1.
TUBERCULOSIS (TB)
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2.
OUTLINE OF THE SEMINAR
 Introduction,
 Prevalence/Magnitude of the disease in the Nepalese
and global context
 Cause and Factors,
 Signs and Symptoms,
 Mode of Transmission
 Medicine used for treatment based on National
protocol/Guidelines of Nepal/WHO,
 prevention and controlling measures
 References
2

3.
CHAPTER I: INTRODUCTION
 Tuberculosis (TB) is a disease caused by a germ called
Mycobacterium tuberculosis that is spread from person to
person through the air. TB usually affects the lungs, but it can
also affect other parts of the body, such as the brain, the
kidneys, or the spine.
 TB is spread from person to person through the air. When
people with lung TB cough, sneeze or spit, they propel the TB
germs into the air. A person needs to inhale only a few of
these germs to become infected. However, not everyone
infected with TB bacteria becomes sick. As a result, two TB-
related conditions exist: latent TB infection and TB disease.
 Tuberculosis is one of the world`s most widespread and deadly
illnesses.
 Tuberculosis is a major public health problem not only in Nepal but also
throughout the world.
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4.
 Tuberculosis has a long, rich history, dating back as far
as Ancient Egypt, with evidence of its presence found in
the preserved spines of Egyptian mummies.
 In the 18th and 19th centuries, a tuberculosis epidemic
rampaged throughout Europe and North America, before
the German microbiologist Robert Koch discovered the
microbial causes of tuberculosis in 1882.
 In 1993 WHO declared that TB was a global
emergency; the first time that a disease had been
labeled as such. 4

5.
Tuberculosis is
 Social disease
 An infectious disease caused by Mycobacterium
Tuberculosis
 Tuberculosis is ‘Barometer of Social Welfare’
 Tuberculosis is the most common opportunistic
infection (OI) in HIV
 Tuberculosis is preventable and curable.
5

6.
 Tuberculosis (TB) is a communicable disease that is a major cause of ill health, one of
the top 10 causes of death worldwide and in Nepal, and the leading cause of death
from a single infectious agent (ranking above HIV/AIDS).
 The disease typically affects the lungs (pulmonary TB) but can also affect
other sites (extrapulmonary TB). About a quarter of the world’s population is
infected with M. tuberculosis which is similar for Nepal. which means people have
been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit it.
 People infected with TB bacteria have a 5–10% lifetime risk of falling ill with TB. Those with
compromised immune systems, such as people living with HIV, malnutrition or diabetes, or
people who use tobacco, have a higher risk of falling ill.
 The age adjusted death rate was 27.80/100,000 of population, which ranks Nepal as
the 43rd most affected country.
 Ending the TB epidemic by 2030 is among the health targets of the Sustainable
Development Goals and priority area of MDG too.
 TB morbidity and mortality is unacceptably high given that most deaths are
preventable with public health interventions (P3CE).
6

7.
 TB morbidity and mortality is unacceptably high given
that most deaths are preventable with public health
interventions (P3CE).
 TB can lead to catastrophic out-of-pocket
expenditure and cause patients to lose an average of 3
to 4 months’ wages due to illness related absence from
work
 Ending the TB epidemic by 2030 is among the
health targets of the United Nations Sustainable
Development Goals (SDGs). 7

8.
8

9.
TUBERCULOSIS
 Every TB sputum positive patient can infect up to 10-
15 individuals in a year.
 Without treatment,
 50% of TB patients will die,
 25% will remain healthy, and
 25% will develop chronic infectious TB.
 Elimination level for Tuberculosis : <1 case per
million population i.e to eliminate TB as a public
health problem. (1,4)
9

