TUBERCULOSIS

1. TUBERCULOSIS

2. The most important communicable disease in the world. • Eight million cases occurring each year (95%of them in the developing countries). 1. Identification: TB is a mycobacterium disease that is important as a major cause of disability and death in many parts of the world. The initial infections usually goes unnoticed. Early lung lesions commonly heal, and approximately 90-95 % of those initially infected enter latent phase from which there is life risk of reactivation. • Classification System: • The current clinical classification system for TB is based on the pathogenesis of the disease. A patient should not have a class 5 classification for more than 3 months. • The number of cases in Egypt (WHO annual report,2006) • Year1990199719992005Cases15,61711,0409,65018,508 new cases and 23,691 all cases

3. Classification System for TB • No Evidence of infectionHistory of exposureNegative reaction to tuberculin skin test2TB infectionNo diseasePositive reaction to tuberculin skin testNegative bacteriologic studies (if done)No clinical or radiographic evidence of TB3Current TB diseaseM. tuberculosis cultured (if done) orPositive reaction to tuberculin skin test and Clinical or radiographic evidence of current disease4Previous TB diseaseHistory of episode(s) of TB orAbnormal but stable radiographic findingsPositive reaction to the tuberculin skin testNegative bacteriologic studies (if done)andNo clinical or radiographic evidence of current disease5TB suspectedDiagnosis pending2. Occurrence: For 2004, WHO reported an estimated 1.7 million deaths from TB; mostly in Africa. Over one third of the world’s population, appproximately 1.86 billion people is now infected (not diseased) with the TB bacillus, and at risk of developing the diseases. • 16.2 million people currently have TB disease. 95% of cases and 98% of deaths due TB occurs in developing countries. • Egypt is one of the countries with intermediate incidence of TB (20-100/100,000 population). TB is ranked after bilharzias, the second most important public health problem in Egypt.

4. Causative organism; • Mycobacterium tuberculosis: It is an aerobic, optimum temperature for growth 37 °C(33-39). • Stained with: • -Modified gram stain: gram positive. • -Zeihl Neelsen: resist decolourisation with acid and alcohol (Acid fast alcohol fast bacilli). • - Fluorescent dyes: rhodamine and auramine stains.

5. Cultures: • - Lowenstein Jensen media: 6-8 weeks. • - Bactec media: 2-6days.

6. Primary pulmonary tuberculosis *The first infection with tubercle bacillus. Includes the involvement of the draining lymph nodes in addition to the initial lesion(Ghon). Route of infection: inhalation. Primary tuberculosis was relatively common in the intestine or tonsils due to infection from milk

7. Clinical features: Majority: symptomless.(specially in young adults) Brief febrile illness. Loss of appetite. Failure to gain weight in children. Cough is not unusual and may mimic paroxysm of whooping cough.

8. Physical signs: • may be normal, • crepitation may be heard. • primary lesion could be heard. • Segmental or lobar collapse may occur.

9. Radiological features: • Lymphadenoathy: hilar lymph nodes are most commonly involved rarely paratracheal.Calciflcation of the nodes may occur. • Pulmonary componEnt: ( mainly in adults) segmental or lobar consolidation or obstructive emphysema. • Resolution of radiological shadow 6m- 2ys.

10. Diagnosis: • *Vague ill health with history of contact.* X-ray. • *Tuberculin test: is usually strongly positive. • *Sputum and gastric lavage for direct smear and culture helpful in 20-25% of cases.* DNA amplification: PCR.

11. Complications: • 1. Collapse or consolidation."middle lobe is mostly affected." • 2. Bronchiectasis. • 3. Obstructive emphysema. • 4. Broncholith. • 5. Erythema nodosum. • 6. Phlyctenular conjunctivitis. • 7. Pleural effusion.

12. Post primary pulmonary tuberculosisThe most important type of tuberculosis because it is the most frequent and smear positive sputum is the mainsource of infection responsible for the persistence of the disease in the community.

13. Source; • 1. Direct progression of the primary lesion. • 2. Reactivation of the quiescent primary or post primary. • 3. Exogenous infection.

14. Predisposing factors for reactivation: • 1. Malnutrition. • 2. Poor housing and overcrowding. • 3. Steroid and other immunosuppressive drugs. • 4. Alcoholism. • 5.Other diseases: HIV malignancy, lymphomas , Leukaemia,Diabetes.

