6. Tuberculosis is a specific infectious disease caused
by Mycobacterium tuberculosis.
The disease primarily affects lungs and causes
pulmonary tuberculosis.
6/21/2023 6
7. It can also affect intestines, meninges, bones and
joints, lymph glands, skin and other tissues of the
body.
6/21/2023 7
8. A total of 1.4 million people died from TB in 2019
(including 208 000 people with HIV).
Worldwide, TB is one of the top 10 causes of death
and the leading cause from a single infectious agent
(above HIV/AIDS).
6/21/2023 8
9. In 2019, an estimated 10 million people fell ill with
tuberculosis(TB) worldwide.
5.6 million men, 3.2 million women and 1.2
million children.
6/21/2023 9
10. TB is present in all countries and age groups. But
TB is curable and preventable.
In 2019, 1.2 million children fell ill with TB
globally.
Child and adolescent TB is often overlooked by
health providers and can be difficult to diagnose
and treat.
6/21/2023 10
11. Multidrug-resistant TB (MDR-TB) remains a
public health crisis and a health security threat.
A global total of 2,06,030 people with multidrug- or
rifampicin-resistant TB (MDR/RR-TB) were
detected and notified in 2019, a 10% increase from
1,86,883 in 2018.
6/21/2023 11
12. Globally, TB incidence is falling at about 2% per
year.
An estimated 60 million lives were saved through
TB diagnosis and treatment between 2000 and 2019.
6/21/2023 12
13. Ending the TB epidemic by 2030 is among the
health targets of the United Nations Sustainable
Development Goals (SDGs).
6/21/2023 13
16. In Nepal, an estimated 69,000 fell ill with TB during
FY 2077/78.
National Tuberculosis Programme registered 28,677
all forms of TB. (Nearly 58% missing cases)
6/21/2023 16
17. TB cases were reported from all parts of the country,
but the Terai belt reported the highest numbers of
cases which is 60%
The childhood TB cases reported are nearly 5.5%
of all cases which is still a huge challenge in Nepal.
6/21/2023 17
18. Among the reported cases, male TB cases were
reported nearly 2 times more than female.
6/21/2023 18
19. Nepal TB program is also missing out to find nearly
58% of estimated cases annually, which has played
a big role in control of TB program.
6/21/2023 19
20. TB-HIV co-infection rate in Nepal is 1.1% (HIV
among TB) and
HIV testing among TB patient are also improving
(18% of 2017 to 54% 2018).
6/21/2023 20
22. The proportion of MDR-TB was 2.2% among new
cases and 15.4% among retreatment cases based
on DRS (Drug Resistant Survey) survey carried
out in 2011/12.
6/21/2023 22
23. Nepal aims to end tuberculosis epidemic by 2050
with the intermediate target of reducing TB incidence
by 20% by the year 2021 compared to 2015 and
increase case notifications by a cumulative total of
20,000 from July 2016 to July 2021.
6/21/2023 23
24. Targets linked to the SDGs and the End TB
strategy:
• Detect 100% of new sputum smear-positive TB
cases and cure at least 85% of these cases.
• Eliminate TB as a public health problem (<1 case
per million population) by 2050
6/21/2023 24
27. Communicability: Patient are infective as long as
they remain untreated.
Effective anti-microbial treatment reduces
infectivity by 90% within 48 hours.
6/21/2023 27
28. ii. Host Factors:
Age: It affects all ages. Majority of TB patients are
in the productive age group (25–64 years).
Sex: More prevalent in males.
Nutrition: Malnutrition is widely believed to
predispose tuberculosis.
6/21/2023 28
30. iv. Mode of transmission
Tuberculosis is mainly transmitted by droplet
infection and droplet nuclei generated by sputum
positive patients with pulmonary tuberculosis.
6/21/2023 30
32. Only about 10% of people infected with M.
tuberculosis ever develop tuberculosis disease.
Many of those who suffer TB do so in the first few
years following infection, but the bacillus may lie
dormant in the body for decades.
