TB Lecture Notes PDF

TUBERCULOSIS  Session 1: Understanding the Basic Facts of Tuberculosis What is Tuberculosis? Caused by a bacteria, Mycobacterium tuberculosis Discovered by Robert Koch in March 24, 1882 Affects the lungs most often (pulmonary); other parts of the body such as bones, intes...

TUBERCULOSIS  Session 1: Understanding the Basic Facts of Tuberculosis What is Tuberculosis? Caused by a bacteria, Mycobacterium tuberculosis Discovered by Robert Koch in March 24, 1882 Affects the lungs most often (pulmonary); other parts of the body such as bones, intestines, kidney, meninges of the brain, liver, etc., may also be affected (extra- pulmonary)  A Pulmonary TB patient whose sputum is positive for TB bacilli may spread the disease to about 10-20 persons in one year. Tubercle bacilli Opportunistic Very sensitive to direct sunlight (can be killed in 5 minutes), may survive in the dark for years Can be destroyed in 20 mins at 60 degrees and 5 mins at 70 degrees Celsius How is TB spread to other people? Through air Transmitted by aerosol / droplet, inhalation through coughing/sneezing a person with TB Droplets inhaled by susceptible people Within a year, a smear positive patient can infect 10 – 20 people in the community Who are affected by Tuberculosis? Affects all ages most common among the productive years 15-55, affects men more than women. TB Cases Detected by Gender, DOH; 2004-2008 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2004 2005 2006 2007 2008 Male Female  New Sm(+)’s By Gender and Age Groups (DOH 2004 to 2008) 0-14 15-24 25-34 35-44 45-54 55-64 >65 Female Male 2008 Female Male 2007 Female Male 2006 Female 2005 Male Female 2004 Male 0 10000 20000 30000 40000 50000 60000 70000 The Philippines is one of the high TB burden countries, and the fourth major contributor of people who developed TB in 2021. Incidence of TB is estimated to be higher in men than women (519,000 per year vs. 222,000 per year). This ratio of 2.34 male-to-female exceeds the ratio of reported incident cases in the 2022 WHO Global TB Report, which was only 2.0. Signs and Symptoms COUGH, productive or not, of two weeks or more, with or without: Loss of weight, appetite Chest and/or back pain Low Grade Fever usually in the afternoon Blood streaked sputum Body weakness There are cases of asymptomatic TB Diagnosis Sputum examination 3 specimens within 2 days 1st sample: initial consultation in the health center (Day 1) 2nd sample: early morning (Day 2) 3rd sample: in the health center when the 2nd sample was submitted to the health center (Day 2) Chest X-Ray can be done after a negative sputum exam. How to prevent TB transmission? Ensuring good ventilation Maintaining a clean environment Consulting a physician regularly Eating healthy food Exercising regularly Practicing the right way to cough using the UBOkabularyo guide UBOkabularyo guide BCG Bacillus-Calmette-Guerin Given at birth Can give 80% protection for 15 years if given before first infection. How to treat TB? Treated with four to five anti-TB drugs Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) With standard treatment regiment ranging from 6 to 8 months Coupled with a healthy lifestyle What is MDR-TB? MDR TB stands for Multi- Drug Resistant TB More severe form of TB caused by a stronger TB Bacilli that do not respond to ordinary anti-TB drugs used to treat TB Requires 18-24 months of treatment Treatment done only in designated Treatment Centers strictly under DOTS Strategy What is MDR-TB? - At least isoniazid and rifampicin - Isoniazid and rifampin are the two most potent TB drugs. This drugs are used to treat all persons with TB disease. What is XDR-TB? - Resistance to isoniazid and rifampicin + Flouroquinolone and atleast one injectable second- line drugs (amikacin, kanamycin, capreomycin). - XDR-TB is for special concern for persons with HIV or other diseases that weakens the immune system. Current Status: (DOH) Philippines 9th among the 22 high burdened countries (HBCs) worldwide – Global TB Control Report 