10.
WORLD TB DAY
 Celebrated on 24 March each year.
 It is an opportunity to raise awareness about the
burden of tuberculosis (TB) worldwide and the
status of TB prevention and control efforts.
 It is also an opportunity to mobilize political and
social commitment for efforts to end TB.
The theme for 2022
“Invest to End TB. Save Lives”.
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11.
CLASSIFICATION BASED ON ANATOMICAL
SITE OF DISEASE
 It primarily affects
lungs and causes
pulmonary
tuberculosis (PTB)
 Extra Pulmonary sites
are intestine,
meninges, bones and
joints, lymph glands,
skin and other tissues
of body.
Pulmonary TB Extra Pulmonary TB
•Bovine tuberculosis primarily affect animal,
may communicate to man.
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12.
STATEMENT OF PROBLEM
Q1. Country with highest tuberculosis burden in the world?
 Globally, an estimated 9.9 million people fell ill with TB in
2020. There were an estimated 1.3 million TB deaths. Men
(aged ≥15years) accounted for 53% and children (aged <15
years) for 16%. 8% were people living with HIV.
 A total of 1.6 million people died from TB in 2021 (including
187 000 people with HIV). Worldwide, TB is the 13th leading
cause of death and the second leading infectious killer after
COVID-19 (above HIV/AIDS)
 In 2021, an estimated 10.6 million people fell ill with
tuberculosis(TB) worldwide. Six million men, 3.4 million
women and 1.2 million children. TB is present in all countries
and age groups. But TB is curable and preventable, espite
being a preventable and curable disease, 1.5 million people
die from TB each year – making it the world’s top infectious
killer.
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13.
STATEMENT OF PROBLEM
 In 2021, 1.2 million children fell ill with TB globally.
Child and adolescent TB is often overlooked by health
providers and can be difficult to diagnose and treat
 Globally, TB incidence is falling at about 2% per year
and between 2015 and 2020 the cumulative reduction
was 11%. This was over half way to the End TB Strategy
milestone of 20% reduction between 2015 and 2020
 Over 95% of TB deaths occur in low and middle income
countries.
 About half of all people with TB can be found in 8
countries: Bangladesh, China, India, Indonesia, Nigeria,
Pakistan, Philippines and South Africa 13

14.
STATEMENT OF PROBLEM
 Multidrug-resistant TB (MDR-TB) remains a
public health crisis and a health security threat.
 An estimated 66 million lives were saved
through TB diagnosis and treatment
between 2000 and 2020..
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15.
BURDEN OF TUBERCULOSIS IN NEPAL
 In Nepal, an estimated 69,000 fell ill with TB during FY 2077/78.
 National Tuberculosis Programme (NTP) registered 28,677 (nearly
58% missing vs. the projection) all forms of TB cases (38% female
and 62% male).
 Out of 28,677 all forms of TB cases, 28,182 incident TB cases; Out
of 28,677 TB cases, 16,258 (56.7%) were
pulmonary bacteriologically confirmed (PBC) cases, 3,960 (13.8%)
were pulmonary clinically diagnosed (PCD) cases and 8,459 (29.5%)
were extra pulmonary TB cases
 Geographically, most people who reported TB TB were from terai
region (60%). At provincial level, Bagmati Province, Madesh
Province and Lumbini province reported at 23.24, 23, 16, and 21
percent respectively.
 Among CMNN diseases, respiratory infections and TB were the leading
causes of death. Approximately 8.4% of total deaths in both sexes
combined, 8.7% of total deaths in males and 8.1% of total deaths in females
were due to respiratory infections and TB.
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16.
BURDEN OF TUBERCULOSIS IN NEPAL
 Drug-resistant TB continues to be a public health
threat. Worldwide in 2019, close to half a million
people developed rifampicin-resistant TB (RR-
TB),8 of which 78% had multidrug-resistant TB
(MDRTB).
 In Nepal nearly 2,200 people were estimated to
developed DR TB, but only 517 were detected (i.e.
76.% were missed) and out of those diagnosed,
NTCC was able to put 384 on DR TB treatment.
(i.e. 25.8% were lost to follow up).
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17.
BURDEN OF TUBERCULOSIS IN NEPAL
NATIONAL TB PREVALENCE SURVEY, 2018-19
 From the study findings, the revised estimates of TB burden in Nepal for 2018 are:
 Prevalence: 416 (314 - 518)/ 100,000, around 117,000 (88,000 – 145,000) people
with TB disease are living in Nepal
 Incidence: 245 (147 - 367)/ 100,000, around 69, 000 (41,000 – 103,000) people
developed TB disease in 2018
 Around sixty-nine thousand, 69, 000 (41,000 – 103,000) people developed TB in
2018. TB burden is much higher, almost 1.6 times higher than previously estimated.
 Around, one hundred and seventeen thousand, 117,000 (88,000 – 145,000)
people with TB disease are living in Nepal today
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18.
EPIDEMIOLOGICAL TRIAD
Epidemiological Triad of Tuberculosis
A) Agent
B) Host
C) Environment
18