15. Clinical features: Mainly in middle aged and elderly.A-Symptoms: 1. May be no symptoms, or just mild debility.Gradual onset of symptoms over weeks or months. 2. General malaise. 3. Loss of appetite, loss of weight. 4. Febrile course. 5. Night sweating. 6. Cough with or without sputum. 7. Sputum could be mucoid, purulent or blood stained. 8. Could be presented with frank haemoptysis. 9. Tuberculous pneunonia.

16. B-Signs: 1. May be no signs. 2. Pallor, cachexia. 3. Fever. 4. Post tussive crepitations on the apices. 5. Signs of Consolidation. 6. Signs of fibrosis. 7. Signs of cavitary lesion. 8. Localised wheezes in endobronchial tuberculosis

17. Radiology: • 1. Bilateral upper zone fibrotic shadows: with shift of trachea, mediastinum, distortion of fissures and diaphragm, and elevation of the pulmonary hila. • 2. Soft confluent shadows of exudative lesion (D.D pneumonia) • 3 Calcification. • 4. Cavitation. • 5. Tuberculoma. • 6. Hilar and paratracheal lymph node enlargement may be present.

18. Radiological classification: • Minimal: slight or moderate opacity. No cavity. Extent not more than space above 2nd costocondral junction. • 2. Moderately advanced: In one or both lungs. slight or moderate opacity, extent equivalent to volume of one lung. Dense confluent shadow equivalent to one third the volume of one lung. Diameter of cavities not more than 4 cm. • 3. Far advanced: • Any lesion>the moderately advanced.

19. Diagnosis: • 1) Clinical • 2) Plain X-ray. • 3) Sputum Examination: direct smear and culture (very important). • 4) Other samples: Gastric aspirate, laryngeal swab, fiberoptic specimens (wash,brush,biopsy),transtracheal spirate. • 5) Polymerase chain reaction. • 6) Tuberclin test: mainly strongly positive • 7) Others • White blood cells if normal favour the diagnosis • ESR may be elevated. • Normocytic normochromic anaemia.CT may be useful in detecting small cavities,or calcification.

20. Complications: • 1) Pleurisy. • 2) Tuberculous empyema. • 3) Tuberculous laryngitis. • 4) Spread to other organs. • 5) Asperigellomas. • 6) Scar lung cancer. • 7) Adult respiratory distress syndrome. • 8) Cor pulmonale (rare) • 9) Amyloidosis.

21. Miliary Tuberculosis • Produced by acute dissemination of tubercle bacilli via the blood stream. • The term miliary derives from the radiological picture of diffuse, discrete nodular shadows about the size of milletseed (2mm).

22. A- Classical form: • Clinical features: • Most common in infants and young children with acute or subacute febrile illness. • In adults: the onset is insidious, gradual vague ill health. Malaise, Cough (usually dry), dyspnea.Night sweat is less common. • Headache suggest associated tuberculous meningitis • Chest examination is free, crepitations may be found. • Hepatomegaly, splenomegaly, lymphadenopathy,neck rigidity may be found in rare cases.

23. Diasnosis: 1) Clinical. 2) Xray. 3) Choroidal tubercles in fundus examination 4) Tuberclin test not conclusive 5) Direct smear and culture of sputum if present. 6) Other samples as transtracheal aspirate, fiberoptic specimens may be obtained. 7) If failed to prove therapeutic trial for 2 weeks

24. Antituberculous drugs: A. First line drugs; Isoniazide (INH) or H Rifampicin ( R ) Pyrizinamide ( Z ) Streptomycin ( S ) Ethamutol ( E ) B.Second line drugs : Thiacetazone (150mg) Para amino salicylic acid (10-20 g) Ethionamide (<50Kg, 750mg&>50Kg, Ig) Cyclosporin (15-20mg/Kg) Kanamycin, Capreomycin, Viomycin (20mg/Kg max Ig) C.New drugs: Amikacin, Quinolones, Rifabutin, new macrolides, and Amoxicillin-clavulinic acid.

