medical

1. .
INSTITUTE OF HEALTH SCIENCES
SCHOOL OF NURSING AND MIDWIFERY
DEPARTMENT OF ADULT HEALTH NURSING
PRESENTATION ON TUBERCULOSIS
By Demiso Geneti ( MSc fellow)
Wollega, Oromia, Ethiopia
2/8/2023 TB B by Damee 1

2. Learning objectives
At the end of this section the learners will be able to:
1. Define tuberculosis
2. Describe epidemiology of tuberculosis
3. Listing pathophysiology of tuberculosis
4. Define risk factors of tuberculosis
5. Describe clinical features of tuberculosis
6. List treatment guideline of tuberculosis
7. List nursing intervention of tuberculosis
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3. Pulmonary Tuberculosis (PTB)
Tuberculosis (TB) is an infectious disease that primarily
affects the lung parenchyma in which case it is called
pulmonary TB.
In addition to the lungs, any part of the body can be
affected with this bacterium and in this case it is called
extra pulmonary TB.
TB affects individuals of all ages and both sexes, and
estimated to infect 1/3 of world population leaving
increased pool of vulnerability to develop active.
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4. TB….
Infectious agent
1. M. tuberculosis :- human tubercle bacilli (commonest
cause)
2. M. bovis:- causes cattle and man infection
3. M. avium:- causes infection in birds and man
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5. Epidemiology of TB
 TB affects an estimated 10 million people per year (range 8.9–
11.0 million) and is one of the world’s leading infectious disease
killers. Due to malnutrition, immunity, overcrowded, susceptible
 Of the estimated 10 million, approximately 70% are diagnosed
and treated and also reported to the WHO, resulting in 7.1
million TB notifications by National TB Programme,
 Of the 7.1 million persons notified in 2019, 5.9 million (84%)
had PTB (WHO consolidated guidelines on TB 2022)
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6. TB situations in Ethiopia
 TB remains a major public health problem worldwide and leading
cause of morbidity and mortality.
 Currently, 1.7 billion (26%) of the world’s population are
considered to be infected with MTB.
 In Ethiopia, TB is a major public health problem.
 The country is still among the 22 high TB burden countries with
high number of missed and infectious TB cases in the community.
 TB is among the top ten causes of admission and deaths in adults.
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7. Epidemiology of TB…
It is also estimated that Ethiopia had 191,000 new TB
cases in 2015.
This number ranks Ethiopia 10th globally and 4th in
Africa, after Nigeria, South Africa and the DR Congo.
Ethiopia is also one of the 27 countries with a high
burden of multidrug-resistant TB.
A study conducted in Addis Ababa, Ethiopia showed
that the prevalence of both PTB and EPTB was 46.0%
(Eshetu Temesgen, etl, Addis Ababa, 2021)
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8. Epidemiology of TB…
 In Ethiopia, TB case detection is below the WHO target.
 In 2019, 29.3% of cases were not notified to the national TB
program
 The prevalence of pulmonary TB cases among people who
sought health care with cough of any duration was 16.7%, of
which 95.5% PTB cases were diagnosed at OPDs.
 Of 16.7% of TB cases, 60% was confirmed by sputum and 40%
was confirmed by CXR, history & clinical.
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9. Epidemiology of TB…
The prevalence of confirmed PTB among routine
outpatients was high, and this included those with a
low duration of cough who can serve as a source of
infection.
Screening all patients at outpatient departments who
passively report any cough irrespective of duration is
important to increase TB case finding and reduce TB
transmission and mortality (Hussen M, etl, Ethiopia,
2020)
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10. CONT…
 TB related mortality is highlighted in the top ten reported
causes of death among hospital admissions, with annual
estimated death rate of 26 per 100,000 populations in 2015.
 TB incidence 42% of decline from annual 369 cases per
100,000 populations to 177 per 100,000 populations in 2016
 Ethiopia remains to be among the 30 countries reported with
high burden of TB, TB/HIV and DR-TB for 2015 to 2020.
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11. ….
 In 2016, estimated 35% of incident TB cases were
missed
 TB remains to be the leading causes of death of
people with HIV, accounting for around 40% of
AIDS-related deaths.