19.
AGENT
19
Fig: Mycobacterium Tuberculosis

20.
AGENT
 Mycobacterium Tuberculosis
 TB Bacillus discovered by: Robert Koch
 Gram -ve, rod shaped, aerobic bacilli
 Acid Fast Bacillus (AFB)
 Generation time of TB bacilli: 18-24 hours (20
hours)
 TB bacteria remain alive:-
-in sputum for 1 day and
-in droplet nuclei for 10 days (3) 20

21.
AGENT
Source of infection
 Human case is a common source and
 Infected milk is bovine source
COMMUNICABILITY
Patients are infective as long as they remain untreated.
21

22.
HOST
Age:-Affects all ages. Developing countries shows rise
in infection rates from childhood to adolescence
but in developed countries disease is more
common in elderly.
Sex:- Prevalent more in males than females.
Heredity:-Not a heredity disease
Nutrition:-Malnourished are vulnerable
Immunity:-Result of natural infection or BCG
vaccination
22

23.
HOST
Generally persons at high risk for developing TB
disease fall into two categories:
a) Person who recently infected with TB bacteria
b) Person with medical conditions that weak
immune systems
23

24.
HOST
a) Person who recently infected with TB bacteria
includes:-
 Close contact of a person with infectious TB disease
 Immigrated person from areas with high rate of TB
 Children < 5 years of age who have a positive TB test
 Groups with high rate of TB transmission, such as
homeless person, IDU, and person with HIV infection
24

25.
HOST
b) Babies and young children often have weak immune
systems. Other people can have weak immune
system
 HIV infection
 Substance abuse
 Silicosis
 Diabetes mellitus
 Severely kidney disease
 LBW
25

26.
ENVIRONMENT
It is also know as social disease.
 Poor quality of life,
 Poor housing,
 Overcrowding,
 Population explosion,
 Under nutrition,
 Smoking,
 Alcohol use,
 Lack of awareness of causes of illness.
 Lack of education,
 Large families,
 Early marriages,
 Unemployment, 26

27.
ENVIRONMENT
 Environmental factors (temperature, humidity,
sunlight), social factors (crowding and person-to-
person contact), and delays in the diagnosis and
treatment of tuberculosis particularly in winter.
27

28.
PROBABILITY THAT TB WILL BE TRANSMITTED
DEPENDS UPON
 Environment in which exposure occurs
 Length of exposure
 Virulence of Mycobacterium Tuberculosis
28

29.
RISK FACTOR OF TB
29

30.
RISK FACTOR OF TB
 Nutrition:-Malnourished are more vulnerable.
 Tobacco: Tobacco use greatly increases the risk of TB
disease and death. 8% of TB cases worldwide are
attributable to smoking.
 Alcohol: On examining the tobacco and alcohol
consumption of 100 tuberculous patients before
diagnosis, and of controls, it was found that
tuberculosis patients were excessively heavy
consumers of alcohol.
30

31.
TB RISK FACTORS
Generally, persons at high risk for developing TB disease fall
into two categories:
 Persons who have been recently infected with TB bacteria.
 Persons with medical conditions that weaken the immune
system.
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32.
This includes:
 Close contacts of a person with infectious TB disease,
 Immigrated person from areas with high rates of TB,
 Children less than 5 years of age who have a positive TB test,
 Groups with high rates of TB transmission, such as homeless persons,
injection drug users, and persons with HIV infection,
 Persons who work or reside with people who are at high risk for TB in
facilities or institutions such as hospitals, homeless shelters, correctional
facilities, nursing homes, and residential homes for those with HIV.
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2/9/2023
Persons who have been Recently Infected with TB Bacteria

33.
PERSONS WITH MEDICAL CONDITIONS THAT WEAKEN THE IMMUNE SYSTEM
Babies and young children often have weak immune systems.
Other people can have weak immune systems, too, especially people with any of
these conditions:
 HIV infection (the virus that causes AIDS),
 Substance abuse,
 Silicosis,
 Diabetes mellitus,
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34.
CONT….
 Severe kidney disease,
 Low body weight,
 Organ transplants,
 Head and neck cancer,
 Medical treatments such as corticosteroids,
 Specialized treatment for rheumatoid arthritis or Crohn’s disease.
2/9/2023 34

