Prepared by:

Mecor M. Riego BSM III

TUBERCULOSIS

What You Need to Know About Tuberculosis (TB)

The TB Scenario

Defining TB: Cause, Transmission, and Manifestations

Risk of TB infection

Diagnosing Pulmonary Tuberculosis

TB Treatment and Cure

Preventing transmission

Proper Management of TB cases

DOH: National Tuberculosis Program (NTP)

TB Burden in the World

9 million people fell ill with TB in 2013, including 1.1 million cases among people living with HIV.

In 2013, 1.5 million people died from TB, including 360 000 among people who were HIV-positive.

Source: ww.who.int

Tuberculosis is a major public health problem in the Philippines. In 2010, TB was the 6th leading cause of mortality with a rate of 26.3 deaths for

every 100,000 population and accounts for 5.1% of total deaths. More males died (17,103) compared to females (7,611). An estimated 200,000 to 600,000 Filipinos have active TB.  Out of 196 countries, the Philippines has the distinction of being included in the top 22 high-burden tuberculosis countries in the world. This report is according to the World Health Organizations (WHO), which ranks the Philippines at number nine worldwide. Together, these 22 countries (including the Philippines) contribute 80 percent of the global TB burden. Seventy-five (75) Filipinos die of TB every day, most of them in the prime of their life.  If untreated, a person with tuberculosis can transmit the TB bacteria to as many as 10 to 15 people during the course of one year, who, in turn, may develop the disease.

What is Tuberculosis?Tuberculosis (TB) is an infection caused by bacteria that usually affect the lungs. These bacteria, called Mycobacterium tuberculosis, can be passed on to another person through tiny droplets spread by coughing and

9 million people fell ill with TB in 2013, including 1.1 million cases among people living with HIV.

In 2013, 1.5 million people died from TB, including 360 000 among people who were HIV-positive.

TB Burden in the Philippines

sneezing. Even the accidental spread of saliva through laughing, singing, and spitting can pass on the TB bacteria.

The Tubercle Bacilli or Mycobacterium Tuberculosis is the bacteria that cause Tuberculosis. It can be seen under the microscope as red rods. The TB germ, as it is also called, is slow growing, thus no immediate signs and symptoms can be seen in an infected person. It is only when the TB germ multiplies in number that the TB infection will develop into a TB disease. When this happens, signs and symptoms will be manifested. The TB germ can easily be killed when exposed to direct sunlight.

How it is TRANSMITTED?

A person with TB can transmit the bacteria when he or she coughs and/or sneezes, laughing, shouting. The TB germ is airborne, thus inhalation of droplets from a person with TB may cause TB infection. Invasion may occur through mucous membranes or damaged skin.

But is should be emphasized that being TB infected does not absolutely lead to TB disease.

How Are TB Germs NOT Spread?

Through quick, casual contact, like passing someone on the street By sharing utensils or food By sharing cigarettes or drinking containers By exchanging saliva or other body fluids By shaking hands Using public telephones

1. TB bacilli enters the body and lodges in the lungs (TB Infection).2. In the lungs, they multiply and slowly eat the cells and the body begins to

experience symptoms (TB Disease)3. If undiagnosed, lungs cells are eaten up leading that may lead death.

TB INFECTION vs. 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.

How does PTB develop?

A person is

infected after

inhaling

droplets

from a person

with TB

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

Persistent cough for at least 2 weeks Chest pains/ Back Pains (breathlessness) Persistent low grade fever for more than a month significant weight loss with or without

loss of appetite Hemoptysis (Blood-tinged sputum) Feeling of weakness (tiredness) Night Sweats

Treatment for TB Disease

o TB disease is treated with medicine to kill the TB germs.

o Usually, the treatment will last for 6-9 months.

o TB disease can be cured if the medicine is taken as prescribed, even after you no longer feel sick.

o The treatment for TB is a combination of 3-4 anti-TB drugs. 

o NEVER should we prescribe a SINGLE DRUG for TB treatment!  This will worsen the patient's

condition.o Drug formulations

1. Fixed–dose combination (FDCs) – Two or more first-line anti-TB drugs are combined in one tablet. There are 2-, 3-, or 4-drug fixed-dose combinations, namely: HR, HRE and HRZE. These are usually provided in kits with boxes of blister packs corresponding to treatment phases of an average-weight patient.

o 2. Single drug formulation (SDF) – Each drug is prepared individually, either as tablet, capsule, syrup or

injectable (Streptomycin) form.