6/21/2023 32
33. Classic clinical features associated with active
pulmonary TB are:
Cough may be non-productive or mucopurulent sputum
may be expectorated (2 weeks or more)
Fatigue
Unintentional weight loss/anorexia
6/21/2023 33
35. Common forms of extra- pulmonary TB are skeletal
TB, tubercular meningitis, genito-urinary TB, and
gastro-intestinal TB.
Patient usually presents with features like fever,
night sweats, weight loss and local features related
to the site of disease.
6/21/2023 35
36. Many patient with extra-pulmonary TB also have
co-existent pulmonary TB.
If a patient has extra-pulmonary TB, look for
pulmonary TB, send sputum samples for AFBs and
if sputum AFBs are negative, do a chest x-ray.
6/21/2023 36
37. The control measures consist of:
a. Curative component - Case finding and
treatment;
b. Preventive component - BCG vaccination.
6/21/2023 37
38. 1. Case detection
A person with cough for 2 (two) weeks or more is a
presumptive TB patient and must have a sputum
examination.
6/21/2023 38
39. 1. Persons to be evaluated for TB both adults and
children are the following:
Signs and symptoms suggestive of TB
Household or other close contacts of bacteriologically
confirmed pulmonary TB
6/21/2023 39
41. Routine screening of patients with illness who are at
high risk for TB includes the followings.
1. HIV positive patients
2. Patients on long term steroid therapy
3. Diabetic patients
4. Cancer patients
6/21/2023 41
43. Case Finding Tools
(i) Xpert MTB/RIF : is the rapid molecular test,
currently recommended by WHO (first-line
diagnostic for TB diagnosis).
It can provide results within 2 hours.
Since 2013, it has also been recommended for use in
children and to diagnose specific forms of
extrapulmonary TB. 6/21/2023 43
44. The test has much better sensitivity than sputum
smear microscopy.
Xpert MTB/RIF test can detect TB and rifampicin-
resistant TB
6/21/2023 44
45. Case Finding Tools
ii. Sputum smear microscopy
Direct sputum smear examination should be done
for all patients with presumptive TB where Xpert
MTB/RIF is not available.
6/21/2023 45
47. Case Finding Tools
iii. Sputum culture and DST.
All patients with Rifampicin resistant TB
identified by Xpert MTB/RIF should have
specimen sent for TB culture and DST and LPA
where applicable.
6/21/2023 47
48. Case Finding Tools
iv. Line Probe Assay
LPA is a PCR based test used for diagnosis of TB
and for determining susceptibility to different anti
TB drugs.
It needs higher bacterial load in samples than for
Xpert MTB/RIF for a positive result and hence
smear-positive samples and cultures are preferred
6/21/2023 48
49. Case Finding Tools
v. Chest X-Ray
It help in assessing the extent of lung damage in
complicated cases but not for a diagnosis.
It may also be used as a screening tools in the
group considered at risk of developing TB
followed by a confirmatory test for diagnosis.
6/21/2023 49
50. It is required for diagnosis of TB in
bacteriologically non-confirmed patients with
persistent symptoms and extra-pulmonary cases
such as pleural effusion.
6/21/2023 50
51. Globally, use of rapid molecular tests is
increasing, and many countries are phasing out
the use of smear microscopy for diagnostic
purposes (although microscopy and culture remain
necessary for treatment monitoring).
6/21/2023 51
52. Treatment
The best way to ensure effective treatment for TB
patients is to support medicine intake through Directly
Observed Treatment (DOT) using fixed-dose
combination tablets.
All TB treatment must be given under DOT
6/21/2023 52
53. There is now only one category of treatment for TB
patients needing first-line treatment.
All TB patients whether bacteriologically confirmed
or clinically diagnosed will receive Treatment
Regimen (2HRZE (intensive phase /4HR
(continuation phase)).