35.
 Habits, Lifestyles: Overcrowding, temperature,
humidity, sunlight and person-to-person contact
 Urbanization: has enabled HIV infection to spread in
densely populated areas. For these reasons, factors
that increase HIV infection will clearly contribute to
increase the tuberculosis incidence. (8)
 People infected with TB bacteria have a 5–15%
lifetime risk of falling ill with TB.
 However, persons with compromised immune
systems, such as people living with HIV,
malnutrition or diabetes, or people who use tobacco,
have a much higher risk of falling ill. 35

36.
Mode of transmission (MOT)
 Droplet infection
 Droplet nuclei
Incubation period
 Weeks to years generally 3-6 weeks
Period of communicability
 As long as not treated
36

37.
MODE OF TRANSMISSION (MOT)
 TB spread person to person through the air via
droplet nuclei. M. tuberculosis may be expelled
when an infectious person
Cough-Sneezes-Speaks-Sings
 A person needs to inhale only a few of these
germs to become infected.
 People with active TB can infect 10-15 other
people through close contact over the course of a
year.
37

38.
 About one-quarter of the world's population has latent TB
Then
Q. What do you mean by Latent TB?
Q. Latent Tuberculosis is infectious or non infectious?
38

39.
1) Latent TB Infection
TB bacteria can live in the body without making person sick.
This is called latent TB infection.
In most people who breathe in TB bacteria and become
infected, the body is able to fight the bacteria to stop them from
growing.
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2/9/2023

40.
People with latent TB infection:
 Have no symptoms,
 Don’t feel sick,
 Can’t spread TB bacteria to others,
 Usually have a positive TB skin test reaction or positive
TB blood test,
 May develop TB disease if they do not receive treatment
for latent TB infection.
2/9/2023 40

41.
2) TB Disease
Has symptoms that may include :
2/9/2023 41

42.
CONT….
2/9/2023 42
Weakness or fatigue
Coughing up blood or
Blood in sputum

43.
 A bad cough that lasts 3 weeks or longer,
 Pain in chest,
 Chills,
 Sweating at night.
 Symptoms of Extra pulmonary TB may vary
upon the organ involved.
2/9/2023 43

44.
 Without proper treatment, 45% of HIV-negative
people with TB on average and nearly all HIV-
positive people with TB will die.
44

45.
CLINICAL FEATURES
Divided into 3 types
1. Pulmonary Tuberculosis: Most infective and
consolidation is seen in X-ray lungs
2. Extra pulmonary Tuberculosis: Like GI tract
(most common), Spine (Potts spine), skin (Lupus
Vulgaris), meninges, bones
3. Millary Tuberculosis: disseminated tuberculosis
in blood.
45

46.
 According to national TB protocol 2070 the
types and classification of TB is followings
1. Pulmonary, Bacteriological Confirmed (PBC)
2. Pulmonary, Clinically Diagnosed (PCD)
3. Extra Pulmonary, Bacteriologically Confirmed
of Clinically Diagnosed (EP)
46

47.
SIGN AND SYMPTOMS OF TUBERCULOSIS
47

48.
CLINICAL FEATURES
Clinical features depends on the site of
tuberculosis. In pulmonary tuberculosis:-
 Cough for 2 or more week duration
 Night sweats
 Sputum production
 Shortness of breath
 Chest and or back pain
 Hemoptysis (blood stain sputum)
 Loss of appetite 48

49.
DIAGNOSIS OF TB
 Case finding tools in tuberculosis :
• Sputum microscopy : Method of choice
• Sputum culture
• Mass miniature radiography
• Tuberculin test
49

50.
DIAGNOSIS OF TB
i) Tuberculin test (screening Test)/Mantoux test
 Discovered by Van Pirquet
 Only means of estimating prevalence of infection
 1 tuberculin unit of PPD (Purified Protein
Derivative) in 0.1 ml is injected ID on the flexor
surface of the forearm.
 Result will read after 72 hours (3rd day)
50
Interpretation of test: Reaction shows
a) > 10 mm-Positive b) < 6 mm-Negative c) 6-9 mm -Doubtful

51.
DIAGNOSIS OF TB
ii)Sputum examination
 Sputum examination by direct microscopy is the
method of choice
 3 samples are to be examined by for consecutive
3 days
 Sputum culture: second important method
iii) Radiography: Chest x ray
51