2009 4th in Case Notification Rate (TB all forms) amongst the WPRO countries – TB Control in the Western Pacific Region, 2009 Report 8th among 27 priority countries with highest number of MDR-TB cases TB is 6th in mortality and morbidity – FHSIS Report 2007 TB Situation 75 Filipinos die of TB each day One third of the Filipinos are infected with the TB Bacilli. Frequently Asked Questions Is TB hereditary? TB is not hereditary. Bacteria causing TB come from air droplets from a person with TB when he/she coughs, sneezes or spit. However, it is infectious such that household members of TB patients are at risk of acquiring the disease. Can a person die of TB? Yes, if treatment is not started early enough and if a patient does not finish the treatment regimen. Does TB afflict only the thin, the elderly, or the poor people? No. Everybody is at risk of getting TB. Those with higher risk are the malnourished, immuno- compromised (HIV-infected, diabetic, cancer patients), and those in contact with patients who are sputum smear-positive. Can one contract TB from doing heavy work? No. However, if heavy work leads to a lowering of body resistance, a person becomes susceptible to the disease. Can a person contract TB from too much drinking or smoking? No, but excessive drinking or smoking may weaken a person’s body resistance, making him/her susceptible to the disease. Is there a need to separate the personal belongings, especially utensils, of the TB patient?  Is there a need to separate the personal belongings, especially utensils, of the TB patient? There is no need to do so, because TB in transmitted through inhalation (not ingestion) of aerosol.  Can a patient breastfeed while on treatment? A woman taking anti-TB drugs can continue to breastfeed. All anti-TB drugs are compatible with breastfeeding. A breastfeeding woman with TB should receive a full course of anti-TB treatment. BCG vaccination should be given to the infant immediately at birth.  Can pregnant women take anti-TB drugs? Most anti-TB drugs are safe for pregnant women, except Streptomycin, which can cause ototoxicity (deafness) to the fetus.  Is it alright for a patient on pills to take anti-TB drugs? A woman taking anti-TB drugs while on pills/oral contraceptives has two options: 1) Take an oral contraceptive pill containing a higher dose of estrogen, following consultation with a clinician; 2) Use another form of contraception. Rifampicin may decrease oral contraceptive’s protective efficacy against pregnancy.  Can a cured TB patient contract TB again? Yes, if he/she inhales TB bacilli when the body resistance is low.  Can a TB patient engage in sex? Yes. In most cases, a patient is no longer infectious after two weeks of proper medication.  Can a TB patient go back to work? Yes, after 2-3 weeks of treatment, patient is usually non-infectious. It is advised that before patient reports back to work, he/she should undergo sputum examination and is smear negative.  BATANGAS CURE RATE & CASE DETECTION RATE (2006-2010) 90 80 70 60 50 CD 40 R CR 30 20 10 0 2006 2007 2008 2009 2010  Distribution of Municipalities by Case Detection Rate and Cure Rate 2010 Report 180 HIGH CDR - LOW CR HIGH CDR - HIGH CR 160 140 Case Detection Rate (in Percent) 120 Cuenca 100 Balete Balayan 80 Nasugbo Sto. Tomas Lemery 60 Rosario AgoncilloCalatagan Calaca Lian Taal Batangas Prov Mabini Alitagtag CHO-Batangas Mataas na Bahay Lobo 40 Laurel San Nicolas Padre Garcia San Jose Bauan Ibaan 20 Lipa Taysan LOW CDR - LOW CR LOW CDR - HIGH CR - - 10 20 30 40 50 60 70 80 90 100 Cure Rate (in Percent)  Low CDR - Low CR Municipality CDR CR 1. Alitagtag 47 67 2. Agoncillo 54 79 3. Batangas City 46 78 4. Ibaan 37 75 5. Lemery 64 61 6. Lipa City 21 42 7. Mabini 49 82 8. Mataas na Kahoy 45 61 9. San Luis 69 72 10. Sta. Teresita 9 0 11. Sto. Tomas 63 36  Low CDR - High CR Municipality CDR CR 1. Bauan 41 88 2. Calaca 60 87 3. Calatagan 51 95 4. Laurel 41 100 5. Lian 53 100 6. Lobo 43 100 7. Malvar 47 94 8. Padre Garcia 37 93 9. Rosario 59 100 10. San