6/21/2023 53
55. In patients who require TB re-treatment, drug
susceptibility testing should be conducted to inform
the choice of treatment regimen.
6/21/2023 55
56. It is very important that all TB patients MUST
RECEIVE SUPERVISED TB TREATMENT OR
DOT (Directly Observed Treatment).
6/21/2023 56
57. Community-Based DOT:
any TB patients who cannot attend to the TB
Treatment Centre regularly
such patients will be treated in the community
closed to their home by a community volunteer.
6/21/2023 57
59. Preventive component
BCG vaccination
The aim of BCG vaccination is to induce a benign, artificial
primary infection which will stimulate an acquired resistance to
possible subsequent infection with virulent tubercle bacilli,
Thus reduce the morbidity and mortality from primary
tuberculosis among those most at risk.
6/21/2023 59
60. Drug Resistant TB (DR TB) is TB that is resistant to
TB drugs.
Resistance can be developed to one or more TB
drugs (1st or 2nd line drugs).
MDR TB and other drug resistant TB result from
poor management of susceptible TB
6/21/2023 60
61. Ensuring all TB patients complete TB treatment
under supervision (DOT) is the most effective way
to ensure TB patients are successfully treated and
that drug resistant strains of TB are not created.
6/21/2023 61
64. Influenza is an acute respiratory tract infection caused by
influenza virus, of which there are 3 types – A, B and C.
Influenza is commonly known as “Flu”. All known
pandemics were caused by influenza A strains. The
disease is characterized by
sudden onset of chills,
malaise,
fever,
muscular pains and cough.
6/21/2023 64
65. Influenza occurs in all countries and affects millions
of people every year. Outbreak of influenza type A
occurs almost every year. It may occur in pandemics
every 10-40 years due to major antigenic changes.
Some of these are
Spanish Influenza( 1918)
Asian Influenza (1957)
Hong kong influenza( 1968)
6/21/2023 65
66. In between pandemics, epidemics tend to occur at
intervals of 2-3 years in case of influenza A and 3-6
years in case of influenza B.
6/21/2023 66
67. At present three types of influenza viruses are
circulating in the world:
A( H1N1)
A( H3N2) and
B virus.
More recently, influenza A( H1N1) virus of swine
flu emerged as pandemic in 2009.
6/21/2023 67
68. AGENT FACTORS
AGENT: Influenza viruses are classified within the
family Orthomyxoviridae. There are three viral
subtypes namely influenza type A, type B and type
C. These three viruses are antigenic ally distinct.
6/21/2023 68
69. Influenza A and B viruses which are responsible for
epidemics of disease throughout the world
6/21/2023 69
70. Major reservoir of influenza virus exists in animals and
birds.
Many influenza viruses have been isolated from a wide
variety of animals and birds (e.g., swine, horses, dogs, cats,
domestic poultry, wild birds, etc).
There is an increasing evidence that the animal reservoirs
provide new strains of influenza virus by recombination
between the influenza viruses of man, animals and birds.
6/21/2023 70
71. Usually a case or subclinical case.
During epidemics, a large number of mild and
asymptomatic infections occur, which play an
important role in the spread of infection.
The secretions of the respiratory tract are infective.
6/21/2023 71
72. Virus is present in the nasopharynx from 1 to
2 days before and 1 to 2 days after onset of
symptoms.
6/21/2023 72
73. Age and sex : Influenza affects all ages and
both sexes. In general, the attack rate is
lower among adults.
Human mobility : This is an important
factor in the spread of infection.
6/21/2023 73
75. Season
• Epidemics usually occurring in winter
• In tropical countries, influenza virus circulates throughout
the year with one or two peaks during rainy season.
Overcrowding
• Enhances transmission. The attack rates are high in close
population groups, e.g., schools, institutions, ships, etc.
6/21/2023 75
79. Good ventilation of the public buildings
Avoidance of crowding place during epidemics
Encourage the patient to cover their faces with
handkerchief while coughing and sneezing.