 Both diseases together form a lethal combination,
each speeding the other's progress.
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12. ….
 In Ethiopia, 82% of notified TB patients in 2016 knew their
HIV status while 82% of reported HIV-positive TB patients
have accessed antiretroviral therapy.
• HIV infection and TB disease on same year leaving people at
increased risk of suffering & mortality
MDG achieved
 HIV prevalence in incident TB cases (TB/HIV co-infection rate)
is about 11%, Global average 13%, African average 34%
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13. ….
 Ethiopia adopted the DOTS strategy since 1997 after
successful pilot program with the development of the
first combined TB and Leprosy Prevention and Control
Program manual.
 TB/HIV collaborative activities were piloted in 2004 and
subsequently scaled up national (Ethiopia National
guideline for TB Leprosy and TB 6th edition Aug-2018)
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14. TB Control strategy
 Globally different control strategies were implemented for the
past two decades to reduce morbidity and mortality due to TB all
over the world. These strategies were, DOTS (directly observed
treatment, short-course) strategy of 1995.
 The stop TB Strategy of 2006 that aided to reduce all forms of
TB including HIV-associated and drug-resistant TB
 These strategies got remarkable achievement in that 37 million
lives were saved between 2000 and 2013/15
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17. TB Control strategy…
Recently, WHO developed the end TB strategy with
an overall goal of a 90% reduction in TB incidence
and a 95% reduction in TB deaths from 2015 to 2035
by integrated patient-centered care and prevention,
bold policies and supportive systems, intensified
research and innovation (Eshetu Temesgen, etl,
Addis Ababa, 2021)
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18. TB Control strategy…
The national TB program has strategic plan in the 5-year
towards achieving the END TB 90-(90)-90 targets set for 2020:
1. Ensure 90% of all people with TB diagnosed and treated.
2. Ensure 90% of the key populations in the country are
diagnosed and treated
3. Ensure 90% of people diagnosed successfully complete
treatment ( FMOH. National TB strategic plan: 2017-2020)
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19. Ethiopia TB Roadmap Overview,2022-2026
 Among the top 30 high TB burden countries, Ethiopia
ranked 12th; and among the high multidrug-resistant TB
(MDR-TB) burden countries, Ethiopia ranked 24th .
 While some gains have been made in decreasing TB
incidence, from 421 (in 2000) to 132 (in 2020) per 100,000,
of incidence and mortality from drug-susceptible TB
remain high, while treatment coverage remains low.
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20. Ethiopia TB Roadmap Overview,2022-2026…
 Currently, the NTP revised its five-year TB and
Leprosy National Strategic Plan , which will cover the
period 2021-2026
 The TBL-NSP aims to reduce TB incidence from151
cases per 100,000 and 22 deaths per 100,000 in 2018
to 91 cases per 100,000 and 7 deaths per 100,000 by
2026 respectively.
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21. By Prioritizing the following interventions
1. Scaling-up the use of rapid diagnostics for routine screening
2. Engaging all care providers in TB diagnosis and care;
3. Prioritizing reaching vulnerable populations
4. Decentralization of TB care and treatment;
5. Mitigating the catastrophic cost of TB care on patients and HHS
6. Increasing contact screening coverage and preventive treatment
7. Mitigating TB-related stigma in the community and healthcare
8. Proactively finding ways to manage other respiratory impacts
(Ethiopia_Narrative_TBRM22_Version_Final)
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22. Transmission of TB
 TB spreads from person to person by airborne transmission.
 An infected person releases droplet nuclei (usually particles
1 to 5 mcm in diameter) through talking, coughing,
sneezing, laughing, or singing.
 Larger droplets settle; smaller droplets remain suspended
in the air and are inhaled by a susceptible person.
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23. Lists risk factors for TB
Ꞝ Close contact with someone who has active TB
Ꞝ Immunocompromised status
Ꞝ Substance abuse (IV/injection drug users and alcoholics).
Ꞝ Any person without adequate health care
Ꞝ Preexisting medical conditions or special treatment
Ꞝ Immigration from or recent travel to countries with a high
prevalence of TB.
