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THIS PRESENTATION IS A UPDATED SLIDE OF THE PREVIOUS ONE WHICH GIVES A LITTLE KNOWLADGE ABOUT THE TREATMENT OF TB

THIS PRESENTATION IS A UPDATED SLIDE OF THE PREVIOUS ONE WHICH GIVES A LITTLE KNOWLADGE ABOUT THE TREATMENT OF TB

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Tuberculosis

  1. 1. TUBERCULOSIS By Sriloy Mohanty B.N.Y.S,4th year S-VYASA
  2. 2. Contents… • Introduction • Problem statement • Natural history of TB • Modes Of Transmission • Control of TB • Chemotherapy • Childhood TB • BCG vaccination • Chemoprophylaxis • NTP • Stop TB strategy • TB and HIV • Epidemiological impact • Yoga • Research
  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 India Population 1151 million Global rank (by estimated number of cases) 1 Incidence (all cases/1 lakh population/year) 168 Incidence (new smear +ve cases/lakh population/year) 75 Prevalence (smear +ve cases/lakh population) 299 TB mortality/1 lakh population/year 28 % of new TB cases HIV positive 1.2 % of new case multidrug resistance 2.8 Previously 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. History of TB  TB has affected humans for millennia  Historically known by a variety of names, including:  Consumption  Wasting disease  White plague  TB was a death sentence for many Vintage image circa 1919 Image credit: National Library of Medicine
  11. 11. History of TB Scientific Discoveries in 1800s  Until mid-1800s, many believed TB was hereditary  1865 Jean Antoine- Villemin proved TB was contagious  1882 Robert Koch discovered M. tuberculosis, the bacterium that causes TB Mycobacterium tuberculosis Image credit: Janice Haney Carr
  12. 12. History of TB  Before TB antibiotics, many patients were sent to sanatoriums  Patients followed a regimen of bed rest, open air, and sunshine  TB patients who could not afford sanatoriums often died at home Sanatorium patients resting outside
  13. 13. Breakthrough in the Fight Against TB Drugs that could kill TB bacteria were discovered in 1940s and 1950s  Streptomycin (SM) discovered in 1943  Isoniazid (INH) and p-aminosalicylic acid (PAS) discovered between 1943 and 1952
  14. 14.  M. tuberculosis causes most TB  Mycobacteria that cause TB:  M. tuberculosis  M. bovis  M. africanum  M. microti  M. canetti  Mycobacteria that do not cause TB  e.g., M. avium complex M. tuberculosis TB Transmission Types of Mycobacteria
  15. 15. Natural history of TB Agent 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 European bacillus
  16. 16.  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
  17. 17. 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
  18. 18. TB Transmission Dots in air represent droplet nuclei containing M. tuberculosis
  19. 19. Incubation period  Ranges from 3-6 week
  20. 20. PATHOGENESIS Susceptible Or Mycobacterium Tuberculosis Latent Infection Recovery Reactivation Active tuberculosis Miliary tuberculosis Extrapulmonary Tuberculosis PULMONARY TUBERCULOSIS
  21. 21. Contribution of Mycobacterial Cellular Envelope to Pathogenesis Resistance to Drying and Other Environmental Factors - Thick, waxy nature of cellular envelope protects M. tuberculosis from drying, alkali conditions, and chemical disinfectants - Hinders entrance of antimicrobial agents Entry into Host Cells - Lipoarabinomannan (LAM) binds to mannose receptors on alveolar macropages leading to entry into the cell Interference of Host Immune Response - Glycolipids and sulfolipids decrease the effects of oxidative cytotoxic mechanism - Inhibition of phagosome and lysosome fusion inside macrophage - Waxy cellular envelope prevents acidification of the bacteria inside the phagosome
  22. 22. Common Symptoms of TB Disease  Cough (2-3 weeks or more)  Coughing up blood  Chest pains  Fever  Night sweats  Feeling weak and tired  Losing weight without trying  Decreased or no appetite  If you have TB outside the lungs, you may have other symptoms
  23. 23. Host Factor  AGE  Affects all ages  In India under 5 age group-1%  At the age of 15years-30%
  24. 24.  SEX  More prevalent in male then female  HEREDITY  It is not a hereditary disease
  25. 25.  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
  26. 26. 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