Isolation of the patient
Administration of Influenza vaccines
Killed vaccines
Live attenuated vaccines
6/21/2023 79
80. • Leprosy is a chronic infectious disease caused by a
type of bacteria, Mycobacterium leprae.
• Predominantly affects the skin and peripheral
nerves. Left untreated, the disease may cause
progressive and permanent disabilities.
• Transmitted via droplets from the nose and mouth
during close and frequent contact with untreated
cases.
6/21/2023 80
81. Leprosy is a neglected tropical disease (NTD)
which still occurs in more than 120 countries, with
more than 200 000 new cases reported every year.
Elimination of leprosy as a public health problem
globally (defined as prevalence of less than 1 per
10 000 population) was achieved in 2000 (as per
World Health Assembly resolution) and in most
countries by 2010.
6/21/2023 81
82. The reduction in the number of new cases has been
gradual, both globally and in the WHO regions.
As per data of 2019, Brazil, India and Indonesia
reported more than 10 000 new cases.
6/21/2023 82
83. While 13 other countries (Bangladesh, Democratic
Republic of the Congo, Ethiopia, Madagascar,
Mozambique, Myanmar, Nepal, Nigeria,
Philippines, Somalia, South Sudan, Sri Lanka and
the United Republic of Tanzania) each reported
1000–10 000 new cases. Forty-five countries
reported 0 cases and 99 reported fewer than 1000
new cases.
6/21/2023 83
84. There are two main types of disease based on the
number of bacteria present:
(WHO classification)
Paucibacillary
Multibacillary
6/21/2023 84
85. The two types are differentiated by the number of
poorly pigmented numb skin patches present, with
paucibacillary having five or fewer and
multibacillary having more than five.
6/21/2023 85
86. AGENT FACTORS
a. Agent:- Mycobacterium leprae
b. Source of infecton:- Mainly multibacillary cases
(lepromatous and borderline lepromatous cases) are
source of infection in the community.
6/21/2023 86
87. AGENT FACTORS
c. Portal of exit:- Nose and ulcerated skin.
d. Infectivity:- Highly infectious disease
6/21/2023 87
88. HOST FACTORS
a. Age (all age)
b. Sex (both but male more than female; 2:1 but
equal in Africa)
6/21/2023 88
89. ENVIRONMENTAL FACTORS:-
The risk of transmission is predominantly
controlled by environmental factors:
o The presence of infectious cases in that
environment.
oOvercrowding and lack of ventilation with
households.
6/21/2023 89
90. - Droplet infection- nasal secretions, saliva etc.
- Contact transmission-fomites such as contaminated
clothes and linen
- Other routes (insects vectors or by tattooing
needles)
6/21/2023 90
95. Leprosy is defined by the number and type of skin
sores. Specific symptoms and treatment depend on
the type of leprosy. The types are:
1. Tuberculoid
2. Lepromatous
3. Borderline
6/21/2023 95
96. A mild, less severe form of leprosy. People with
this type have only one or a few patches of flat,
pale-colored skin (paucibacillary leprosy-1-5 skin
lesion).
6/21/2023 96
97. A more severe form of the disease. It has
widespread skin bumps and rashes (multibacillary
leprosy), numbness, and muscle weakness.
The nose, kidneys, and male reproductive organs
may also be affected. It is more contagious than
tuberculoid leprosy
6/21/2023 97
98. People with this type of leprosy have symptoms of
both the tuberculoid and lepromatous forms.
6/21/2023 98
102. Leprosy has a long incubation period, an average of
3 to 5 years or more.
The Tuberculoid leprosy is thought to have a
shorter incubation period than other type leprosy.
6/21/2023 102
103. Some people do not develop symptoms until 20
years later.
Leprosy's long incubation period makes it very
difficult to determine when and where a person
with leprosy got infected.