Who are at risk of getting TB?

People who share the same breathing space with someone who has infectious TB Health workers, especially those working in long-term facilities (prison, sanitariums, etc.) People who are infected with HIV are 26 to 31 times more likely to become sick with TB Risk of active

TB is also greater in persons suffering from other conditions that impair the immune system. People exposed to silica and those with jobs that compromise the respiratory system (mine workers) People underweight and malnourished (esp. Children) Alcoholics and IV drug users Tuberculosis mostly affects young adults, in their most productive years. However, all age groups are at

risk. Over 95% of cases and deaths are in developing countries. Over half a million children (0-14 years) fell ill with TB.

What are the signs and symptoms of TB?

Tobacco use greatly increases the risk of TB disease and death. More than 20% of TB cases worldwide are attributable to smoking.

How is TB diagnosed?

1. Sputum Microscopy It shows the TB bacilli in the sputum. It is the most definitive diagnostic tool of Tuberculosis.

2. Chest X-Ray Determines extent of the lung damage Not a very definitive diagnostic tool

How is TB cured?

TB can be cured.DOTS (Directly-Observed Treatment Short Course) is the recommended strategy to cure TB. It ensures the right combination and dosage of anti-TB drugs. It ensures regular and complete intake of anti-TB drugs.Patient takes drugs every day with the help of a treatment partner.

With proper treatment…

We want to treat patients with DOTS:To make them get well as soon as possibleTo make them stop spreading the disease onto others in the communityTo avoid complications and multi-drug resistance (MDR)

How can TB be prevented?

BCG vaccination for infants (newborn to 1 year old). This gives 80-85% protection against development of complicated TB among children;

Hygienic practices like covering the mouth when coughing and sneezing; and

Early diagnosis and treatment of TB infectious cases to stop transmission

Maintain open air circulation inside the house

Have enough sleep

Eat nutritious food that boost the immune system

Avoid smoking, drinking alcohol, and use of prohibited drugs

What are some misconceptions about TB?

What is DOTS?

D.O.T.S stands for Directly-Observed Treatment Short Course.

- It is a comprehensive strategy endorsed by the World Health Organization (WHO) and International Union Against Tuberculosis and Lung Diseases (IUATLD) to detect and cure TB patients.

5 Components of TB-DOTS Program

1. Political commitment with increased and sustained financingLegislation, planning, human resources, management, training

2. Case detection through quality-assured bacteriologyStrengthening TB laboratories, drug resistance surveillance

3. Standardized treatment with supervision and patient supportTB treatment and programme management guidelines, International Standards of TB Care (ISTC), PPM, Practical Approach to Lung Health (PAL), community-patient involvement

4. An effective drug supply and management systemAvailability of TB drugs, TB drug management, Global Drug Facility (GDF), Green Light Committee (GLC)

5. Monitoring and evaluation system and impact measurementTB recording and reporting systems, Global TB Control Report, data and country profiles, TB planning and budgeting tool, WHO epidemiology and surveillance online training

The National TB Control Program (NTP) in the PHILIPPINES

The NTP is one of the public health programs being managed and coordinated by the Infectious Diseases for Prevention and Control Division (IDPCD) of the Disease Prevention and Control Bureau (DPCB) of the DOH. The NTP has the mandate to develop TB control policies, standards and guidelines, formulate the national strategic plan, manage program logistics, provide leadership and technical assistance (TA) to the lower health offices/units, manage data, and monitor and evaluate the program. The program’s TB diagnostic and treatment protocols and strategies are in accordance with the global strategy of STOP TB Partnership and the policies of World Health Organization (WHO) and the International Standards for TB Care (ISTC).