Ꞝ Institutionalization
Ꞝ Living in overcrowded, substandard housing.
Ꞝ Being a health care worker performing high-risk activities
(Adapted from CDC and Prevention Sep 1, 2012)
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24. Pathophysiology
 TB begins when a susceptible person inhales
mycobacteria and becomes infected.
 The bacteria are transmitted through the airways to the
alveoli, where they are deposited and begin to multiply.
 The bacilli also are transported via the lymph system
and bloodstream to other parts of the body (kidneys,
bones, cerebral cortex) and other areas of the lungs.
 The body’s immune system responds by initiating an
inflammatory reaction
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25. Pathophysiology….
 Phagocytes (neutrophils and macrophages) engulf many of the
bacteria, and TB-specific lymphocytes destroy the bacilli and
normal tissue.
 This tissue reaction results in the accumulation of exudate in the
alveoli, causing bronchopneumonia.
 The initial infection usually occurs 2 to 10 weeks after exposure.
 Granulomas, new tissue masses of live and dead bacilli, are
surrounded by macrophages, which form a protective wall.
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26. Pathophysiology….
 They are then transformed to a fibrous tissue mass, the central
portion of which is called a Ghon tubercle.
 The material (bacteria and macrophages) becomes necrotic,
forming a cheesy mass. This mass may become calcified and
form a collagenous scar.
 At this point, the bacteria become dormant, and there is no
further progression of active disease.
 After initial exposure and infection, active disease may develop
because of a compromised or inadequate immune system
response
 Active disease also may occur with reinfection & activation
of dormant bacteria.
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27. Pathophysiology….
 In this case, the Ghon tubercle ulcerates, releasing the
cheesy material into the bronchi.
 The bacteria then become airborne, resulting in the
further spread of the disease.
 THIS CAUSES the infected lung to become more
inflamed, resulting in the further development of
bronchopneumonia and TB formation.
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28. Evolution of TB infection and disease
1. Latent TB infection: Individuals with latent TB
infection do not have symptoms as there is no tissue
destruction by the bacilli and are not infectious.
In immunocompetent individuals, only 5-10% of
infected persons develop active disease in their life
time.
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29. CONT…
2. Active TB disease : may arise from progression of the
primary lesion after infection (Primary TB), or from
endogenous reactivation of latent foci, which remained
dormant.
The progression from LTBI to Active TB disease may
occur at any time, from soon to many years later.
Post primary/secondary TB usually affects the lungs
(Pulmonary TB) and
If it disseminated, to all organs can be affected
(MiliaryTB)
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30. CONT….
3. Prognosis of TB: In the great majority (90-95%) of
persons infected with MTB, the immune system either
kills the bacilli or perhaps more often, keeps them
suppressed (silent focus) resulting a latent TB infection
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31. Registration group for TB patient
New TB: patients that have never been treated for TB or have
taken anti-TB drugs for less than one month.
Relapse: patients who were declared cured or treatment
completed at the end of their most recent treatment course, and is
now diagnosed with a recurrent episode of TB.
Treatment after failure: refers to patients who were declared
treatment failure in their most recent course of treatment as per
national protocol.
.
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32. Registration group for TB patient…
Treatment after loss to follow-up: refers to patients
who were declared lost to follow-up at the end of their
most recent course of TB treatment and is now decided
to be treated with full course of TB treatment.
Transfer in: A patient who is transferred to continue
treatment at a given reporting unit after starting
treatment in another reporting unit.
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33. Clinical features
 The clinical features of TB depend on the specific
organ affected.
 The clinical features can be grouped:
1. General (non-specific) and
2. Organ specific
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34. Clinical features….
Tuberculosis has two major clinical forms
Pulmonary (80%) of the total TB cases.
 Primarily occurs during child hold & secondarily 15-45
years or later.
Extra pulmonary (20%) affects all parts of the body.
 Most common sites are lymph nodes, pleura, GUT,
bone and joints, meninges & peritoneum.
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35. Clinical features….
A. General symptoms of TB (PTB or EPT)
 Weight loss
 Fever
 Night sweats
 Loss of appetite
 Fatigue
 Malaise
 Malnourished and chronically sick appearance
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36. Clinical features….
