National Tuberculosis Program NTP

1. National Tuberculosis ProgramNTP

2. WHAT IS TUBERCULOSIS

3. Tuberculosis is an infectious disease caused mainly by Mycobacterium tuberculosis. • It can affect most organs in the body, but the lung is the main organ affected. • If left untreated, each person with smear-positive pulmonary TB will infect, on average, between 10 and 15 persons in each year. • Those who will be infected with TB will not necessarily get the disease. The immune system “walls off” the TB bacilli, which can lie dormant for years. • On average, 10 percent of the infected individuals develop the disease during their lifetime. • When someone’s immune system is weakened, chances of developing TB are increased.

4. History of TB

5. 2400 BCSpinal columns of Egyptian mummies show definite Evidence of tubercular decay

6. 460 BCHIPPOCRATE:Most widespread disease, almost always fatal 1702MANGET explained miliary TB 1720BENJAMIN MARTIN (a new theory of consumption) TB could be caused by wonderfully minute living creature 1854 HERMANN BREHMER (TB is a curable disease) Established first sanatorium in Germany , Beginning of sanatorium era. 1882 ROBERT KOCH, discovered the micro-organisms responsible for TB

7. History of anti-TB drugs

8. 1944 STREPTOMYCIN • 1949 P A S • 1952 ISONIAZID • 1954 PYRIZINAMIDE • 1955 CYCLOSERINE • 1962 ETHAMBUTOL • 1963 RIFAMPICIN • OTHER DRUGS USED • ETHIONAMIDE,THIACETAZONE, QUINILONES

9. TB Infection

10. Source of Infection: The source of infection can be either: • human: Mycobacterium Tuberculosis • animal: Mycobacterium Bovis

11. Mode of Infection: Exogenous: • Inhalation: droplet nuclei, 1-5 microns, consisting of two to three viable bacteria surrounded by a layer of moisture. • Ingestion: usually contaminated milk • Cutaneous transmission: very rare, the organism gain entrance either through broken skin. • Congenital transmission: also very rare, the fetus acquires the infection either transplacentally from the diseased mother through umbilical vein, or by aspirating amniotic fluid that contains viable mycobacteria. Endogenous: • Activation of a dormant focus.

12. Natural history of untreated TB Without treatment, after 5 years. • 50% of pulmonary TB patients will be dead. • 25% will be healthy (self-cured by strong immune defense). • 25% will remain ill with chronic, infectious TB.

13. TB evolution

14. Primary infection • Phenomena that take place when an individual comes into contact with the tubercle bacillus for the first time. • 95% of all affected individuals remain asymptomatic or present with minimal clinical manifestations similar to those of common cold. • Only 5% develop manifest disease. • This phenomenon typically takes place in childhood. • As a result of which primary infection is often associated with childhood TB.

15. Primary infection, cont. Upon arrival in the alveolar region, the bacteria encounter three types of cells that potentially oppose infection: • the alveolar macrophages within the alveolar lumen, the key cell • the natural killer cells, and • the / T lymphocytes.

16. Primary infection, cont. • The initial interaction between M. tuberculosis and alveolar Macrophages involves Non-specific phagocytosis of the bacilli. • This phase concludes with destruction of the alveolar macrophages by proliferating intracellular bacilli. • Attracted blood monocytes ingest the released bacilli. • The monocytes have not been activated yet. The tubercle bacilli increase in number, killing host cells and spread locally. • In the lung, intense alveolitis takes place at the expense of the young cells of the mononuclear phagocyte system.

17. Primary infection, cont. • Then Mycobacterial spread via lymphatics towards the regional lymph nodes. • In this region, the host immune response to tuberculous infection takes place. • In some instances, this immune response is sufficient to arrest the progression of infection. • In more often times the bacilli escape towards the lymphatic duct and penetrate the pulmonary bloodstream, from where there is hematogenous spreading of the bacilli to the other organs.

18. Primary infection, cont. • The main target zones of such bacterial dissemination are the highly irrigated organs and tissues—the central nervous system, spongy bone, liver, kidneys, and genitals. • In each of these zones, the arriving bacilli are phagocytosed by the local cells of the mononuclear phagocyte system. • In most cases, this period implies immunologic control of the infection as a result of two mechanisms: cell-mediated immunity and delayed hypersensitivity.