52.
SOME TERMINOLOGIES
 New Case
 Relapse
 Treatment Failure
 Defaulter
 Cured
52

53.
• New case: Apatient who had never had treatment for TBor has
taken Anti tubercular drugs for less than 4weeks can be sputum
smear +veor -ve.
• Relapse - A patient who returns smear +ve having previously
been treated for TBand declared cured after the completion of
histreatment.
• Treatmentafterfailure: Asmear +vepatient who remain smear+ve
at 5months or later during the causeoftreatment.
• Treatmentafterloss to follow up:Apatient who returns smear
+veafter having left treatment forat least 2months.
• Cured:Initially smear +vepatient who becomesmear-ve
result on at least two occasionsafter completion of
treatment.
53

54.
TREATMENT OF TUBERCULOSIS
 TB treated with multiple drugs i.e. multidrug treatment
Multidrug treatment has following benefits:
a. Prevents emergence of persisters
b. Prevents relapse
c. Prevents emergence of resistance
d. Shorter the duration
Multidrug treatment is given in two phase:
a. Intensive phase:
 Short phase lasting for 1-3 months
 Aim to kill as many bacilli as possible
 Prevents emergence of persisters
 Reduce risk of relapse
b. Continuation phase:
 Last for 4-5 months
 Aim at sterilizing smaller number of dormant or persisting bacilli
54

55.
MEDICINE USED FOR TREATMENT BASED ON
NATIONAL PROTOCOL
CAT Intensive phase Contionous Phase
I New pulmonary TB case
(PBC+PCD)
2HRZE 4HR
New EP TB case (BC+CD) 2HRZE 4HR
All Pulmonary Retreatment cases
at least RIF sensencative
All uncomplicated EP TB
Retreatment case
3 HRZE 5HRE
II For exceptionally complicated
EP TB cases
2 HRZE 7 HRE
55
The number before the letters refers to the number of months of treatment.
H: Isoniazid (600mg), R: Rifampicin (450mg), Z: Pyrazinamide (1500mg), E: Ethambutol (1200mg) Patients who
weight more than 60 kg receive additional Rifampicin 150 mg. Patient in categories I and II, who have a positive
sputum smear at the end of the initial intensive phase, receive an additional month of intensive phase treatment.
*The Category II regimen should no longer be used in Nepal.
The new treatment regimen consists of only 2 months of intensive phase with 4
drugs (RHZE) and 4 months continuation phase with 2 drugs (RH) only.

56.
MEDICINE USED FOR TREATMENT BASED ON NATIONAL
PROTOCOL: THE NEW TREATMENT REGIMEN
56

57.
NEW TREATMENT REGIMEN FOR ALL TB CASES
(PTB & EPTB) AND ADULT DOSAGES
57

58.
58

59.
TREATMENT OF MULTIDRUG RESISTANCE
(MDR) TB:
• Previously it was classified as category IV under
DOTS (DOTS-Plus) of TB
• Total duration of treatment for regimen for MDR TB
is 24-27 months, depending on IP duration
 Treatment regimen comprises:
 a. Intensive phase (6-9 mths): Kanamycin (kmc),
pyrazinamide (z), levofloxacin (lvx), ethionamide
(eto) and cycloserine(cs) b. Continuous phase (18
mths): four drugs(pyrazinamide, levofloxacin,
ethionamide and cycloserine )
59

60.
TREATMENT OF EXTENSIVE DRUG
RESISTANCE (XDR) TB
 XDR-TB is defined as resistance to any fluoroquinone
and at least one of the following three second line drugs
(capreomycin, kanamycin and amikacin), in addition to
multidrug resistance.
 The regimen for XDR-TB would be of 24-30 months
duration with 6-12 months intensive phase (IP) and 18
months continuation phase (CP)
• Regimen is:
a. Intensive phase (6-12 months): seven drugs-
capreomycin, PAS, moxifloxacin, high dose INH,
clofazimine, linezolid, amoxiclav
b. Continuation phase (18 months): six drugs- PAS,
moxifloxacin, high dose INH, clofazimine, linezolid,
amoxiclav 60

61.
ANTI-TUBERCULAR DRUGS
Bactericidal drugs Bacteriostatic drugs
Isoniazid (H)
Rifampicin (R)
Streptomycin
Pyrizinamide (Z)
Ethambutol (E)
Ciprofloxacin
Ofloxacin
Kanamycin
Thiaacetazone
Cycloserine
PAS
Ethionamide 61