B. Organ specific
 Pulmonary tuberculosis
 Cough that lasts for more than 2weeks with or without
sputum production
 Chest pain
 Hemoptysis
 Shortness of breath
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37. Clinical features….
Tuberculosis lymphadenitis
 Slowly growing painless lymph node enlargement
 Initially firm and discrete, later become matted and
fluctuant
 Formation of abscesses and discharging sinuses,
which heal with scarring
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38. Clinical features….
Tuberculous pleurisy
 Pleuritic chest pain (pain while breathing /coughing
/sneezing)
 Intermittent cough
 Shortness of breath
 Signs of pleural effusion (dullness, decreased/absent
air entry and decreased tactile fremitus)
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39. Clinical features….
 TB of bones and or joints
 Localized pain and or swelling +/-discharge ,stiffness of joints
 Spine(TB spondylitis):localized swelling over the back ,back
pain paralysis (weakness of the lower extremities)
 Abdominal TB
 Chronic non- specific abdominal pain with diarrhea or constipation
 Fluid in the abdominal cavity(ascites).
 Mass(inflammatory mass) in the abdomen
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40. Clinical features….
Tuberculous meningitis
 Head ache, fever, vomiting: insidious onset
 Neck stiffness, impaired level of consciousness.
Tuberculous pericarditis
 Chest pain (pleuritic)
 Shortness of breath
 Pericardial friction rub or distant t heart sound
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41. Diagnosis of Pulmonary Tuberculosis in
Adult and Adolescents
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43. Investigations and diagnosis
The diagnosis of TB requires the following
 Clinical suspicion,
 Physical examinations and
 Microbiologic identification of the bacilli.
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44. Investigations and diagnosis…
Ꞝ Sputum direct microscopy: Acid Fast Bacilli(AFB)
staining
 Three sputum specimens(Spot early morning-spot),
need to be collected and examined in two consecutive
days
 Result must be available on the second day.
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45. Investigations and diagnosis…
Ꞝ Gene Xpert MTB/RIF
 A fully automated DNA/molecular diagnostic test to
detect TB and Rifampicin resistance simultaneously.
 It is recommended as the initial diagnostic test for all
persons being evaluated for TB
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46. Investigations and diagnosis…
Ꞝ Sputum culture and drug susceptibility
 Culture is the gold standard
 It takes weeks to get the results.
 If sputum AFB and/or Gene Xpert are negative and there
is a strong suspicion, sputum culture can be send to a
referral laboratory.
 However, treatment for an alternative diagnosis or
“clinical TB”should not be delayed
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47. Investigations and diagnosis…
Ꞝ Tuberculin Skin Test
 The Mantoux method is used to determine whether a person
has been infected with the TB bacillus
 Is used widely in screening for latent MTB infection.
 The Mantoux method is a standardized,intracutaneous
injection procedure.
 Purified protein derivative (PPD) 0.1 ml is injected into the ID
layer of the inner aspect of the forearm, approximately 4
inches below the elbow.
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48. Tuberculin Skin Test…
• The test result is read 48 to 72 hours after injection.
• Tests read after 72 hours tend to underestimate the
true size of induration (raised hard area or swelling).
• A delayed localized reaction indicates that the person
is sensitive to tuberculin
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49. Interpretations
 The size of the induration determines the significance of the rxn.
 A reaction of 0 to 4 mm is considered not significant or negative
 A reaction of 5 mm or greater may be significant in people who
are considered to be at risk.
 An induration of 10 mm or greater is usually considered
significant in people or positive
 In general, the more intense the reaction, the greater the
likelihood of an active infection.
 A negative tuberculin skin test doesn’t exclude TB, so its no help
in deciding that some one does not have TB.
(2018.14edi.Brunner & Suddarth’s Textbook of.pdf)
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50. CONT…
 The criterion for a significant or 'positive' tuberculin test
depends on whether a child has previously had BCG
vaccination or not.
 This is because a reaction to tuberculin is usual after a
previous BCG, for several years
 A significant reaction indicates past exposure to M.
tuberculosis or vaccination with BCG.
