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  1. 1. TUBERCULOSIS By Sriloy Mohanty B.N.Y.S,2nd year S-VYASA
  2. 2. Contents…• Introduction • Childhood TB• Problem statement • BCG vaccination• Epidemological indices • Chemoprophylaxis• Natural history of TB • NTP • Stop TB strategy• Definition of TB cases and • TB and HIV treatment • Epidemiological impact• Natural history of TB• Modes Of Transmission• Control of TB• Chemotherapy
  3. 3. INTRODUCTION Specific infectious diseases Caused by-M. tuberculosis Primary effect on lungs-pulmonary tuberculosis Also affects intestine,meninges,bones, joints,lymph nodes,etc.
  4. 4. Cont… It affects also animals like cattles Known as “Bovine tuberculosis” May communicated to man
  5. 5. Problem statement Distribution-worldwide WHO estimates that about 9.2 million new cases of TB occurred in 2006 Of these cases, 4.1 million were new smear positive cases This includes 789,000 tuberculosis with HIV co- infected cases There were 14.4 million prevalent cases An estimated 1.7 million people died from TB which 231,000 were those co-infected with HIV
  6. 6.  31.8 million new and relapse cases and 15.5 million smear positive case were notified by DOTS Programme between 1995-2006
  7. 7. India India is the first rank in incidence 1/5th of global burden of TB 1.8 million persons develop TB of which 0.8 million are new smear positive (highly infectious) 0.37 million people die every year DOTS program was launched in March 1997
  8. 8. TB estimates for IndiaPopulation 1151 millionGlobal rank (by estimated number of cases) 1Incidence (all cases/1 lakh population/year) 168Incidence (new smear +ve cases/lakh population/year) 75Prevalence (smear +ve cases/lakh population) 299TB mortality/1 lakh population/year 28% of new TB cases HIV positive 1.2% of new case multidrug resistance 2.8Previously treated TB cases multidrug resistance (%) 17
  9. 9.  It is mainly a disease of the poor Majority of victims are migrant laborers, slum dwellers, residents of backward areas and tribal pockets
  10. 10. Epidemological indices Prevalence of infection  Percentage of individual who are positive to tuberculin test Incidence of new cases  Percentage of new cases/1000people/1year Prevalance of suspect cases  Based on X-ray examination of chast
  11. 11.  Mortality rate  Number of death from TB Prevalance of drugs  Prevalance of patient excreting tubercle bacilli resistant to anti-tubercle drugs
  12. 12. Definition of TB cases and treatment Case of TB  patient in whom TB is confirmed by tests Sputum smear examination  Test for screening of TB (acid fast bacilli are stain red by ziehl neelsen method) New case  Person with smear positive test having pulmonary TB who had never taken any treatment
  13. 13.  Relapse  Person who returns smear +ve having previously been treated and declared cured Failure case  Person with smear +ve treated and again become +ve at 5th month or later during treatment Return after default  Person,returns to sputum positive ,after having left treatment for atleast two months Transfer in  A patient recorded in another administrative area register and transferred into another area to continue treatment
  14. 14.  Transfer out  A patient who has been transferred to another area register and treatment results are not known Cured  Negative smear after treatment Treatment completed  Initially smear –ve or +ve and after receiving full course of treatment becomes –ve Adherence  Person takes appropriate drugs regimen for required time
  15. 15. Natural history of TBAgent factor M.tuberculosis is a intracellular parasite Ingested by phagocytes but resistant to intracellular killing Indian tubercle bacillus is said to be less virulent then the europian bacillus
  16. 16. Cont… Number of “atypical” myobacteria have been isolated from man They are of 4 types  Photochromogens  Scotochromogens  Non-photochromogens  Rapid growers
  17. 17.  Source of infection Two source of infection  Human source-person whose sputum is positive for tubercle bacilli  Discharge of bacilli in their sputum  Bovine source-infection is usually by milk  Not a problem in India because of the practice of boiling milk before consuption
  18. 18. Communicability Patient are infective as long as they remain untreated Infection can be reduced by 90% within 48 hours by using anti-microbial treatment
  19. 19. Host Factor AGE  Affects all ages  In India under 5 age group-1%  At the age of 15years-30%
  20. 20.  SEX  More prevalent in male then female HEREDITY  It is not a hereditary disease
  21. 21.  NUTRITION  Malnutrition is believed to predispose to TB  Diet had no effect on the recovery of patient IMMUNITY  No inherited immunity against TB  Acquired after natural infection or BCG vaccination