62.
REASONS FOR DRUG RESISTANT TB
 Using only one drug for treatment
 Defaulter
 Irregular use of drug
 Low quality drug use
 Inadequate dose use
62

63.
DRUG RESISTANT TB
 Multi Drug Resistant TB (MDR TB)
 Extensively Drug Resistant TB (XDR TB)
63

64.
MILESTONE OF TB CONTROL IN NEPAL
 1995-Adoption of DOTS policy by GON
 1996- Establishment of 4 model DOTS centre
 1997-DOTS coverage to 14% population
through 29 DOTS centre.
 1998-DOTS coverage to 19% population
through 41 DOTS centre, DOTS through private
sector in Lalitpur
 1999-DOTS coverage to 53% population
through 122 DOTS centre in 48 districts. (4)
64

65.
MILESTONE OF TB CONTROL IN NEPAL
 1999-Initiation of urban DOTS program, DOTS
program initiation in prison, Biratnagar
 2000-DOTS coverage to 75 % population
through 202 DOTS centre and 635 sub centers in
69 districts.
 2001-DOTS coverage to 84 % population
through 224 DOTS centre and 785 sub centers in
75 districts.
 2004-DOTS coverage to 98 % population
through 354 DOTS centre and 1696 sub centers
in 75 districts. (4)
65

66.
MILESTONE OF TB CONTROL IN NEPAL
 2005- Commencement of DOTS plus pilot
project in one place of each five region.
 2006-Adoption of revised DOTS strategy and
MDG by Nepal TB program.
 2007-Adoption and initiation of fixed dose
combination (FDC) system
 2009-Collaboration and expansion of TB/HIV
program (4)
66

67.
MILESTONE OF TB CONTROL IN NEPAL
 2010-Initiation of treatment of XDR-TB
 2012-Initiation of Gen-xpert technology
 2013-DOTS Coverage and access to 100%
population through 1351 DOTS centre and 2916
sub centers.
67

68.
GLOBAL AND COUNTRY COMMITMENTS AND
STRATEGY TO END TB
 In the year2014 and 2015, all Member States of WHO and the
UN committed to ending the TB epidemic,
through the adoption of WHO’s End TB Strategy and the UN
Sustainable Development Goals (SDGs).
 The strategy and SDGs include milestones and targets for
large reductions in TB incidence, TB deaths and costs faced
by TB patients and their households.
 This was followed by the Moscow Declaration to End TB and
then by the UN General Assembly held its first-ever high-level
meeting on TB in 2018. The outcome was a
political declaration in which commitments to the SDGs and
End TB Strategy were reaffirmed and new ones added (Multi-
sectoral accountability framework and meaningful
engagement of civil society).
 Nepal also committed to these declarations and developed
strategies in line with these commitments
68

69.
69

70.
ALL THE COMMITMENTS AND CALLS FOR ACTION WERE TO REACH
SDG AND END TB TARGETS AS MENTIONED BELOW
SDG Target 3.3 By 2030, end the epidemics of AIDS, TB, malaria and neglected
tropical
diseases, and comba the patitis, water-borne diseases and other
communicable diseases
WHO End TB
Strategy
80% reduction in the TB incidence rate(new and relapse cases per
100000
population per year) by 2030, compared with 2015 2020 milestone:
20%
reduction; 2025 milestone: 50% reduction
90% reduction in the annual number of TB deaths by 2030,
compared with 2015
2020 milestone: 35% reduction;
2025 milestone: 75% reduction
No households affected by TB face cata strophic costs by 2020
70

71.
NATIONAL TUBERCULOSIS CENTER
Government of Nepal
Ministry of Health
Department of Health Services
National Tuberculosis Center
 Based commitments with aim to reach the set targets, NTC
developed its National Strategic plan 2016-21with
 VISION of TB Free Nepal by 2050: “Ending TB” defined as less
than 1 TB patient per 1,000,000 population.
 The goals were to decrease the TB Incidence Rate by 20%, from
2015 to 2021 i.e. to identify additional 20,000 new TB cases by the
next 5 years.
71