 The BCG vaccine is given to produce a greater resistance
to development of TB (60%-80% protect)
 A positive tuberculin test is only one piece of evidence in
favor of the diagnosis of TB.
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51. Investigations and diagnosis…
Ꞝ Imaging:
 Chest X-ray:- patients who cannot produce sputum or
who have negative Xpert results. But CXR is non-
specific for TB
 Depending on the suspected extra pulmonary sites
other imaging modalities may be needed.
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52. Investigations and diagnosis…
Ꞝ Other investigation:-
 HIV test, CBC, ESR, CSF analysis
 Body fluid analysis and identification of pathogen
 Tissue biopsy and histopathology
 Fine needle aspiration and histopathology examination:
enlarged lymph nodes
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53. Treatment of drug susceptible TB
Objectives
Cure
Prevent death from active TB or its late complications
Restore quality of life and productivity
Decrease transmission
Prevent relapse
Prevent the development and transmission of medicine
resistance
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54. Essential properties of TB treatment
In order to achieve the designed aim of treatment, an
anti-TB treatment regimen should be administered:
 In appropriate combination of drugs
 In the correct dosage
 Regularly taken by the patient, and
 For a sufficient period of time
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55. Non pharmacologic
Counseling: adherence, the nature of treatment,
contact screening
Good nutrition
Adequate rest
Admission for severely ill patients
E.g. Tb meningitis, pericarditis
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56. Pharmacologic
Standardized combination treatment:
All patients in a defined group receive the same
treatment regimen.
A combination of 4 or more anti-TB medicines.
Directly observed treatment (DOT)
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57. First line anti-TB Medicines
The first line anti-TB treatment available in Ethiopia are:
1. Rifampicin(R):the most bactericidal and potent sterilizing
agent
2. Isoniazid(H):highly bactericidal especially in the first few
days
3. Pyrazinamide (Z):only active in acidic environment and
bacilli inside macrophages
4. Ethambutol(E):bacteriostatic and effective to prevent drug
resistance when administered with other potent drugs
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58. Table :- The essential anti-TB drugs and their dose
Recommended adult dose and body weight
Daily dose (mg/kg) Maximum (mg) First line TB drugs
5 (4-6) 300 Isoniazid(H)
10 (8-12) 600 Rifampicin(R)
25 (20-30) 2,000 Pyrazinamide(Z)
15 (15-20) 1,600 Ethambutol(E)
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59. Phases of chemotherapy
TB treatment is administered in two phases:
1. Intensive (initial) phase: aims to reduce the patient non-
infectious by rapidly reducing the bacillary load in the
sputum and brings clinical improvement in most patients
receiving effective treatment.
2. Continuation phase: aims to sterilize the remaining semi-
dormant bacilli and is important to ensure cure/completion
of treatment and prevent relapse after completion of Rx.
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60. A. Standardized first line treatment regimen for new drug
Susceptible or presumed to be drug susceptible TB
1. New pulmonary TB patients presumed or known to have drug-
susceptible TB
2. New extra pulmonary patients
 Standardized regimen: 6 months total (2months intensive and
4months continuation phase) : 2RHZE/4RH
 Intensive phase: 2 months Rifampicin, Isoniazid, Pyrazinamide
& Ethambutol (2RHZE)
 Continuation: 4months Rifampicin and Isoniazid (4RH)
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61. First line TB treatment adult dosing chart using
patient’s body weight
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62. B. Previously treated TB patients presumed or known to
have drug-susceptible TB
In all previously treated TB patients who require re-
treatment, specimen for rapid molecular-based drug
susceptibility testing for first line TB drugs
 While awaiting the result, the standard first line
treatment regimen is recommended:2(RHZE)/4(RH)
 Re- treatment regimen” with addition of streptomycin
is not recommended.
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63. C. Patients who presented with active TB after known
contact with patient documented to have drug-resistant TB
 Sample should be sent for rapid drug susceptibility Test
(DST)
 Treatment should be decided based on rapid DST result.
 While awaiting DST result, the patient may be initiated
treatment with the regimen based on the DST of the
presumed source case.