  22. 22. Social factor TB is a disease with both social and medical aspects Social factors includes  Poor quality of life  Poor housing  Population explosion  Early marriages  Lack of awareness of causes of disease
  23. 23. TUBERCULIN TEST Discovered by Von Pirquet(1907) Three main test are currently in use  Mantoux intradermal test  Heaf test  Tine multiple puncture test
  24. 24. Modes Of Transmission Mainly by droplate infection and droplate nuclei generated by sputum positive patient Particle should be fresh enough to carry Coughing generates all size of droplates Notes-not transmitted by fomites
  25. 25. Incubation period Ranges from 3-6 week
  26. 26. Control of TB Reduction in prevalence and incidence WHO defines control as prevalance of natural infection in the age 0-14yrs is of the order of 1% In india it is about 40% Control measure consists of  Curative component-case finding and treatment  Preventive component-BCG vaccination
  27. 27. Case finding THE CASE  Detection of sputum positive case  Case is defined by WHO as patient with sputum positive for tubercle bacilli Target group  Pulmonary TB has one or more of the symptoms like  Cough and Fever  Chest problems
  28. 28.  Case finding tools  Sputum examination  Sputum smear examination  Who also have problems like  persistant cough of about 3-4weeks  Continous fever  Chest pain  haemoptysis
  29. 29. Chemotherapy Indicated for every case of active BT Objectives are  Elimination of both the fast and slow multiplying bacilli  Mainly elimination of bacilli from patients sputum Available for free of charge
  30. 30. Anti-tuberculosis drugs An anti-tuberculosis drug should follow some criterias like  Free from side effects  Highly effective  Easy to administrate  Reasonably cheap
  31. 31. Classification of drugs Currently used drugs are classified in to  Bactericidal drugs-kills the bacteria  Bacteriostatic drugs-inhibits the multiplication of the bacilli and leads to destruction by the immune mechanism of the host
  32. 32. Bactericidal drugs Rifampicin(RMP)  Powerful Bactericidal drugs  Permeates all tissue membrane  Only Bactericidal drugs active against the dormant bacilli  Only oral drug  10-12mg/kg body weight  May feel nausea,gastritis,purpra
  33. 33.  INH  Most powerful drug  Can penitrate the cell membrane  Active against intracellular and extracellular bacilli  It can also pass BBB,present in CSF  4-5gm/kg body weight
  34. 34.  Streptomycin  Act on rapidly multiplying bacilli  Less active on slow multiplying bacilli  No action on persisters  Non-permeate cell wall  0.75-1gm in a single injection
  35. 35.  Pyrazinamide  Active against slow-multiplying intracellular bacilli  Drug given orally  Usual dose 30gm/kg body weight  Recommended in tuberculous meningitis
  36. 36. Bacteriostatic drugs Ethambutol  Used in combination to prevent the emergence to the drugs  Given orally  Side-effect-retro-bulbar neuritis  15mg/kg body weight given in 2-3 doses
  37. 37.  Thioacetazone  Companion drug to INH  Adult dose-2mg/kg body weight  Side-effect includes gastrointestinal disturbances, blurring of vision, haemolytic anaemia
  38. 38. Two-phase chemotherapy Consist of two phase of effective treatment  Short aggressive or intense phase  Lasting 1-3months  Three or more drugs are combined to kill initialy  Continuation phase  Aimed to sterilizing the smaller number of dormant  Not less then 18 months  If rifampcin and pyrazinamide applied,then it can reduced to 6-9 months
  39. 39. Treatment during pregnancy Streptomycin can cause permanent deafness in the baby So ethambutol should be used instead of streptomycin, Isoniazid, rifampicin, pyrazinamide and ethambutol are safe to use Second line drugs should not be used becouse these are teratogenic (flouroquinolomes,ethionamide)
  40. 40. Childhood TB TB in children present between 10-20% of all BT Sourse is usually adult Frequency of childhood TB depends  Number of infectious case  Closeness of contact with an infectious case  Age of the child when exposed to TB
  41. 41.  Childhood TB is mainly due to failure in control of TB in adult Under 5 age group-20% The commonest age-1-4years
  42. 42. BCG vaccination Calmette and guerin in 1919 discovered bacille Calmette guerin(BCG) Avirulent for man while retaining its capacity to induce an immune response During 1921-1925-given orally After 1927-intradermal technique 1948-it is accepted by TB workers
  43. 43. AIM Induce benign artificial primary infection By stimulating an acquired resistance
  44. 44. Vaccine Widely used live bacterial vaccination Derived from an attenuated bovine stain of tubercle bacilli WHO has recommended the “Danish 1331” stain for production of BCG vaccination
  45. 45. Types of vaccination Two types of BCG vaccination  Liquid vaccination(fresh)  Freeze-dried vaccination(stable)