72.
INSTITUTIONAL COVERAGE FOR TB
TREATMENT AND DIAGNOSIS
 Nepal adopted the DOTS strategy in 1996 and
achieved nationwide coverage in 2001.
 All DOTS centers are integrated into public health
services or run through NTP partner organizations in the
public and private sectors.
 In 2077/78, a total of 5,503 institutions were offering TB
diagnosis and treatment; DOTS-based TB
control services.
 To increase access to treatment services, NTP has
developed partnerships with different organizations
including private nursing homes, polyclinics, I/NGO
health clinics, prisons, refugee camps, police hospitals,
medical colleges, and municipalities 72

73.
PREVENTION AND CONTROL
Based on level of prevention
 Primordial prevention
 Primary prevention
 Secondary prevention
 Tertiary prevention
73

74.
PRIMORDIAL PREVENTION
Prevention of emergence or development of risk
factors in population by:-
 Improve housing and habitat
 Decrease crowding
 Better nutrition of children
 Better hygiene and sanitation
74

75.
PRIMARY PREVENTION
Health Promotion
 Health Education: Educated about tuberculosis,
particularly regarding its mode of spread, potential
hazards of transmission and prevention and control
methods.
 Environmental modification: Manage
overcrowding, better hygiene and sanitation.
Eg: Public transport users have greater risk of TB
infection
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76.
PRIMARY PREVENTION
 Nutrition education: Protein energy
malnutrition and micronutrients deficiencies
increase the risk of tuberculosis, raising
nutritional status of population may prove to be
an effective measure to control tuberculosis in
underdeveloped areas of world.
 Life style and behavior changes: Smoking
cessation, avoid harmful use of alcohol
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77.
PRIMARY PREVENTION
Specific Protection
 Immunization: BCG vaccination at birth
 Use of specific nutrition: to prevent from
malnutrition.
 Chemoprophylaxis: of tuberculosis by using
drugs eg. Isoniazid and Rifampicin
 Protection against carcinogen: occupational
hazard eg. In COPD tuberculosis is observed.
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78.
PRIMARY PREVENTION
 Environmental control: good ventilation, proper
sunlight.
 Face masks: use for health workers and TB
patients
 HIV positive health workers shouldn’t work with
pulmonary TB patients.
 Protection of immune compromised people from
opportunistic infections like TB.
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79.
BCG VACCINE
 BCG stands for ‘Bacille Calmette Guerin’ an
‘avirulent strain’
 Live attenuated vaccine
 WHO recommended strain: DANISH 1331
strain
 1 time at birth within a year
 Contradiction in HIV infected children
 Dose: 0.05 ml
 Intra-dermal route of administration
 Vaccine storage at 2-8 ºC.
79

80.
SECONDARY PREVENTION
Early diagnosis and prompt treatment
 Screening tests: Tuberculin test
 Diagnostic test:
i)Sputum examination
 Sputum examination by direct microscopy is the
method of choice in which 2 samples are to be
examined by for consecutive 2 days. Sputum
culture is taken as second important method
ii) Radiography: Chest x ray
 Pulmonary TB suspects should be diagnosed for
TB
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81.
TERTIARY PREVENTION
Disability limitation and Rehabilitation
 The theme of World TB Day 2017 is “Invest to
End TB. Save Lives”.
 Enabling TB patients to take more responsibility
for their health.
 Organization of TB patient groups and clubs.
 Instituting more patient-centered TB and general
health care
 Improving the advocacy skills of TB patients
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82.
BCG VACCINE
 BCG vaccine is a live attenuated vaccine produced
by 'BacilleCalmete Guerin'
 There are two types of vaccine:
 Freeze dried (lypholized): more stable and currently in
use
 Fresh/liquid vaccine:
 Strain required for vaccine preparation is DANISH
1331 strain, derived from M. bovis.
 Normal saline is used as a diluent for reconstituting
vaccine, as distilled water may cause irritation. The
reconstituted vaccine should be used within 3 hours
(reconstituted vaccine of measles should be used
within 1 hour) 82

83.
 Site: just above insertion of deltoid, intradermal
injection, dose is 0.1 ml for all ages and given at birth or
at 6 weeks of age simultaneous with DPT and polio.
 Direct BCG vaccination- BCG vaccination without prior
mantoux test
 Recommended upto 1 year of age.
 Indirect BCG vaccination - BCG vaccination is given
after mantoux test
 Recommended beyond age of 1 year
 Duration of protection is around 15-20 years
 Vaccine must be protected from exposure to light during
storage (wrapped upon double layer of red and black
cloth )
83

84.
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Thank You!!
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