Jose 34 100 11. San Nicolas 40 100 12. San Pascual 32 100 13. Taal 50 88 14. Talisay 72 86 15. Taysan 16 100 16. Tingloy 57 100 17. Tuy 57 93 18. Tanauan 52 90  High CDR - Low CR Municipality CDR CR 1. Balayan 83 79 2. Cuenca 121 61 3. San Jose 79 79 4. Nasugbu 80 65  High CDR High CR Municipality CDR CR 1. Balete 87 91  Session 2 NTP 101 Importance of the National TB Program What is NTP? It stands for National Tuberculosis Program It is the Government's commitment to address the TB problem in the country. The NTP is being implemented nationwide in all government health centers, government hospitals and selected private institution. Its objectives are to detect active TB cases (at least 70%) and cure them (at least 85%). Achieving and sustaining targets will eventually result to the decline of the TB problem in the Philippines.  Vision, Mission and Goal of NTP A country Ensure that TB-DOTS To reduce where TB is no Services are available, mortality and longer a public accessible and morbidity from TB health problem affordable to the by half by the year communities in 2015 collaboration with the LGUs and other partners Goal Vision Mission  NTP Targets (70/85) Case Detection Effective Increase Rate to 70 % or more TB Control Efforts through Cure Rate to 85% DOTS Increase or more Strategy 5 Elements of DOTS Strategy Sustained political commitment Access to quality-assured TB sputum microscopy Standardized short-course treatment for all TB cases under proper case management conditions (DOT), technically sound and socially supportive treatment services Uninterrupted supply of quality-assured drugs Recording and reporting system that enables the assessment of each patient’s treatment outcome and that of the program’s performance Major Components of NTP I. Case Finding II. Case Holding I. Case Finding Is the identification and diagnosis of TB cases among individuals with suspected signs and symptoms of TB ▪ It is the basic step in TB control. Objective – early identify & diagnose TB cases Types: ▪ Passive case finding – finding TB cases among TB symptomatics who consults TB DOTS facility ▪ Active case finding – purposive action/effort to find TB cases who do not consult TB DOTS facility  Flow of NTP Activities - Workplace COMMUNITY/WORKPLACE Case Finding IDENTIFY AND REFER: TB Symptomatic case DOTS FACILITY Asymptomatic PTB with abnormal Chest X-ray Finding MICROSCOPY CENTER Diagnosis EVALUATE & RECOMMEND referred DSSM smear TBDC negative with chest x-ray suggestive of PTB Initiation of Treatment One sputum specimen with Laboratory Request Form for DSSM every 2 Holding months (as scheduled) Case MICROSCOPY CENTER Results (DSSM for follow-up) Treatment Completion Report Treatment Outcome / Request Supplies Monitoring and Supervision I. Case Finding TB symptomatic case – any person with cough for 2 or more weeks with or without the following symptoms ▪ Fever ▪ Chest and/back pains not referable to any musculoskeletal disorders ▪ Hemoptysis or recurrent blood-streaked sputum ▪ Significant weight loss ▪ Other symptoms oSweating, fatigue, body malaise, shortness of breath NTP 101 Challenge: “TRUTH or LIE” Direct sputum smear microscopy is the basic test needed in diagnosing pulmonary TB. TRUTH or LIE? FACTS Direct Sputum Smear Microscopy (DSSM) ▪ Principal diagnostic method/tool in NTP case finding because : ✓It provides a definitive diagnosis of active TB ✓The procedure is simple ✓It is economical ✓A microscopy center could be put up even in remote areas ▪ Only trained medtechs or microscopists shall perform DSSM. However, in far flung areas, BHWs or other community health volunteers may be allowed to do smearing and fixing specimens, as long as they have been trained and are supervised by their respective NTP MedTech/microscopist TB suspects should be referred to any laboratory for direct sputum smear microscopy. TRUTH or LIE? FACTS All TB symptomatics identified shall be asked to undergo DSSM for diagnosis before start of treatment, regardless of whether or not they have