Roles and Functions of a Midwife in the NTP

Under the supervision of a Nurse do the following;- Identify presumptive TB patients and ensure proper collection and transport of sputum specimen.- Refer all diagnosed TB patients to physician and nurse for clinical evaluation and initiation of treatment.- Maintain and update NTP treatment cards.- Provide continuous health education to patients.- Supervise intake of anti-TB drugs.- Collect sputum for follow-up examination.- Report and retrieve defaulters within 2 days.- Refer patients with adverse reactions to physician for evaluation and management.- Supervise and mentor treatment partners.

Classifications of TB Disease

1. Classification based on bacteriological status

a. Bacteriologically-confirmed – A TB patient from whom a biological specimen is positive by smear microscopy, culture or rapid diagnostic tests (such as Xpert MTB/RIF [GeneXpert Mycobacterium tuberculosis/Rifampicin assay]).

b. Clinically-diagnosed – A PTB patient who does not fulfill the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment. This definition includes cases diagnosed on the basis of CXR abnormalities or suggestive histology, and extra-pulmonary cases without laboratory confirmation.

2. Classification based on anatomical site

a. Pulmonary TB (PTB) – Refers to a case of tuberculosis involving the lung parenchyma. A patient with both pulmonary and extra-pulmonary TB should be classified as a case of pulmonary TB.

b. Extra-pulmonary TB (EPTB) – Refers to a case of tuberculosis involving organs other than the lungs (e.g., larynx, pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, meninges). Histologically-diagnosed EPTB through biopsy of appropriate sites will be considered clinically-diagnosed TB. Laryngeal TB, though likely sputum smear-positive, is considered an extrapulmonary case in the absence of lung infiltrates on CXR.

Classification based on drug-susceptibility testing

a. Monoresistant-TB – Resistance to one first-line anti-TB drug only.

b. Polydrug-resistant TB – Resistance to more than one first-line anti-TB drug (other than both Isoniazid and Rifampicin).

c. Multidrug-resistant TB (MDR-TB) – Resistance to at least both Isoniazid and Rifampicin.

d. Extensively drug-resistant TB (XDR-TB) – Resistance to any fluoroquinolone and to at least one of three second-line injectable drugs (Capreomycin, Kanamycin and Amikacin), in addition to multidrug resistance.

e. Rifampicin-resistant TB (RR-TB) – Resistance to Rifampicin detected using phenotypic or genotypic methods, with or without resistance to other antiTB drugs. It includes any resistance to Rifampicin, whether monoresistance, multidrug resistance, polydrug resistance or extensive drug resistance.

TB drugs used to treat drug resistant TB according to group (class)

Group 1 TB drugs: First Line Oral Agents Pyrazinamide Ethambutol

Rifampicin

Group 2 TB drugs: Injectable Agents Kanamycin Amikacin Capreomycin Streptomycin

Group 3 TB drugs : Fluoroquinolones Levofloxacin Moxifloxacin Ofloxacin

Group 4 TB drugs: Oral Bacteriostatic Second Line Agents Para–aminosalicylic acid Cycloserine Terizidone Thionamide Protionamide

Group 5 TB drugs: Agents with an unclear role in the treatment of drug resistant TB Clofazimine Linezolid Amoxicillin/clavulanate Thioacetazone Imipenem/cilastatin High dose isoniazid Clarithromycin

Classification of Patients in Categories for Standardized Treatment Regimen

DOTS is THE MOST EFFECTIVE STRATEGY available for controlling the worldwide TB epidemic today.

References;

http://www.doh.gov.ph/sites/default/files/NTCP-MOP.pdfhttp://www.who.int/tb/en/http://www.tbfacts.org/tb-drugs/