  27. 27. TB Infection vs. TB Disease  There is a difference between TB “infection” and TB “disease”  TB infection: TB germs stay in your lungs, but they do not multiply or make you sick  You cannot pass TB germs to others  TB disease: TB germs stay in your lungs or move to other parts of your body, multiply, and make you sick  You can pass the TB germs to other people
  28. 28. LTBI vs. TB Disease Latent TB Infection (LTBI) TB Disease (in the lungs) Inactive, contained tubercle bacilli Active, multiplying tubercle bacilli in the body in the body TST or blood test results usually positive TST or blood test results usually positive Chest x-ray usually normal Chest x-ray usually abnormal Sputum smears and cultures negative Sputum smears and cultures may be positive No symptoms Symptoms such as cough, fever, weight loss Not infectious Often infectious before treatment Not a case of TB A case of TB
  29. 29. Progression to TB Disease  Risk of developing TB disease is highest the first 2 years after infection  People with LTBI can be given treatment to prevent them from developing TB disease  Detecting TB infection early and providing treatment helps prevent new cases of TB disease
  30. 30. Progression to TB Disease Some conditions increase probability of LTBI progressing to TB disease  Infection with HIV  Chest x-ray findings suggestive of previous TB  Substance abuse  Recent TB infection  Prolonged therapy with corticosteroids and other immunosuppressive therapy, such as prednisone and tumor necrosis factor-alpha [TNF-α] antagonists  Organ transplant  Silicosis  Diabetes mellitus  Severe kidney disease  Certain types of cancer  Certain intestinal conditions  Low body weight
  31. 31. Progression to TB Disease People Exposed to TB Not TB Infected Latent TB Infection (LTBI) Not Infectious Positive TST or QFT-G test result Latent TB Infection May go on to develop TB disease Not Infectious Negative TST or QFT-G test result No TB Infection
  32. 32. TB Classification System Based on pathogenesis of TB Class Type Description 0 No TB exposure Not infected No history of TB exposure Negative result to a TST or IGRA 1 TB exposure No evidence of infection History of TB exposure Negative result to a TST (given at least 8- 10 weeks after exposure) or IGRA 2 TB infection No TB disease Positive result to a TST or IGRA Negative smears and cultures (if done) No clinical or x-ray evidence of active TB disease
  33. 33. TB Classification System Based on pathogenesis of TB Class Type Description 3 TB, clinically active Positive culture (if done) for M. tuberculosis Positive result to a TST or IGRA, and clinical, bacteriological, or x-ray evidence of TB disease 4 Previous TB disease (not clinically active) Medical history of TB disease Abnormal but stable x-ray findings Positive result to a TST or IGRA Negative smears and cultures (if done) No clinical or x-ray evidence of active TB disease 5 TB suspected Signs and symptoms of TB disease, but evaluation not complete
  34. 34. Sites of TB Disease Bacilli may reach any part of the body, but common sites include: Brain Lymph node Pleura Lung Spine Larynx Bone Kidney
  35. 35. Sites of TB Disease Location Frequency Pulmonary TB Lungs Most TB cases are pulmonary Extrapulmonary TB Places other than lungs such as: • Larynx • Lymph nodes • Pleura • Brain • Kidneys • Bones and joints Found more often in: • HIV-infected or other immunosuppressed persons • Young children Miliary TB Carried to all parts of body, through bloodstream Rare
  36. 36. Diagnosis and Treatment for Latent & Active TB Tools for Diagnosing TB Infection  Mantoux skin test (PPD)  Chest x-ray  Sputum cultures
  37. 37. TUBERCULIN TEST  Discovered by Von Pirquet(1907)  Three main test are currently in use  Mantoux intradermal test  Heaf test  Tine multiple puncture test
  38. 38. Diagnosis and Treatment for Latent & Active TB Tools for Diagnosing TB Infection Chest X-Ray  A chest x-ray is ordered when a person presents a recent skin test conversion and is suspected of having TB.  If a chest x-ray is normal, further diagnostic testing may not be necessary.
  39. 39. Diagnosis and Treatment for Latent & Active TB Tools for Diagnosing TB Infection Sputum  A sputum specimen is necessary to confirm that the TB bacteria is present in the lung.  The sputum specimens should: -come from deep within the lungs; -be obtained from the first coughed up sputum of the day, for 3 consecutive days -may be obtained through special respiratory therapy procedures.