25. Drugs Dose Dose Adverse effect Adult Child Isoniazide (INH) or H 5 mg/Kg up to12mg/Kg inmiliary. 10 mg/Kg Peripheralneuritis,hepatitis,hypersensitivity. Rifampicin (R) lOmg /Kg<50Kg, 450mg>50Kg, 600mg 10-20mg Orange urineFlu like illnessHepatitisHypersensitivityBlood dyscriasis. Ethambutol (E) 25mg/Kg fortwo months,then 15mg/Kg Contraindicated Retrobulbarneuritis Pyrazinamie (Z) <50Kg,1.5g50-74Kg, 2g>75Kg, 2.5g 40mg/Kg HepatotoxicityHyperuricaemia Streptomycin (S) 20mg/Kg (maxIg) 20mg/Kg Ototoxicity(vestibular)NephrotoxicityHypersensitivity

26. Drus regimens: according to WHO guidelines 1-New smear positive patient 2SRHZ/6HE(8months regimens)or 2SHE/10HE(12months regimens)or 2SRHZ/4RH (6 months regimen) 2-Previously treated smear positive patients 2SRHZE/1RHZE/6RHE (9month regimen) a sensitivity pattern is recommended. 3- Smear negative and extrapulmonary TB 2SHE/10HE (12 months regimen) 4- Chronic smear positive patient(Treated in hospital): a Sensitivity pattern is recommended to give special treatment regimen.

27. Corticosteroid therapy in tuberculosis Corticosteroid should never be given to patientswith tuberculosis unless they are receiving adequateantituberculous therapy Indications of steroids: *In very ill patient. *To control drug hypersensitivity. *In tuberculosis of serous sacs (pericarditis, peritonitis and pleural effusion). *In tuberculous meningitis. *Genitourinary tuberculosis. *Occasionally to suppress lymph node enlargement.

