Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis that primarily affects the lungs. The cardinal signs of pulmonary TB include chronic cough lasting more than 2-3 weeks, chest pain, fever, night sweats, and weight loss. TB transmission occurs via airborne droplets. Nepal has a high burden of TB and implements the WHO-recommended DOTS strategy for prevention and control, which involves directly observed treatment to improve adherence and cure rates. Expansion of DOTS nationwide and addressing issues like drug-resistant TB and co-infection with HIV are national policy priorities.

1. PRESENTED BY:PRESENTED BY:
Bibek Bhattarai
Amrita Thapa
Ashmita Bhusal
Dipendra Sunar
Deepika Thapa
BPH 3rd
SEM

2. INTRODUCTIONINTRODUCTION
Tuberculosis is an infectious disease caused by
Mycobacterium tuberculosis, primarily affecting the lungs and
causing pulmonary tuberculosis but can also affect intestine,
meninges, bones and joints, lymph glands and other tissues of
the body.

3. CARDINAL SIGNS OF PULMONARYCARDINAL SIGNS OF PULMONARY
TUBERCULOSISTUBERCULOSIS
•Chronic productive cough
•Persistent for greater than 2-3 weeks
•That does not respond to routine treatment
•With or without hemoptysis
•Chest pain
Systemic symptoms :
•low grade fever, usually occurring in the evenings or night
•night sweats
•easy fatigability
•weight loss

4. EPIDEMIOLOGYEPIDEMIOLOGY

5. Agent FactorsAgent Factors
Agent: Mycobacterium tuberculosis
M. bovine affects mainly cattale and other
animal
Source of infection:
Human source: Fresh droplet nuclei of sputum from
the cases whose sputum is positive for tubercle bacilli
and who has either received no treatment or not
been treated fully.
Bovine source: Infected milk
Communicability: Patients are infective as long as
they remain untreated.

6. Host FactorsHost Factors
Age: All but ages more common from infancy to
adolescence.
Sex: More prevalent in males than females.
Hereditary: Not a hereditary disease.
Nutrition: Malnutrition is widely believed to
predispose TB.
Immunity: Acquired as a result of natural infection or
BCG vaccination.

7. Environmental FactorsEnvironmental Factors
TB is social disease with medical aspects
Poor housing, over crowding as in jails, common
lodge houses, Slum dwellers, industrial areas.
Poor quality of life.
Population explosion.
Lack of awareness on prevention and treatment.
Occupation

8. Mode of TransmissionMode of Transmission
Droplet infection
Droplet nuclei
Incubation PeriodIncubation Period
May be weeks, months or years.
It takes 3 to 6 weeks for development of positive
tuberculin test after infection.

9. MAGNITUDE OF THE PROBLEMMAGNITUDE OF THE PROBLEM

10. GLOBAL STATUSGLOBAL STATUS
Defined as “Global emergency” By WHO in 1993.
About one third of the world population has latent
TB.
TB kills 5000 people a day, 2 million a year.
According to WHO global report 2008,
9.27 million estimated new cases of TB (2007)
i.e. 139 per 100 000 population
9.24 million estimated new cases (2006)
i.e. 140 per 100 000 population
Of these 9.27 million new cases, an estimated 44% or
4.1 million (61 per 100 000 population) were new
smear positive cases

11. SITUATION OF TB IN ASIASITUATION OF TB IN ASIA
Asia has the highest burden of TB in the world.
Out of the 22 high-burden TB countries reported by
the WHO, 11 are in Asia.
TB is the leading infectious disease killer in this
continent.
Three-fourths of TB patients in Asia develop active
TB during their most productive years between the
ages of 15 and 54 years old.

12. NATIONAL STATUSNATIONAL STATUS
Major public health problem.
About 45% of the population is infected with TB, out
of which 60% are in the productive age group.
Every year, 44,000 people develop active TB, of
whom 20,000 have infectious pulmonary disease.
These 20,000 can spread the disease to others.
Introduction of treatment by Directly Observed
Treatment Short course (DOTS) has already reduced
the numbers of deaths; however, 8,000-11,000 people
continue to die every year from this disease.

15. PREVENTION AND CONTROLPREVENTION AND CONTROL
PROGRAM STATUSPROGRAM STATUS

16. For the prevention of TB, following points should be
considered.
Protection against exposure to TB.
Prompt diagnosis and treatment of of patients with
sputum smear positive PTB.
Out patients diagnosis and treatment.
Environmental control
Patients education, use of mask, etc.
HIV positive health workers should not work with
PTB positive.
PTB suspects should be diagnosed for TB.
Periodic screening etc…

17. Control measuresControl measures consist of
Curative component (Case finding and treatment)
Preventive Component(By BCG vaccination)

18. ANTIBIOTICS FOR ACTIVE PULMONARYANTIBIOTICS FOR ACTIVE PULMONARY
DISEASEDISEASE• Almost all recommended treatment regimens have two phases,
on the basis of extensive evidence from controlled clinical
trials.
• Intensive phase designed to kill actively growing and
semidormant bacilli. This action shortens the duration of
infectiousness with rapid smear and culture conversion after 23
months of treatment, in most cases (80-90%).
• At least two bactericidal drugs, isoniazid and rifampicin, are
necessary in the initial phase.
• Pyrazinamide given in the initial intensive phase allows the
duration of treatment to be reduced from 9 to 6 months, but it
offers no benefit if given past the second month to patients
with drug susceptible tuberculosis.
18

19. DOTSDOTS
( DIRECT OBSERVED TREATMENT SHORT COURSE)( DIRECT OBSERVED TREATMENT SHORT COURSE)

20. Directly observed Treatment short course (DOTS)
chemotherapy as recommended by WHO has been
successfully implemented throughout Nepal since
2001.
DOTS is an approach to ensure complete treatment
of tuberculosis, as recommended by the WHO. It is
direct supervision of drug intake.
In DOTS, during the intensive phase of treatment, a
health worker or other trained person watches as the
patient swallows the drug in his presence.