available x-ray results or whether or not they are suspected of having Extrapulmonary TB ▪ The only contraindication for sputum collection is hemoptysis; in which case, DSSM will be requested after control of hemoptysis Direct sputum smear microscopy requires three early morning specimens. TRUTH or LIE? FACTS For Diagnosis: 3 sputum specimens taken/collected w/in 2 days ▪ 1st specimen – “spot specimen” – collected at the time of consultation in TB DOTS facility ▪ 2nd specimen – very first sputum produced early in the morning immediately after waking up – collected by patient in the house ▪ 3rd specimen – “2nd spot specimen” – collected in TB DOTS facility when the patient comes back to submit the 2nd specimen 1st and 3rd sputum specimen collections are supervised by the TB DOTS facility staff to ensure quality sputum specimen collection If patient fails to complete the 3 specimen collection within one week, another set of 3 should be collected FACTS For Diagnosis: 3 sputum specimens taken/collected w/in 2 days ▪ Sputum cup for sputum specimen collection is provided by TB DOTS facility ▪ “QUALITY sputum specimen” – phlegm, mucoid ▪ Instruction how to collect/produce quality sputum 1. Rinse mouth with water 2. Breathe deeply thru the nose, hold breath, then exhale slowly thru the mouth (Done twice) 3. Breathe deeply thru the nose, hold breath, then cough strongly at the height of deep inspiration and spit the sputum/phlegm in the container ▪ Label body of sputum cup indicating patient’s complete name and order of specimen (1st, 2nd, or 3rd) ▪ Observe precautions against infection during the demonstration. Stay behind the patient. Collect specimen outside the facility. DSSM positive cases should be referred to a physician primarily for close contacts investigation in their household. TRUTH or LIE? FACTS DSSM Smear (+) cases ▪ DSSM results serve as bases for: ✓categorizing TB symptomatics according to standard case definition ✓Proper treatment regimen ✓Monitoring progress of patients with sputum smear (+) TB while on anti-TB treatment ✓Confirming cure at the end of anti – TB treatment ▪ Smear (+) cases are the basis for tracing TB illness among children and other family members Smear negative PTB cases are routinely treated with anti-TB drugs immediately after the DSSM result. TRUTH or LIE? FACTS DSSM Smear (-) cases ▪ TB symptomatics shall be asked to undergo other diagnostic tests (chest x-ray and / or culture), if necessary, only after they have undergone DSSM for diagnosis with 3 sputum specimens yielding negative results. ▪ If the chest x-ray result is suggestive of Pulmonary TB, the TB DOTS facility will refer the patient’s case and submit necessary documents (complete case history, DSSM results and chest x- ray film of the patient) to the TBDC for further evaluation. Referral to TBDC would reduce over- diagnosis and over-treatment of symptomatic smear positive cases. TRUTH or LIE? FACTS TBDC ▪ Evaluates the results of the chest x-ray film reading together with the complete history and findings ( Smear negative with x-ray suggestive of Pulmonary TB cases only) ▪ Recommends to TB DOTS facility whether or not the case will be started on treatment ▪ Composition ▪ NTP Medical Coordinator ▪ Radiologist ▪ Clinician/Internist/Pulmonologist ▪ NTP Nurse Coordinator How to confirm TB cases? Ask the symptoms –TB Symptomatic – presence of chronic cough lasting of 2 or more than 2 weeks –TB Asymptomatic– absence of cough with or without associated other symptoms Common among workers and applicants with accidental finding on Chest X-ray Collect sputum specimen for –Direct Sputum Smear Microscopy(DSSM) –Sputum Culture & Drug Sensitivity Testing for M. Tuberculosis Refer cases for chest X-ray, if negative for DSSM FLOW CHART FOR TB Symptomatic THE DIAGNOSIS OF (cough for 2 weeks or more) PULMONARY TB Three (3) sputum collection A. 2 or 3 Smear-Positive B. Only one (1) Smear-Positive C. All 3 Smear-Negative Classify as Collect another 3 sputum Refer to Physician Smear Positive