28. TUBERCULOSIS • 3. Agent: Mycobacterium TB, the tubercle bacillus that was identified by Kock in 1882. There are 3 types that are pathogenic to man: • Human type: it is the essential causative organism of TB in man that causes all or nearly all pulmonary cases and 20-50 % of extra-pulmonary cases. • Bovine type: cattle are reservoir of infection, and infect man causing 50-80 % extra-pulmonary cases and aminority of pulmonary cases. • Avian type: Poultry are the reservoir of infection, and rarely infect man, possibly by ingestion of infected eggs, causing reported sporadic cases of extra-pulmonary TB. • 4. Reservoir: Primarily humans, rarely primates; in some areas diseased cattle, badgers, swine, and other mammals are infected. • 5. Mode of transmission: TB is spread from person to person through the air. When a person with pulmonary or laryngeal TB coughs or sneezes, droplet nuclei containing M. tuberculosis are expelled into the air. These tiny particles (1-5 microns in diameter) can remain suspended in the air for several hours. If another person inhales air containing droplet nuclei, transmission may occur. The probability that TB will be transmitted depends on three factors: the infectiousness of the person with TB, the environment in which exposure occurred, and the duration of exposure. • Persons at the highest risk of becoming infected with M. tuberculosis are close contacts persons who often spend time with someone who has infectious TB. Close contacts may be family members, roommates, friends, coworkers, or others. These persons are at risk for TB infection because they are more likely to be exposed to TB. Infection rates have been relatively stable since 1987, ranging from 21% to 23% for the contacts of infectious TB patients. • Extra-pulmonary TB is rarely contagious; however, transmission from extra-pulmonary sites has been reported during aerosol-producing procedures, such as autopsies and tissue irrigation. • 6. Incubation period: From infection to demonstrable primary lesion or significant tuberculin reaction, about 2-10 weeks. While the subsequent risk of progressive pulmonary or extra-pulmonary TB is greatest within the first year or two after infection, latent infection may persist for a lifetime. • HIV infection appears to increase the risk greatly and shorten the interval for the development of TB disease. • 7. Clinical picture: The symptoms of pulmonary TB include a productive, prolonged cough (duration of more than 3 weeks), chest pain, and hemoptysis. Systemic symptoms of TB include fever, chills, night sweats, easy fatigability, loss of appetite, and weight loss. Approximately 15% of TB cases are extra-pulmonary. The symptoms of extra-pulmonary TB depend on the site affected. TB of the spine may cause pain in the back; TB of the kidney may cause blood in the urine. • Diagnosis: • Physical Examination: A physical examination is an essential part of the evaluation of any patient. It cannot be used to confirm or rule out TB, but it can provide valuable information about the patient's overall condition and other factors that may affect how TB is treated. • Tuberculin Skin Testing: The tuberculin skin test is useful for: • examining a person who is not ill but may be infected with M. tuberculosis, such as a person who has been exposed to someone who has TB. The tuberculin skin test is the only way to diagnose TB infection before the infection has progressed to TB disease • determining how many people in a group are infected with M. tuberculosis • Administration of the Tuberculin Test: Mantoux tuberculin skin testing is the standard method of identifying persons infected with M. tuberculosis. • The Mantoux test is performed by giving an intradermal injection of 0.1 ml of purified protein derivative (PPD) tuberculin containing 5 tuberculin units (TU) into either the volar or dorsal surface of the forearm. The injection should be made with a disposable tuberculin syringe, just beneath the surface of the skin, with the needle level facing upward. • The reaction to the Mantoux test should be read by a trained health care worker 48 to 72 hours after the injection. The area of induration (palpable swelling) around the site of injection is the reaction to tuberculin. The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis). Erythema (redness) should not be measured. • Classification of the Tuberculin Reaction: • A tuberculin reaction of 5 mm or greater of induration is classified as positive in the following groups: • persons known to have or suspected of having HIV infection • close contacts of a person with infectious TB • persons who have chest radiograph findings suggestive of previous TB and who have received inadequate or no treatment. • Persons who inject drugs and whose HIV status is unknown. • A tuberculin reaction of 10 mm or greater of induration is classified as positive in persons who do not meet the preceding criteria but who have other risk factors for TB. These include: • persons with certain medical conditions, excluding HIV infection • persons who inject drugs and who are known to be HIV negative • foreign-born persons from areas of the world where TB is common (e.g., Asia, Africa, and Latin America) • medically underserved, low-income populations, including high-risk racial and ethnic groups (e.g., Asians and Pacific Islanders, blacks, Hispanics, and Native Americans) • residents of long-term care facilities (e.g., correctional facilities and nursing homes) • children younger than 4 years of age • other groups identified locally as having an increased prevalence of TB (e.g., migrant farm workers or homeless persons) • A tuberculin reaction of 15 mm or greater of induration is classified as positive in persons with no known risk factors for TB. • The tuberculin skin test is a valuable tool, but it is not perfect. Several factors can affect the skin test reaction: for example, infection with mycobacterium other than M. tuberculosis (nontuberculous mycobacterium) and vaccination with bacille Calmette-Guerin (BCG). These factors can lead to false-positive reactions (a positive skin test reaction in a person not infected with M. tuberculosis). • Radiographic Examination: A postero-anterior view of the chest is the standard radiograph needed for the detection and description of chest abnormalities. In some instances, other views (e.g., lateral) or additional studies (e.g., CT scans) may be necessary. • Laboratory Examination: Detection of acid-fast bacilli (AFB) in stained