 This so-called acid-fast property is characteristic
of the tubercle bacillus.

12. Quantiferon-TB test:
 The IFN-γ by T-cells into the plasma is measured by ELISA
to indicatsecreted e the likelihood of TB infection .
 Different studies demonstrated that the QuantiFERON-TB
test was comparable to TST in its ability to detect latent
TB infection. also showed that the QuantiFERON-TB test
was less affected by BCG vaccination.
 QuantiFERON-TB was approved by the Food and Drug
Administration (FDA) of the United States (US) in 2001.
 In 2003, the US Centers for Disease Control and
Prevention released guidelines for using the
QuantiFERON®-TB Test in the diagnosis of latent M.
tuberculosis infection.

13.  Patient will be treated with the standard
treatment of four drugs :
 Isonicotinylhydrazine (INH),
 Rifampicin.
 Ethambutol,
 Pyrazinamide) for an initial 2 months.
 Followed by a combination of INH and rifampicin
for another 4 months.

14.  Patients should be treated under DOTS.
 DOTS (directly observed treatment, short-
course), is the name given to the tuberculosis
control strategy recommended by the World
Health Organization.
 According to WHO, “The most cost-effective way
to stop the spread of TB in communities with a
high incidence is by curing it.
 The best curative method for TB is known as
DOTS.”

15. DOTS has five components:
1) Government commitment (including political will at all
levels, and establishment of a centralized and
prioritized system of TB monitoring, recording and
training).
2) Case detection by sputum smear microscopy.
3) Standardized treatment regimen directly of six to eight
months observed by a healthcare worker or
community health worker for at least the first two
months.
4) A regular, uninterrupted drug supply.
5) A standardized recording and reporting system that
allows assessment of treatment results.

16. METHODS OF CONTROLLING TB:
1. Isolation:
 Immediate isolation of people who have
confirmed or suspected cases of tuberculosis
can help stop the spread of the disease.
 Patients do not need to be kept isolated for
longer than two weeks.
 Isolation should last until the patient responds
to treatment and is not coughing.

17. 2.Respiratory Protection:
 This type of protection should be
worn by a healthcare worker who
enters a tuberculosis patients room.
 This will protect them from contracting
tuberculosis.
 The respirator should be a N-95 disposable
particulate respirator (PR) that filters inhaled air.
 A surgical mask is not adequate protection to
protect someone from contracting tuberculosis.

18. 3. Training
 Educating healthcare workers, and anyone that
might come into contact with a tuberculosis patient,
is the first step in helping to prevent the spread of
tuberculosis.
 They should know the symptoms of tuberculosis
infection, how it is spread, what the difference is
between infection and disease, how it is diagnosed,
how to prevent spread, and treatment for
tuberculosis infection and active disease.

19. 4. Ventilation
 One method of ventilation is dilution and removal of
contaminants in the air.
 An exhaust system should vent air outside the building.
Air should flow into a tuberculosis patients room from
the areas nearby, creating a low or negative pressure
in the patients room.
 In hospitals that use recirculated air, HEPA filters should
be installed the ventilation system. The filters remove
most of the tuberculosis contaminants in the air.

21.  Global efforts to control TB were reinvigorated in
1991, when a World Health Assembly (WHA)
resolution recognized TB as a major global public
health problem.
 Two targets for TB control were established as part
of this resolution:
 Detection of 70% of new smear- positive cases,
 Cure of 85% of such cases, by the year 2000.
Stop TB Program:

22.  WHO’s Stop TB Strategy aims to reach all patients
and achieve the target under Millennium
Development Goal Six (MDG6):
 To reduce by 2015 the prevalence of and deaths due to
TB by 50% relative to 1990 and reverse the trend in
incidence.
 The strategy emphasizes the need for proper health
systems and the importance of effective primary health
care to address the TB epidemic.