21. Tuberculin test is done on childrenDOTS is a abbreviation of Directly Observed

22. FIVE ELEMENTS OF THE DOTS STRATEGYFIVE ELEMENTS OF THE DOTS STRATEGY
Government commitment for sustained TB control
activities.
Case detection by sputum smear microscopy among
symptomatic patients self-reporting to health services.
Standardized treatment regimen of six to eight months for
at least all sputum smear positive cases, with directly
observed therapy (DOT) for at least the initial two months.
A regular, uninterrupted supply of all essential anti-TB
drugs.
A standardized recording and reporting system that allows
assessment of treatment results for each patient and of the
TB control programme performance overall.

23. FUNCTIONS OF DOTSFUNCTIONS OF DOTS
Increase the public awareness about TB in the
community through advocacy and education.
Support people with TB in the community by
providing treatment observers either in the health
centers or patient’s home.
Identify local problems and their solution.
Encourage cooperation between health institutions,
health workers, volunteers and NGOs.
Support health workers at treatment centers and sub
centers by providing daily dose medicines to the
patients.

24. BENEFITS OF DOTSBENEFITS OF DOTS
It increases the proportion of patient cured.
Cure is rapid.
Decreases death rate and relapses.
Reduce community transmission of tubercle bacilli as
well as emergence of drugs resistant strains.
It uses standard regimen for all patients as
recommended by WHO.
DOTS are the internationally recommended cost
effective strategy for TB control.
It is the only strategy which has been documented to
be effective worldwide in the program basis.

25. LIMITATIONS OF DOTSLIMITATIONS OF DOTS
No currently available method of screening reliably
detects all TB cases.
Multi drug resistant cases are being wide spread.
Expansion of DOTS in areas difficult to access.
Patient may be pushed into private sector where they
get costly and ineffective care due to headache of
regular visits in DOTS.
It may be hampered by political instability.

26. DOTS was first introduced in 4 districts of Nepal
which were Kailali, Nawalparasi, Parsa and
Bhaktapur.
DOTS has been implemented through out the
country since April 2001.
By 16th
July 2007 DOTS has been expanded to 874
treatment centers with 3117 sub centers.
In the year 2007 33,450 TB patients have been
registered of whom 14,353 infectious and are being
treated under the DOTS strategy in NTP.

27. MDR TB
TB drug resistance is a major problem that threatens
the success of DOTS.
Drug resistance arises due to the improper use of
drugs in chemotherapy of drug-susceptible TB
patients.
MDR-TB requires longer duration of treatment (up to
2 years) to achieve cure, in comparison with 8 months
treatment for drug susceptible TB.

28. Result of Multi Drug Resistance
Surveillance
Source: NTC, DoHS
1.2%
3.6%
1.3%
2.9%
1996/97 1998/99 1998/99 2002/03
1%

29. HIV/AIDS AND TBHIV/AIDS AND TB
The prevalence of HIV is rising rapidly in Nepal
The life time risk of developing TB for people infected
is 5-10 % and this sharply rises to 30-50 % if they are
co infected with HIV because of weakened immune
system.
In 2006, 2.4% of TB patient also had HIV.

30. NATIONAL POLICY ANDNATIONAL POLICY AND
STRATEGIESSTRATEGIES

31. Goals:
To reduce the mortality, morbidity and
transmission of tuberculosis until it is no longer a
public health problem.
OBJECTIVES:
85 % cure rate in new smear-positive pulmonary
tuberculosis cases.
70 % case detection ratio in new smear-positive
pulmonary tuberculosis cases.

32. STRATEGIESSTRATEGIES
Expansion of DOTS through out the country up to the
community level.
Establish a treatment centre and sub centre in health post
and sub health post or in partnership at community level.
Establish a diagnostic microscopy centre at each
constituency level either at PHCC or run by private
sector.
Pursue quality DOTS expansion.
Address TB/HIV, MDR TB and other challenges
Contribute to health system strengthening .
Involve all care providers.
Engage people with TB and affected communities.


33. CONCLUSIONCONCLUSION
Finally we concluded that tuberculosis infection and
disease remain common in populations characterized
by poor housing conditions, drug use, and HIV
infection. Linking a major medical provider with
community-based organizations is an effective means to
provide highly targeted screening services to ah
population at serious risk for disease acquisition and
transmission.

34. ReferencesReferences
Annual Report, Department of Health Services,
2071/72.
Tuberculosis in the SAARC Region An Update 2014,
SAARC Tuberculosis and HIV/AIDS Centre .
Global Tuberculosis Control 2009, Epidemiology
strategy financing, WHO
http://www.saarctb.com.np/tuberculosis.php#mdr
http://www.moh.gov.np/programmes/Tb.asp
http://www.cdc.gov/Features/TBsymptoms/

35. Thank You…!!!