smears examined microscopically may provide the first bacteriologic clue of TB. • 8. Period of communicability: theoretically, as long as viable tubercle bacilli are being discharged in the sputum. Some untreated or inadequately treated patients may be sputum positive intermittently for years. • 9. Susceptibility and resistance: The risk of infection with the tubercle bacillus is directly related to the degree of exposure, and does not appear to be related to genetic or other host factors. The most hazardous period for development of clinical disease is the first 6-12 months after infection. The risk of developing disease is highest in children under 3 years old, lowest in later childhood, and high again among adolescents, young adults, the-very old and the immunosupprcsscd. • Some medical conditions increase the risk that TB infection will progress to disease. The risk may be approximately 3 times greater (as with diabetes) to more than 100 times greater (as with HIV infection) for persons who have these conditions than for those who do not. Some of these conditions include: • HIV infection • substance abuse (especially drug injection) • recent infection with M. tuberculosis (within the past 2 years) • chest radiograph findings suggestive of previous TB (in a person who received inadequate or no treatment) • diabetes mellitus • silicosis • prolonged corticosteroid therapy • other immunosuppressive therapy • cancer of the head and neck • hematologic and reticuloendothelial diseases (e.g., leukemia and Hodgkin's disease) • end-stage renal disease • intestinal bypass or gastrectomy • chronic malabsorption syndromes • low body weight (10% or more below the ideal) • 10. Methods of control: • A. Primary prevention: • 1) Educate the public in mode of spread and methods of control, and the importance of early diagnosis. ' • 2) Reduce or eliminate those social conditions that increase the risk of infection, such as overcrowding. • 3) TB prevention and control programs should be established in all institutional settings in which health care is provided. • 4) Use preventive treatment with isoniazid, which has been; shown to be effective in preventing the progression of latent TB infection to TB disease. • Standard Regimens: Clinical trials have shown that daily isoniazid preventive therapy for 12 months reduces the risk for TB disease by more than 90% in infected patients who complete a full course of therapy. There is evidence that 6 months of preventive therapy with isoniazid also confers a high degree of protection (approximately 69% in patients who complete the regimen) against the progression of TB infection to TB disease. Every effort should be made to ensure that patient adhere to preventive therapy for at least 6 months. Children should receive at least 9 months of preventive therapy. HIV-infected persons should receive 12 months of isoniazid preventive therapy. • Isoniazid is normally used alone for preventive therapy in a single daily dose of 300 mg in adults and 10 to 15 mg/kg body weight in children, not to exceed 300 mg per dose. • For persons who are at especially high risk for TB and whose adherence is questionable, directly observed preventive therapy should be considered. This method of treatment is especially appropriate in institutions and facilities where preventive therapy can be observed by a staff member. Isoniazid can be given two times a week at a dosage of 15 mg/kg as directly observed preventive therapy. Data on the effectiveness of intermittent isoniazid preventive therapy are limited. However, the results of studies of twice-weekly therapy with isoniazid suggest that it is an effective form of preventive therapy in adults and children. • Alternative Regimens: For patients who have a positive tuberculin skin test result and either silicosis or a chest radiograph demonstrating old fibrotic lesions and who have no evidence of current disease, acceptable regimens include either 4 months of isoniazid plus rifampin or 12 months of isoniazid, provided that infection with drug-resistant organisms is judged to be unlikely. • NB. Before preventive therapy is started, clinicians should: • rule out the possibility of TB disease (with a medical history and chest radiograph) • question for a history of treatment for TB infection or disease • check for contraindications, including previous isoniazid-associated hepatic injury; history of severe adverse reactions to isoniazid, such as a drug fever, rash, or arthritis; and acute or unstable liver disease of any cause • determine whether the patient is at high risk for adverse reactions • 5) Provide public health nursing and outreach services for direct supervision of patient therapy, and arrange for the examination and preventive treatment of contacts. • 6) Persons infected with HIV should be skin tested by the Mantoux method, using intermediate strength PPD started on prophylactic treatment if they are PPD positive. • 7) BCG immunization of uninfected (tuberculin negative) people can induce tuberculin reactivity in more than 90% of vaccinees. The protection conferred has varied markedly, that protection may persist for as long as 20 years in high incidence situations, while others have shown no protection at all. • 8) Eliminate bovine tuberculosis among dairy cattle by tuberculin testing and slaughter of reactors; pasteurize or boil milk. • 9) Take measures to prevent silicosis among those working in industrial plants and mines. • B-Secondary prevention (Control of patients, contacts and the immediate environment): • 1) Report to local health authority when diagnosis is suspected. • 2) Isolation: For pulmonary tuberculosis, control of infectivity is best achieved by prompt specific drug therapy, which usually produces sputum conversion within 4-8 weeks. Hospital treatment is necessary only for patients with severe illness and for those whose medical or social circumstances make treatment at home impossible. • 3) Concurrent disinfections: Hand-washing and good housekeeping practices should be maintained according to routine policy. Decontamination of air may be achieved by ventilation; this may be supplemented by ultraviolet light. • 4) Quarantine: None. • 5) Investigation of contacts and source of infection: PPD testing of all members of the household and other close contacts is recommended. If negative, a repeat skin test should be performed 2-3 months after exposure has ended. Chest radiographs should be obtained on positive reactors when they are