6/21/2023 103
104. WHO expert committee on leprosy has defined a
case of leprosy as an individual who has one of the
following cardinal signs of leprosy but who has not
received a full course of multi-drug therapy (MDT)
for the type of leprosy identified:
• A definite loss of sensation in a pale
(hypopigmented) or reddish skin patch
6/21/2023 104
105. WHO expert committee on leprosy has defined a
case of leprosy as an individual who has one of the
following cardinal signs of leprosy but who has not
received a full course of multi-drug therapy (MDT)
for the type of leprosy identified:
• A definite loss of sensation in a pale
(hypopigmented) or reddish skin patch
6/21/2023 105
106. • A thickened or enlarged peripheral nerve with a
loss of sensation and/or weakness in the muscles
supplied by the nerve
The presence of acid-fast bacilli in an SSS (slit-skin
smear)
skin smears are usually taken from 6 “routine sites”
(both earlobes, elbows, and knees) as w
6/21/2023 106
107. Based on the above, the cases are classified into
two types for treatment purposes: Paucibacillary
(PB) case and Multibacillary (MB) case
PB case: a case of leprosy with 1 to 5 skin lesions,
without demonstrated presence of bacilli in a skin
smear.
6/21/2023 107
108. MB case: a case of leprosy with more than five
skin lesions; or with nerve involvement (pure
neuritis, or any number of skin lesions and
neuritis); or with the demonstrated presence of
bacilli in a slit-skin smear, irrespective of the
number of skin lesions
6/21/2023 108
109. In 2018, the WHO recommended that all leprosy
patients receive treatment with three drugs.
6/21/2023 109
111. Case detection and treatment with MDT alone have
proven insufficient to interrupt transmission.
To boost the prevention of leprosy, with the
consent of the index case, WHO recommends
tracing household contacts along with
neighbourhood and social contacts of each patient,
accompanied by the administration of a single dose
of rifampicin as preventive chemotherapy.
6/21/2023 111
112. Leprosy was eliminated at the national level in
2009 and declared so in 2010 with the registered
prevalence rate of 0.77 case per 10,000 population.
This rate is well below the cut-off point of below 1
per 10,000 population set by World Health
Organization, to measure the elimination of leprosy
as public health problem.
6/21/2023 112
113. Vision
To make a leprosy-free society where there is no new leprosy
case and all the needs of existing leprosy affected persons
having been fully met.
Mission
To provide accessible and acceptable cost effective quality
leprosy services including rehabilitation and continue to
provide such services as long as and wherever needed.
6/21/2023 113
114. Goal
Reduce further burden of leprosy and to break channel of
transmission of leprosy from person to person by providing
quality service to all affected community.
6/21/2023 114
115. Acute highly infectious disease of childhood caused
by a specific virus (RNA paramyxovirus)
Also known as “Rubeola”
6/21/2023 115
117. Agent : measles is caused by an RNA paramyxovirus.
Source of infection: the only source of infection is a case
of measles. Carriers are not known to occur.
Communicability: measles is highly infectious during the
prodromal period and at the time of eruption.
Communicability declines rapidly after the appearance of
the rash. The period of communicability is approximately 4
days before and 4 days after the appearance of the rash.
6/21/2023 117
118. Age: Affects virtually everyone in infancy or childhood-
between 6 months and 3 years.
Sex: incidence equal.
Immunity: One attack of measles generally confers life-long
immunity. Second attacks are rare.
6/21/2023 118
119. Transmission occurs directly from person to person mainly
by droplet infection and droplet nuclei, from 4 days before
onset of rash until 4 days thereafter.
The portal of entry is respiratory tract.
Incubation period: is commonly 10 days from exposure to
onset of fever, and 14 days to appearance of rash.
6/21/2023 119
121. fever and malaise, followed in 24 hours by
Coryza
Cough
Conjunctivitis
Koplik spots (small, irregular red spot`s with minute,
bluish white center first seen on buccal mucosa opposite to
first and second lower molars)
6/21/2023 121
123. Characterized by a typical, dusky-red, macular or maculo-
papular rash which begins behind the ears and spreads
rapidly in a few hours over the face and neck, and extends
down the body taking 2-3 days to progress to the lower
extremities
6/21/2023 123
124. ►The child will have lost weight and will remain weak for a
number of days. There may be failure to recover and a
gradual deterioration into chronic illness.