PTB Specimens Immediately (observe him/her with Symptomatic Treatment for 2 to 3 weeks) If at least one (1) Smear-Positive If all smear-Negative If symptoms persist, request for CXR Classify as Smear-Positive TB Request for CXRay (Refer to the flow chart on the next page) If consistent with active TB If not consistent with active TB Classify as smear-positive TB Observation/further exam., If necessary  C. All 3 Smear-Negative Refer to Physician Process Flow in (Symptomatic Tx for 2-3 wks) Diagnosing of Smear Negative PTB If symptoms persist, request for CXR Abnormal No Abnormal findings on findings on CXR CXR TB Diagnostic Observation/ Committee further exam. Non Consistent Consistent with active TB with active TB Classify as Observation/ Smear- further exam. Negative TB I. Case Finding Summary Fundamental to case finding is the detection of infectious cases through DSSM - Sputum smear (+) The most common symptoms of pulmonary TB is cough of 2 or more weeks with or without other signs/symptoms. – The associated symptoms can be remembered as FEWBANS for fever, easy fatigability, weight loss, blood –tinged phlegm/back pain, anorexia, night sweating and shortness of breath. Advise all TB suspects to submit 3 QUALITY sputum specimens for DSSM for diagnosis. Smear negative PTB with x-ray suggestive of pulmonary TB should be referred to TBDC prior to treatment. Household members of identified TB cases who are also TB symptomatics should be encouraged to undergo DSSM Major Components of NTP II. Case Holding  Flow of NTP Activities - Workplace COMMUNITY/WORKPLACE IDENTIFY AND REFER: TB Symptomatic case Asymptomatic PTB with abnormal Chest X-ray Finding Case Finding 3 Sputum specimens with NTP Laboratory Request Form For Direct Sputum Smear Microscopy (DSSM) DOTS FACILITY MICROSCOPY CENTER Diagnosis TBDC recommended for EVALUATE & RECOMMEND referred (+) DSSM treatment of (-) DSSM w/ (+) X-ray TBDC DSSM smear negative with chest x- ray suggestive of PTB Initiation of Treatment Holding One sputum specimen with Laboratory Request Form for DSSM every 2 months (as scheduled) Case MICROSCOPY CENTER Results (DSSM for follow-up) Treatment Completion Report Treatment Outcome / Request Supplies Monitoring and Supervision The aim of case holding is to cure TB cases after six months of treatment. TRUTH or LIE? II. Case Holding Is the procedure which ensures that patients complete their treatment Objective – effective and complete treatment of TB cases, esp. pulmonary sputum smear positive cases Classification of TB cases ▪ based on the location of lesions and DSSM result Types of TB Cases ▪ based on history of anti-TB treatment Types of Treatment Outcome ▪ based on the result of current treatment Classification of TB Case Location of DSSM Definition Lesion Result Patient w/ at least 2 DSSM (+) results, w/ or w/out x-ray abnormalities consistent w/ active TB OR Patient w/ 1 sputum specimen (+) for AFB & w/ x-ray abnormalities consistent w/ active Smear (+) pulmonary TB as determined by the doctor OR Pulmonary TB Patient w/ one sputum specimen positive for AFB & sputum culture positive for (PTB) Mycobacterium tuberculosis Patient w/ at least 3 sputum specimen is negative for AFB w/ x-ray abnormalities consistent w/ active pulmonary TB & there has been no response to a course of antibiotic Smear (-) &/or symptomatic medications, & there is a decision by a doctor &/or TBDC to treat the patient w/ a full course of anti-TB chemotherapy Extra- Patient w/ at least one mycobacterial smear/culture positive from EP site OR Pulmonary TB Patient w/ histological &/or clinical evidence consistent w/ active EP TB & a decision by a doctor to treat (EP) the patient w/ anti-TB drugs Types of TB Cases Types Definition New Patient who has never had treatment for TB or who has taken anti-TB drugs for less than one month Relapse Patient previously treated for TB, who has been declared cured or treatment completed & is diagnosed w/ bacteriologically (+) TB (smear or culture) Treatment Patient ongoing