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64. D. Extended continuation phase
 EPTB forms of TB require prolonged continuation phase
A.CNS (TB meningitis orTuberculoma)
B. Bone or joint TB (Vertebral (TB spondylitis), joint &
osteomyelitis.
 Regimen (a total of 12 months:2months intensive phase and10
months continuation phase); -2RHZE/10RH
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65. E. Adjuvant corticosteroid therapy
Adjuvant corticosteroid therapy, dexamethasone or
prednisolone tapered over 6- 8weeks should be used
for patients with the following two extra pulmonary
forms
TB meningitis
TB pericarditis
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66. Monitoring of patients on treatment
1. Clinical monitoring: During scheduled visit patient checked for:
Persistence or reappearance of clinical feature of TB
Weight monitoring: weight is a useful indicator of improvement
Occurrence of Adverse drug reaction
Development of TB complication
Adherence: By reviewing the“ treatment supporter card” or Unit
TB register
Risk for drug resistance & need for drug susceptibility screen test
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67. 2. Bacteriologic monitoring for initially
bacteriologically confirmed PTB
 Sputum AFB should be done at end of 2nd,5th and 6th
month of therapy.
 Molecular technique like Gene Xpert, MTB cannot be
used to monitor. WHY?
 Treatment as the technique may give false positive
result by identifying dead bacilli
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68. Bacteriologic monitoring…
 If AFB positive at the end of 2nd month: send sputum sample for
Xpert for DST.
 If at least Rifampicin sensitive: continue to the continuation phase.
 If Rifampicin resistance: Mark as Rifampicin-resistant Tb & the
outcome is labeled as“ MDR TB”. Treatment will be started as
MDR-TB.
 If AFB is positive at the end of 5th or 6th month: the outcome is
treatment failure. DST testing and treatment will proceed as
MDR-TB suspect
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69. Treatment of patients also infected with HIV
 All patients with HIV and active TB who are not on ART should
be started on ART as described below:
 CD4<50cells/mm3:Initiate ART within 2weeks of starting TB t/t
 CD4 counts ≥50cells/mm: Initiate ART with in 8weeks of
starting TB treatment.
 During pregnancy, regardless of CD4 count: Initiate ART as
early as feasible for to prevent HIV transmission to the infant.
 With TB meningitis: Initiate ART after 8weeks of TB treatment.
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70. Nursing Management
 Promoting airway clearance
 Increasing the fluid intake promotes systemic hydration
 Nurse instructs the patient about correct positioning
 Promoting adherence to treatment regimen
 Understanding of the medications, schedule, and side effects,
avoiding alcohol consumption.
 Nurse educate the patient about regular drug taking, taking
medication on empty stomach or 1 hr. before meals.
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71. Nursing Management…
 Promoting activity and adequate nutrition
 The nurse plans a progressive activity schedule that focuses
on increasing activity tolerance and muscle strength.
 A nutritional plan that allows for small, frequent meals may
be required.
 Liquid nutritional supplements may assist in meeting basic
caloric requirements
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72. Nursing Management…
 Preventing Transmission of TB Infection
 The nurse carefully instructs the patient about important
hygiene measures, including mouth care, covering the
mouth and nose when coughing and sneezing, proper
disposal of tissues, and hand hygiene.
 TB is a disease that must be reported to the health
department so that people who have been in contact with the
affected patient during the infectious stage ( Brunner
textbook pdf 14th edition)
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73. THANK YOU
4 UR ATTENTION!!!
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74. Reference
1. Ethiopia tuberculosis roadmap overview, fiscal year 2022
2. CDC U.S. TB Clinical Guidelines Update, 2022
3. Final draft TBL-NSP July 2021 – June 2026, August 2020 by MOH
4. WHO Regional Office for Africa, 2017
5. Ethiopia-National-guideline-for-TB-Leprosy-and-DR TB-6th-ed-Aug-2018
6. WHO consolidated guidelines on drug-resistant TB treatment
7. 2018.14 edi.Brunner & Suddarth’s Textbook of.pdf
8. STG for general Hospitals in Ethiopia 4thEdition,2021by MOH
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