23.  By 2005, detect at least 70% of new sputum smear-
positive TB cases and cure at least 85% of these
cases.
 By 2015, reduce TB prevalence and death rates by
50% relative to 1990.
 By 2015: the global burden of TB disease (deaths
and prevalence) will be reduced by 50% relative to
1990 levels.
 By 2050, eliminate TB as a public health problem
(<1 case per million population).
 By 2050: The global incidence of TB disease will be
less than 1 per million population. (Elimination of TB
as a global public health problem.)

24. TB in Kingdom of Saudi
Arabia
 According to Dr.Ibrahim Al-Orinay’s study which titled :
Tuberculosis incidence Trends in Saudi Arabia over 20
years: 1990-2010
 There were a total of 64,345 TB cases reported to the
Ministry of Health during 1991-2010.
 Of these, there were 46,827 (73%) pulmonary TB cases
 17,518 (27%) extra-pulmonary TB.
 There were 33,468 (52%) Saudi patients and 30,837 (48%)
non-Saudis.
 The majority (62%) were males.
 Over 70% of the cases were reported from the Central
and Makkah regions. These two regions have 52% of the
population of the kingdom.

25.  The annual incidence of TB ranged between 14
and 17/100,000 over the study period.
 Saudis had an incidence between 8.6 and
12.2/100,000 while non-Saudis had an incidence
of 24.3-32.3/100,000.
 TB incidence showed a rising trend over the first
10 years of the study period.

26. Annual TB patient numbers and
incidence rate/100,000 in Saudi Arabia
(1990-2010)

27. Tuberculosis incidence rates/100,000
by age group in Saudi Arabia (1990-
2010)

28. Tuberculosis incidence rates and
trend in Saudi Arabia (1990-2010)

29. Tuberculosis incidence rates and trend
for Saudi population by region (1990-
2010)

30. The study concluded the
following:
 The NTP had an ambitious goal to reduce the
incidence of TB to 1/100,000 by the year 2010.
 This goal unfortunately could not be achieved.
Since 1992, the incidence showed a rising trend
that peaked in 1999, and then it started to fall but
only slightly. Foreign population had 2-3 times
higher incidence than Saudi nationals.
 The majority of Non-Saudis came from countries
with high burden of TB such as India, Pakistan,
Bangladesh, Indonesia, and Yemen.
 Most of them are unskilled workers that tend to
live in crowded housing conditions with poor
nutrition and stressful work.

31.  TB incidence for Non-Saudis showed a falling
trend over the last 10 years while the trend for
Saudis remained stationary.
 In the year 2000, the NTP started to implement a
strategy of DOTS to all regions in the Kingdom.
 This may partially explain the falling overall trend
among non-Saudis over the last decade.
 For Saudis, the trend showed a significant rise
between 1995 and 2010. It was not affected by
the implementation of DOTS. The absence of an
effect on Saudis trend is difficult to explain.

32.  As the rise in trend was mainly in the Central and
Makkah regions, it may be related to the higher
proportion of Non-Saudis in urban areas of these
regions.
 Globally, TB incidence trends showed variations
among countries and regions of the world. In some
areas, the rates have stabilized while in others, they
continue to decline slowly.

33. Current Situation In Medina:
 In 2011 the newly diagnosed cases reported
were 200.
 In 2012 the newly diagnosed cases reported
were 180.
 In 2013 the newly diagnosed cases reported
were 141.

34. 39.72%
(56)
60.28%
(85)
Case Distribution According to
Nationality in 2013
Saudi
Non Saudi

35. 65.25%
34.75%
Case distribution according to sex
Male Female

36. References:
 World Health organization. WHO Report 2012: Global
Tuberculosis Control; 2012.
 Dye C, Maher D, Weil D, Espinal M, Raviglsone M.
Targets for global tuberculosis control. Int J Tuberc
Lung Dis 2006;10:460-2.
 Al-Kahtani NH, Al-Jeffri MH. Manual of the National TB
Control Program. Ministry of Health; 2003.
 MOH, KSA, Annual statistical report 2011 (Arabic-
English). Available from:
http://www.moh.gov.sa/Ministry/MediaCenter/News/
Documents/healthybook.pdf