6/21/2023 124
125. According to the District Health Office, 265 persons were
found infected with measles in five local levels of the
district. Nepalgunj alone has 205 patients.
A two-year-old child of Nepalgunj -5 died of measles on
January 4.
The concerned authority started administering vaccines
against the measles from January 6.
6/21/2023 125
126. Nepal had committed to eliminating measles by 2023. To
declare measles as eliminated, the number of cases should
be less than five in every one million people throughout the
year.
Experts say the massive outbreak of the deadly disease at
the start of the new year shows that the country is nowhere
near its elimination target.
6/21/2023 126
127. Agent factors
Myxovirus parotiditis is a RNA virus of the myxovirus family
Source of infection
clinical and subclinical cases.
Period of communicability: usually 4-6 days before the
onset of symptoms and a week or more thereafter. The period
of maximum infectivity is just before and at the onset of
parotitis.
6/21/2023 127
128. Age and : mumps is the most frequent cause of parotitis in
children in the age group 5-9 years.
Immunity : one attack, clinical or subclinical, is assumed to
induce lifelong immunity.
6/21/2023 128
129. Transmission: Disease is spread mainly by droplet infection
and after direct contact with an infected person.
Incubation period: Varies from 2-4 weeks, usually 14-18
days
6/21/2023 129
130. In 30-40 percent of cases mumps infection is clinically
non-apparent.
In clinically apparent cases, it is characterized by pain and
swelling in either one or both the parotid glands but may
also involve the sublingual and submandibular glands.
Ear ache on the affected side prior to the onset of swelling.
Pain and stiffness on opening the mouth before the
swelling of the gland.
In severe cases, there may be fever and headache.
6/21/2023 130
132. Rubella or German measles is an acute childhood
infection, usually mild, of short duration
(approximately 3 days)
6/21/2023 132
133. Agent :
Rubella is caused by an RNA virus of the togavirus family.
Source of infection:
Clinical or subclinical cases of rubella.
Period of communicability:
It probably extends from a week before symptoms to about a
week after rash appears. Infectivity is greatest 1-5 days after
the appearance of rash.
6/21/2023 133
134. Age:
Mainly a disease of childhood particularly in the age group 3
to 10 years.
Immunity :
One attack results in life-long immunity; second attacks are
rare.
6/21/2023 134
135. The virus is transmitted directly from person to person by
droplets from nose and throat, and droplet nuclei, from one
week before onset of rash to one week after it has faded.
Vertical transmission
Congenital rubella
Incubation period: 2-3 weeks; average 18 days
6/21/2023 135
136. A large percentage of infections (50 to 65 per cent) are
asymptomatic.
• Coryza, sore throat, low-grade fever
• Generally mild and insignificant, and less
frequent in children.
PRODROMAL
• Enlargement of the postauricular and
posterior cervical lymph nodes appears as
early as 7 days before the appearance of the
rash.
LYMPHADENOPAT
HY
• Rash is often the first indication of the
disease in children.
• Appears first on the face & is minute,
discrete, pinkish, macular rash
• Conjunctivitis may occur
Rash
6/21/2023 136
137. Park, K. (2019). Park`s Textbook of Preventive and Social Medicine.
M/s Banarsidas Bhanot publishers.
Gupta, MC, Mahajan, BK. (2013). Mahajan and Gupta Textbook of
Preventive and Social Medicine. Brothers Medical Publishers (P) Ltd.
Annual Report, Department of Health Services 2077/2078
https://edcd.gov.np/
National-Tuberculosis-Management-Guidelines-2019_Nepal.pdf
https://kathmandupost.com/health/2023/01/18/nepal-
struggling-to-control-measles
6/21/2023 137