  46. 46.  BCG is stable for several weeks in a tropical climate and for up to 1 year if kept away from direct light and stored in cool environment preferably refrigerator at a temperature below 10 deg C Normal saline is recommended for diluent for reconstituting the vaccine
  47. 47. Dosage For vaccination the usual strength is 0.1 g in 0.1 ml volume For new born (below 4 weeks) 0.5 ml, because the skin of the new born is thin
  48. 48. Administration Inject the vaccine intradermally using a tuberculin syringe (recommended by WHO) If injected subcutaneously an abscess is likely to develop The site of injection should be above the insertion of deltoid
  49. 49. Phenomena aftervaccination  After 2-3 weeks a papule develops at the site of vaccination  It increases slowly in the diameter about 4-8 mm in 5 weeks  Healing occurs within 6-12weeks  Round scar is formed
  50. 50.  complication  Prolonged severe ulceration  Supractive lymphadenitis  Osteomyelitis  Death Protective value  Protection from 15-20years
  51. 51. RevaccinationEven 80 years after the development of the vaccine, it isnot known whether booster doses are indicated oradvisableContraindicationGeneralized eczema, infective dermatosis,hypogammaglobulinaemia, to those with a history ofdeficient immunityPatient under immunosuppresent treatment and inpregnancy
  52. 52.  Direct BCG vaccination Vaccination without a prior tuberculin test has been adopted as a National policy in many developing countries including India No adverse effects have been reported even if BCG is given to tuberculin – positive reactors
  53. 53. Impact BCG is less effective than the chemotherapyBCG vaccination and HIV infection A single dose of BCG vaccine should be given to all healthy infants as soon as possible after birth unless the child presented with symptomatic HIV infection
  54. 54. Combined vaccination BCG may be given at the same time as OPV. DPT vaccine may also be given at the same time as BCG, but in different arm without reducing the immune responses or increasing the rate of complication
  55. 55. Chemoprophylaxis The case against INH chemoprophylaxis rests on 3 points:  It is a costly exercise  It is not strikingly effective  It can induce hepatitis According to WHO mass treatment is not feasible In this context, BCG gets priority over chemoprophylaxis
  56. 56.  Surveillance  An integral part of any effective TB  Concern with two distinct aspect  Surveillance of TB situation  Surveillance of control measures(BCG and chemotherapy) Role of hospital  Inspite of effective domicilliary treatment service there will be need for hospitalization for some person  Indications are  Emergencies  Surgical treatment  Management of serious type of TB(meningeal TB)  Social indication
  57. 57.  Drugs resistance  All drugs used in TB produce resistance  Resistance may be of two types  Pretreatment resistance  Acquired resistance
  58. 58. National Tuberculosis Programme (NTP) NTP has been under operation since 1962 The long term goal of NTP is “to reduce the problem of tuberculosis in the community sufficiently quickly to the level where it ceases to be a public health problem”.
  59. 59. Revised NTP The Govt. of India, WHO and World Bank together reviewed the NTP in the year 1992 The main pillars of the revised strategy are;  Achievement of not less than 85% cure rate amongst infectious cases of TB, through short course chemotherapy involving peripheral health functionary
  60. 60.  Detecting 70% of the estimated cases – through quality sputum microscopy Involvement of NGOs Direct Observed Therapy Short – term (DOTS) – a community based TB treatment and care strategy
  61. 61. Stop TB strategy 2006- WHO launched Core of the strategy – DOTS Indicators used to measure implementation and impact of TB control:  Case detection  Treatment success  Incidence  Prevalence  Deaths
  62. 62. Stop TB partnership target By 2005  70% of people with sputum smear positive TB will be diagnosed By 2015  Global burden of TB will be reduced by 50% relative to 1990 levels By 2050  Global incidence of TB will be less then or equal to 1 case/million population/year
  63. 63. TB and HIV HIV virus damages the bodies natural defense Accelerates the speed at which TB progresses from a harmful infection to life – threatening condition
  64. 64. Epidemiological impact Reactivation of latent infection  People who are infected with both TB and HIV are 25-30 times more likely to develop TB than the people infected with only TB Recurring infection  People having HIV who have been cured of TB may be at more risk of developing TB again In the community  Educate people that TB is curable and the people are no longer infectious after the first few weeks of treatment
  65. 65. Thank You…