19. Primary infection, cont. • Delayed hypersensitivity is the phenomenon responsible for the destruction of macrophages that contain intracytoplasmic bacteria, thereby forming a characteristic focus of caseous necrosis. • Although the bacteria may survive within this necrotic focus for years, they are unable to reproduce due to the prevalent acidosis, the lack of oxygen, and the presence of inhibitory fatty acids. • From the clinical point of view, immunocompetent individuals develop a balance between themselves and the mycobacteria, which persists throughout life until some predisposing event is able to reactivate the infectious focus.

20. Primary TB: • Pulmonary: Ghon’s focus • Glandular: hilar lymph node, draining lymphangitis The infection develops as interplay between virulence of the organism, and immunity of the host. • In 80-90% of infected individuals, immunity takes the upper hand leads to spontaneous healing, resolution, fibrosis and calcification. • In 10-20% of infected individuals, virulence takes the upper hand (progressive primary =childhood tuberculosis) Progressive pulmonary component: • pneumonic • bronchopneumonia • cavitation • pleural effusion Progressive glandular component: • hilar lymph node  other lymph nodes • atelectasis: middle lobe syndrome • haematogenous spread

21. Post-primary: Haematogenous:dissemination by blood stream leads to multiple organs affection • Intra-thoracic: miliary, idiopathic effusion, tuberculoma, punched out cavity. • Extra-thoracic: meningeal, glandular, renal, bone and joint, etc. • Bronchogenic:spread, to other part or other lung Adulthood Tuberculosis • minimal, advanced or far advanced lung lesion • exceptional extra-pulmonary: laryngitis and enteritis • late haematogenous dissemination

22. TB epidemiology

23. Global Burden of Tuberculosis: • In 1993 WHO declared TB a global emergency. • It is estimated by WHO worldwide that: • A nine million new cases of TB occurred/year • Three million TB deaths/year. • Tuberculosis poses a major problem for developing countries. • Deaths from TB comprise 25 % of all avoidable deaths in developing countries. • 95 % of all TB cases occur in developing countries • 98 % of TB deaths occur in developing countries. • 75 % of TB cases in developing countries are in the economically productive age group (15- 50 years).

24. 22 high-burden countries: 80% of all new cases 10000 1000 Estimated new TB cases ('000s) 100 10 India China Brazil Kenya Nigeria Ethiopia Uganda Pakistan Thailand Viet Nam Myanmar Cambodia Indonesia DR Congo Philippines Zimbabwe Bangladesh Mozambique UR Tanzania Afghanistan South Africa Russian Federation

25. Why Does the Global Burden of TB Increase? • Inadequate health services. • Improper management practices resulting in poor case detection, diagnosis and treatment. • Demographic changes: increasing world population and changing age structure. • Impact of HIV. • The emergence of resistance to the first line drugs used to treat TB.

26. The pulmonary form of tuberculosis (smear positive and smear negative) represents roughly 80 to 85 percent of all cases. • The remaining 15 to 20 percent is made up by cases of extra-pulmonary tuberculosis. • The expected number of new smear positive cases in Egypt currently about 10,000 per year. • For every new smear-positive pulmonary tuberculosis case usually a case of smear-negative pulmonary or extra-pulmonary tuberculosis will also be present.

27. Magnitude Of TB Problem in Egypt

28. In terms of incidence of tuberculosis, Egypt is ranked among the mid-level incidence countries. Tuberculosis in Egypt is considered an important public health problem.

30. Indicators

31. Case Detection Indicators • SS+ case detection rate: No. of detected new SS+ cases = >70% Estimated No of new SS+ cases • SS+ cases in relation to all pulmonary cases No. of detected new SS+ cases = 50 – 70% Total No. of new pulmonary cases • SS+ cases in relation to all TB cases No. of detected new SS+ cases = 50 – 60% Total No. of TB cases detected

32. Treatment Outcome

33. Treatment success No. of patient cured + No. of patient completed treatment = > 85% No. of patient registered

34. Diagnosis of tuberculosis refers to the recognition of an active case, i.e. a patient with symptomatic disease due to lesions caused by Mycobacterium tuberculosis. • According to the site of the lesion, TB can be classified to Pulmonary or Extra-Pulmonary Tuberculosis. • Pulmonary TB can further be classified to smear positive or smear negative types.