  40. 40. 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
  41. 41.  Case finding tools  Sputum examination  Sputum smear examination Who also have problems like  persistant cough of about 3-4weeks  Continous fever  Chest pain  haemoptysis
  42. 42. Chemotherapy  Indicated for every case of active TB  Objectives are  Elimination of both the fast and slow multiplying bacilli  Mainly elimination of bacilli from patients sputum  Available for free of charge
  43. 43. Anti-tuberculosis drugs  An anti-tuberculosis drug should follow some criteria's like  Free from side effects  Highly effective  Easy to administrate  Reasonably cheap
  44. 44. 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
  45. 45. 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
  46. 46.  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
  47. 47.  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
  48. 48.  Pyrazinamide  Active against slow-multiplying intracellular bacilli  Drug given orally  Usual dose 30gm/kg body weight  Recommended in tuberculous meningitis
  49. 49. 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
  50. 50.  Thioacetazone  Companion drug to INH  Adult dose-2mg/kg body weight  Side-effect includes gastrointestinal disturbances, blurring of vision, haemolytic anaemia
  51. 51. 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
  52. 52. 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 because these are teratogenic (flouroquinolomes,ethionamide)
  53. 53. Childhood TB  TB in children present between 10-20% of all TB  Source 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
  54. 54.  Childhood TB is mainly due to failure in control of TB in adult  Under 5 age group-20%  The commonest age-1-4years
  55. 55. 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
  56. 56. AIM  Induce benign artificial primary infection  By stimulating an acquired resistance
  57. 57. 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
  58. 58. Types of vaccination  Two types of BCG vaccination  Liquid vaccination(fresh)  Freeze-dried vaccination(stable)
  59. 59.  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
  60. 60. 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
  61. 61. 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
  62. 62. Phenomena after vaccination  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
  63. 63.  complication  Prolonged severe ulceration  Supractive lymphadenitis  Osteomyelitis  Death
  64. 64. Revaccination Even 80 years after the development of the vaccine, it is not known whether booster doses are indicated or advisable Contraindication Generalized eczema, infective dermatosis, hypogammaglobulinaemia, to those with a history of deficient immunity Patient under immunosuppresent treatment and in pregnancy
  65. 65.  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
  66. 66. Impact  BCG is less effective than the chemotherapy BCG 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
  67. 67. 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
  68. 68. 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
  69. 69.  Drugs resistance  All drugs used in TB produce resistance  Resistance may be of two types  Pretreatment resistance  Acquired resistance
  70. 70. 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”.
  71. 71. 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
  72. 72.  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
  73. 73. 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
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. Management and prevention through IAYT
  78. 78. IAYT approach ANNAMAYA PRÁNAMAYA MANÔMAYA VIJÒÁNAMAYA ÁNANDAMAYA
  79. 79.  There are 5 layers of existence 1 Annamaya kosha 2 Pranamaya kosha 3 Manomaya kosha 4 Vijanamaya kosha 5 Anadamaya kosha
  80. 80. Aims and objectives  Improves immune system  Reduce the infection  Reduce the symptom scores  Giving them a healthy life  Reduce the resistance to the medicine
  81. 81. 1 Annamaya kosha  Diet  Kriya  Asana  Cyclic meditation
  82. 82. DIET •Mastery over mind •Better mastery over appetite & satisfaction APPETITE SATIETY
  83. 83.  Tuberculosis is said to be a diseases of calcium deficiency  Exclusive fresh fruit diet with milk  Banana should be avoided  Give more citrus fruits  Custard apple – effective food
  84. 84. KRIYAS  Laghusankha prakshalana  Vamana dhauti  Jala neti
  85. 85. ASANA Mandukasana Ardha matsyendrasna sarvangasana viparitakarani
  86. 86. Cyclic Meditation Aim -Stimulation and deep rest Reduces stress improve immunity
  87. 87. 2.Pranamaya kosha  Disturbed prana balance in disease  Nadi suddhi prnayama  Bharamari  Surya anuloma viloma pranayama
  88. 88.  Advance technique  PET
  89. 89. Manomaya kosha  Darana  Dhayna  Emotional culture ( bhajan , satsang )
  90. 90.  Advance technique  MSRT  MIRT  MEMT
  91. 91. 4. Vijanamaya kosha  Notional correction  Happiness analysis  Study  counselling  Adnance technique  VISAK – vijana sadhana kausala
  92. 92. 5 Anadamaya kosha  Karma yoga (action with bliss)  Yogic games  Advance technique  ANAMS- ananda amruta sinchana
  93. 93. complementary role for yoga in the management of pulmonary tuberculosis  yoga group showed a significant reduction in symptom scores(88.1%), and an increase in weight (10.9%), FVC (64.7%) and FEV(83.6%)  breath awareness group also showed a significant (paired t-test) reduction in symptom scores (16.3%), and an increase in weight (2.1%) and FEV(63.8%)
  94. 94.  Ten of 13 in the yoga group had negative sputum culture after 60 days compared with four of 19 in the breath awareness group  Improvement in the radiographic picture occurred in 16/25 in the yoga group compared to 3/22 in the breath awareness group on day 60
  95. 95. Thank You…

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