identified. Preventive treatment is indicated for contacts who are positive reactors and for some initially negative reactors at high risk of developing active disease, especially young (5 years old or younger) and HIV infected close contacts, at least until the repeat skin test is shown to remain negative. • 6) Specific treatment: • 1) Promptly identify, diagnose and treat potentially infectious patients with TB disease. Establish case finding and treatment facilities for infectious cases to reduce transmission. • 2) Make available medical, laboratory and x-ray facilities for; prompt examination of patients, contacts and suspects; facilities for early treatment of cases and people at high risk of infection; and beds for those needing hospitalization. • 3) Directly observed therapy has been shown to be highly effective and is recommended for treatment of TB disease. Patients with TB disease should be given prompt treatment with an appropriate combination of anti-microbial drugs, with regular monitoring of sputum smears. For drug susceptible disease, a 6 month regimen consisting of isoniazid (INH), rifampin (RIF), and pyrazinamide (PZA) is recommended for the first 2 months followed by INH and PZA for 4 months. A 4 drug initial therapy (including ethambutol (EMB) or streptomycin (SM)) is recommended if the infection was acquired in areas where an increased prevalence of INH resistance has been reported. • DOTSis the most effective strategy available for controlling the TB epidemic today. • DOTS produces cure rates of up to 95 percent even in the poorest countries. • DOTS prevents new infections by curing infectious patients. • DOTS prevents the development of multidrug-resistant tuberculosis (MDR-TB) by ensuring the full course of treatment is followed. • A six-month supply of drugs for DOTS costs US $11 per patient in some parts of the world. The World Bank has ranked the DOTS strategy as one of the "most cost-effective of all health interventions." • Since DOTS was introduced on a global scale in 1995, over 10 million infectious patients have been successfully treated under DOTS programmes. • THE FIVE ELEMENTS OF THE DOTS STRATEGY: • DOTS has FIVE key components: • Government commitment to sustained TB control activities. • Case detection by sputum smear microscopy among symptomatic patients self-reporting to health services. • Standardized treatment regimen of six to eight months for at least all sputum smear- positive cases, with directly observed therapy (DOT) for at least the initial two months. • A regular, uninterrupted supply of all essential anti-TB drugs. • A standardized recording and reporting system that allows assessment of treatment results for each patient and of the TB control programme performance overall. • Political commitment:Government commitment to sustained TB control is essential for the mobilization of resources and the sustainability of TB programmes. • Case detection and diagnosis: Sputum smear microscopy is the most cost-effective method of screening pulmonary TB suspects referring to health services. It identifies sputum smear-positive, highly infectious TB cases. TB is diagnosed using patient history, clinical examination and diagnostic tests. A sputum sample is submitted to the laboratory and the results of the microscopic exam are entered into the laboratory register. The goal is for all suspects to have a sputum smear microscopy exam and for all patients diagnosed with TB to be registered and treated. • Standardized short-course chemotherapy with direct observation of drug intake: Short-course chemotherapy refers to a treatment regimen that lasts six to eight months and uses a combination of powerful anti-TB drugs.  • Directly observed therapy (DOT) is essential at least during the intensive phase of treatment (the first two months) to ensure that the drugs are taken in the right combinations and for the appropriate duration. • With direct observation of treatment, the patient doesn't bear the sole responsibility of adhering to treatment. Health care workers, public health officials, governments, and communities must all share the responsibility and provide a range of support services patients need to continue and finish treatment. One of the aims of effective TB control is to organize TB services which are integral part of health systems so that the patient has flexibility in where he or she receives treatment, for example in the home or at the workplace. Treatment observers can be anyone who is willing, trained, responsible, acceptable to the patient and accountable to the TB control services. • Drug supply: Where DOTS is implemented, an accurate recording and reporting system provides the information needed to plan and maintain adequate drug stocks. • Recording and reporting: The recording and reporting system is used to systematically evaluate patient progress and treatment outcome. The system consists of: a laboratory register that contains a log of all patients who have had a smear test done; patient treatment cards that detail the regular intake of medication and follow-up sputum examinations; the TB register, which lists patients starting treatment and monitors their individual and collective progress towards cure; and reporting forms from districts to the national level, which allow assessment of control efforts. • DOTS-Plus: Based upon DOTS, DOTS-Plus is a comprehensive management strategy under development and testing that includes the five tenets of the DOTS strategy. DOTS-Plus takes into account specific issues (such as the use of second-line anti-TB drugs) that need to be addressed in areas where there is high prevalence of multi-drug resistance TB (MDR-TB). Thus, DOTS-Plus works as a supplement to the standard DOTS strategy. By definition, it is impossible to conduct DOTS-Plus in an area without having an effective DOTS-based TB control programme in place. Sample protocols are available to design standardized or individualized treatment regimens with second-line anti-TB drugs to be used in DOTS-Plus pilot projects. • C. Epidemic measures: Alertness to recognize and treat aggregations of new infections resulting from contact with an unrecognized infectious case, and intensive search for and treatment of the source of infection. • D. Disaster implications: None. • E. International measures: Chest radiograph screening, PPD testing, and smear and culture testing of symptomatic PPD positive persons from high prevalence countries is suggested on immigration.

29. Thank You