treatment, is sputum smear positive at 5th month or later during the course of Failure treatment Return After Patient returning to treatment w/ positive smear or culture ff interruption of treatment for 2 months Default (RAD) or more Transfer – In Patient transferring from another facility adopting NTP policies w/ proper referral slip to continue treatment Other Patient who do not fit into any of the above 1. Other (+) – from new smear (-) to smear (+) during treatment 2. Other (-) – interrupted treatment for 2 or more months & remains smear negative 3. Chronic cases – remains smear (+) at the end of a re-treatment regimen FACTS All patients undergoing treatment shall be supervised (DOT). ▪ No patient shall initiate treatment unless the patient and the TB DOTS facility have agreed upon a case holding mechanism for treatment compliance Aside from clinical findings, treatment of all TB cases shall be based on a reliable diagnostic technique “DSSM” Domiciliary treatment shall be the preferred mode of care National and Local government units shall ensure provision of drugs to all smear-positive TB cases Quality of anti-TB drugs must be ensured FACTS Treatment shall be based on recommended category of treatment regimen Category Types of TB Patient TB Treatment Regimens Intensive Phase Cont. Phase 1 New Smear (+) PTB 2HRZE 4HR New Smear (-) PTB with extensive parenchymal lesions on x- ray (FDC-A) (FDC-B) EPTB; severe concomitant HIV disease II Treatment failure Relapse 2HRZES 5HRE Return-after default (RAD) Other 1HRZE III New Smear (-) PTB with minimal X-ray findings 2HRZE 4HR IV Chronic Case Refer to PHO/CHO or specialized DOTS Plus Center (PMDT)** Legend: R-Rifampicin, H-Isoniazid, Z-Pyrazinamide, E-Ethambutol, S-Streptomycin *PMDT- Programmatic Management of Drug-resistant Tuberculosis FACTS Chronic cases who are still smear-positive after a supervised re- treatment are considered as suspect multi-drug resistant TB cases They are referred to PMDT treatment facilities for further evaluation and management MDR TB – is a condition which is resistant against at least Isoniazid and Rifampicin The duration of MDR treatment ranges 1 – 2 years FACTS Schedule of DSSM Follow-Up 1st Sputum 2nd Sputum 3rd Sputum Follow-up Category Follow-up Exam Follow-up Exam Exam Towards end of Towards end of I 2nd month 4th month Beginning of 6th month Towards end of Towards end of II 3rd month 5th month Beginning of 8th month Towards end of III 2nd month Possible Side-Effects of Anti-TB Drugs Side Effects Drug(s) Responsible What To Do? Major Side Effects: Discontinue taking medicines and refer to MHO/CHO/Physician immediately Severe skin rash Any kind of drug (esp. Discontinue and refer streptomycin) Jaundice due to hepa Any kind of drug (esp. HRZ) Discontinue and refer. If symptoms subside, resume treatment and monitor. Impairment of visual acuity and color Ethambutol Discontinue and refer to vision opthalmologist Hearing impairment Steptomycin Discontinue strep and refer Summary Case holding requires 6-8 months of treatment through DOTS Strategy using 4-5 drugs TB cases can be classified as Pulmonary TB (PTB) if located in the lungs or Extra Pulmonary TB (EPTB) if found in other organs. Category of treatment is based on WHO recommendation All TB cases who developed side effects should be referred to the health service provider for advise, reassurance or treatment. DSSM follow-up must be done regularly as scheduled. Summary Chemotherapy is currently the only way to stop the transmission of TB Effective anti-TB drugs are available in TB DOTS facility Once a TB patient is registered for treatment in a TB DOTS facility he/she has a complete anti-TB drug supplies provided from the start of treatment Poor treatment compliance may lead to worst outcomes DOT (Directly Observed Treatment) is a strategy to ensure treatment compliance of TB patient DOT works by assigning a responsible person to observe or watch the patient take the correct medications daily during the whole course of treatment THANK YOU!