35. Identifying TB suspects

36. What is TB suspect • A TB suspect is any person, who presents with symptoms or signs suggestive of tuberculosis, in particular cough of long duration.

37. When to Suspect Pulmonary Tuberculosis? • Persistent cough for more than two weeks. • Blood tinged sputum. • Breathlessness and chest pain. • General symptoms such as: loss of appetite; loss of weight; malaise and tiredness; night sweats and fever. • A history of contact with a TB patient .

38. What to do when you suspect a case? 1) List the TB suspect in the Suspect Register • The Register of TB Suspects is a record of all patients identified as TB suspects at the health facility, • all sputum samples sent to the laboratory & their results.

40. 2) Collect sputum for smear examination. 3) When the laboratory results are received, record results in the Register. 4) Decide on appropriate action in response to the laboratory results.

41. Diagnosis of TB

42. Diagnosis of Pulmonary TB is A bacteriological one. • Microscopic Direct Smear Examination is an easy and quick procedure. A minimum of three samples must be examined. • Cultures: • To confirm the diagnosis even in smear negative. • To detect drug susceptibility and resistance. • To detect the bacilli in any specimen in extra-pulmonary tuberculosis.

43. Collection of sputum samples • A PTB suspect should submit 3 sputum samples for microscopy. • The chances of finding tubercle bacilli are greater with 3 sputum samples than with 2 samples or 1 sample. • Secretions build up in the airways overnight. • So an early morning sputum sample is more likely than a sample later in the day to contain tubercle bacilli. Sensitivity of sputum smear microscopy • Sputum smear microscopy for tubercle bacilli is positive when there are at least 10,000 organisms present per 1 ml of sputum.

44. False positive results of sputum smear microscopy • A false positive result means that the sputum smear result is positive even though the patient does not really have sputum smear-positive PTB. • This may arise because of the following: • red stain retained by scratches on the slide; • contamination of the slide • various particles that are acid-fast (e.g. food particles, dye precipitates, other micro-organisms).

45. Causes of false negative results of sputum smear microscopy

46. TUBERCULIN SKIN TEST • Tuberculin is a purified protein derived from tubercle bacilli. Thus, another name for tuberculin is PPD (Purified Protein Derivative). • Following infection with M. tuberculosis, a person develops hypersensitivity to tuberculin. • Tuberculin injected into the skin of an infected person produces a delayed local reaction after 48-72 hours. We quantify this reaction by measuring the diameter of skin induration (thickening) at the site of the reaction. • Various conditions may suppress this reaction. • The reaction only shows that the person has at some time had infection with M. tuberculosis

47. Tuberculin Skin Test, cont. • A positive test (induration of 10 mm or more) is suggestive for tuberculous infection in children who are not vaccinated with BCG or 5 years or more after vaccination. • A positive test (induration of 15 mm or more) is suggestive for tuberculous infection in children who are vaccinated with BCG. • A negative test in adults may be suggestive of absence of tuberculous infection. • False negative test may be obtained in immunosuppressed individuals.

48. CONDITIONS WHICH MAY SUPPRESS THE TUBERCULIN SKIN TEST • HIV infection • Malnutrition • Severe bacterial infections, including TB itself • Viral infections, e.g. measles, chickenpox, glandular fever • Cancer • Immunosuppressive drugs, e.g. steroids

49. Tuberculin Testing

50. Chest X-rays in diagnosis No certain x-ray pattern is specific to TB INDICATIONS FOR CHEST X-RAY • Positive sputum smear • The first screening test for PTB suspects is sputum smear microscopy. • In most cases of sputum smear-positive PTB a chest X-ray is un-necessary. • In those few cases of sputum smear-positive PTB when a chest X-ray is necessary, the indications are as follows: