Communicable diseases

1. TUBERCULOSIS

2. INTRODUCTION
Globally,10.0 million people were infected with TB, in the year 2018
which accounted to 132 cases per 100,000 population. TB is one of
the top 10 causes of death.world wide, 1.7 billion people are
infected with M.tuberculosis and are at risk of developing the
disease.
Tuberculosis affects both sexes,but men has highest burden of the
disease that accounted 57% of all TB cases in 2018, adult women
accounted for 32% and children 11% among all TB cases, 8.6%
were people living with HIV.
In 2018, south-east Asia (44%), Africa (24%)and the western Pacific
(18%) regions of WHO showed higher percentages of cases Eastern
Mediterranean(8%),the Americas(3%)and

3. Europe(3%) showed lesser percentages of cases.Eight countries
accounted for two thirds of the global burden of TB:
India(27%),China(9%), Indonesia (8%) Philipines (6%), Pakistan
(6%),Nigeria(4%), Bangladesh (3%),and South Africa (3%).
World TB incidence showed a decline of 1.6% from the years 2000 to
2018 and 2.0% between 2017 and 2018. The global cumulative case
reduction rate was 6.3% and decline in TB death rate was 11% for the
years from 2015 to 2018. SDG 3 aims to end the global TB epidemic by
2030. The goal aims to attain a 90% reduction in TB incidence rate
between 2015 and 2030.

4. DEFINITION
Tuberculosis is a contagious infection that usually attacks your
lungs. It can also spread to other parts of your body, like your brain
and spine. A type of bacteria called Mycobacterium tuberculie
causes it.

5. AGENT
M.tuberculosis
Source of infection -case
Infective material - sputum
Infectious cases- communicable disease
ENVIRONMENT
Housing
Quality of life
Overcrowding
illiteracy
Large family
HOST
Age
Sex
Genetic
Nutrition
Acquired immunity

6. CAUSATIVE AGENT
 The causative organism of tuberculosis is M. tuberculosis
(Mycobacterium tuberculosis) is a facultative intracellular
parasite.
 There are two strains: Human strain responsible for vast
majority of cases occuring among human beings and bovine
strain is responsible for infecting cattle and other animals.
 The source of infection is human cases whose sputum is
positive for tubercle bacilli and milk from infected animal.
 Patients are infected as long as they remain untreated.

7. HOST FACTORS
 Tuberculosis affects all ages and more prevalent in males than in
females.
 Though it is not a hereditary disease, twin studies indicate that
inherited susceptibility is an important risk factor.
 Malnutrition predisposes tuberculosis due to poor resistance.
 Immunity is acquired as a result of natural infection or BCG
vaccination.
 With the initiation of chemotherapy host factors are considered less
relevant in the epidemiology of tuberculosis.

8.  Poor quality of life
 Poor housing condition
 Overcrowding
 Population explosion
 Malnutrition
 Lack of education
 Lack of awareness
 Large families
 Early marriage
ENVIRONMENTAL FACTORS

9. MODE OF TRANSMISSION
 Tuberculosis is transmitted mainly by droplet infection and droplet
nuclei generated by sputum of positive patients with pulmonary
tuberculosis. Droplets are generated by coughing.
 Tuberculosis is transmitted by fomites, such as dishes and other
articles used by patient.

10. INCUBATION PERIOD
The incubation period ranges between 3 and 6 weeks. The
development of disease depends on closeness of contact, extent of
disease, extent of infection and host parasite relation

11. CLINICAL MANIFESTATIONS
 Persistent cough
 Weight loss
 Fever
 Night sweats
 Hemoptysis
 Chest pain
 Fatigue

12. LAB INVESTIGATION
MANTOUX TEST
 The tuberculosis is screening test is conducted by injecting tuberculin
purified protein derivative of 0.1 mL into the inner surface of the
forearm.
 A tuberculin syringe is used to administer this intradermal injection.
The injection will produce a pale elevation of the skin as a wheal 6-10
mm diameter.
 The reaction of the skin test should be read within 48-72 hours of
administration.

13.  In case if the patient does not visit the
clinic within 72 hours he/she has to be
called for another skin test.
 The reaction is measured in milimeters of
the induration, the reader should be
measured across the forearm. If the
induration is more than 10 mm the test is
said to be positive.

14. SKIN TEST INTERPRETATION DEPENDS ON TWO FACTORS
 Measurement of induration in millimetres
 Person's level of risk of being infected with TB and of development
to disease if infected.
PREVENTION AND CONTROL
The control measures consists of :
 case finding and TB treatments as curative measures
 BCG vaccination as preventive measure.
.

15. CASE FINDING
Early detection of all cases means finding people whose
sputum is positive for TB bacilli
 Finding the suspects means whose sputum is negative but
x-ray shows suggestive shadows of TB.
 The patients seeking medical advice voluntarily with chest
symptoms like persistent cough and fever are the most
appropriate target group for case findings.

16. SPUTUM EXAMINATION
Sputum examination is the cheapest and most suited tool for
finding the cases. Sputum smears collected from suspected
person's should be collected early in the morning on three
successive days.The presence of at least 10,000 organisms per
ml of sputum is considered "TB positive ".
As per "Revised national tuberculosis control program" priority
for sputum smear examination should be given to patient who
come on their own to hospital or health center with following
symptoms:

17.  Persistent cough of 3-4 weeks duration
 Continuous fever
 Chest pain
 Hemoptysis
SPUTUM CULTURE
 It is a long process needs trained people to perform.
 It is delivered only as centralized service in district hospitals.
 Advised for the patients whose sputum smear is negative but has
chest symptoms.

18. MASS MINIATURE RADIOGRAPHY
This is abandoned as a case finding measure because of its poor yields
with high cost.
CHEST X-RAY
Chest x-ray is recommended as additional method to diagnose
pulmonary tuberculosis when only one smear is positive.
TUBERCULIN TEST
This test does not have much value as a case finding tool. TB

19. CHEMOTHERAPY
Effective treatment is available to treat tuberculosis. The main aim is to
eliminate fast and slowly multiplying bacilli from a case and provide
cure. Chemotherapy is readily available, free of cost to every detected
case. Patient or the case is the core component of the success of the
treatment because it requires strict compliance from the patient. Most
often tuberculosis patients default since they start to feel good and
active only by completing with 2 weeks of medicine at start.
ANTI-TB DRUGS ARE GROUPED INTO TWO
 First-line drugs
 Second - line drugs

20. FIRST LINE DRUGS ARE FURTHER GROUPED INTO
 Bactericidal drugs: INH, Rifampicin, Pyrazinamide and Streptomycin
 Bacteriostatic drugs: Ethambutol and thik acetazone.
A combination of these are used to treat TB patients
FIRST LINE OF DRUGS
Bactericidal drugs
Rifampicin
This is able to prevade all tissue membranes including blood brain and
placental barriers.

21. This is the only drug which is active against dormant bacilli found in solid
lesion.
 can be used only as oral drugs
 Total daily dose: 10-12 mg/kg body weight
 Administer 1hour before or 2 hours after food because absorption is
reduced by food.
 Patient should be told that the drug will turn the urine red.
Toxic effects of rifampicin -hepatoxicity, gastritis, influenza,
thrombocytopenia and nephrotoxicity.
Administered as single daily dose of 4-5 mg/kg body weight. For
intermittent therapy the dose is 600 mg.

22.  Side effects: peripheral neuritis, gastrointestinal irritation and
hepatitis.
 Addition of 10-20 mg of pyridoxine prevent peripheral neuropathy.
STREPTOMYCIN
Given as daily dose of 0.75-1 g in a single injection.
Side effects: vestibular damage giddiness and ataxia.
PYRAZINAMIDE
Dose: 30 mg/kg body weight divided into two or three doses per day or
45-50 mg/kg body weight twice weekly.
Side effects: hepatitis, arthralgia and rarely gout.

23. BACTERIOSTATIC DRUGS
Ethambutol -15mg/kg body weight (800mg/day) given in 2-3 doses and
1200mg for intermittent therapy.
Side effects: Blurring of vision and retrobulbar neuritis
THIOACETAZONE
 2 mg/ kg body weight (150mg/day)
 Side effects: Gastrointestinal disturbances and Blurring of vision.

24. SECOND LINE OF DRUGS
The second line of drugs is used where first line drugs can't be used
forpatients reasons.
The second -line drugs are ethionamide, prothionamide, cycloserine,
kanamycin, viomycin, ofloxacin and capremycin.
DOMICILIARY TREATMENT
It is the method of self-consumption of prescribed anti-TB drugs by the
patients without getting admitted to the hospital. Domiciliary
treatment includes only oral drugs.

25. TREATMENT REGIMENS
Conventional long course chemotherapy. This is outdated and not
practiced now.
SHORT COURSE CHEMOTHERAPY
Wallace Fox and his colleagues from British medical research council
added (1972) rifampicin and Pyrazinamide to anti TB regimen and
reduced the duration of treatment from 18 months to 6-8 months.
In short course chemotherapy the drugs are given in two phases.

26. INTENSIVE PHASE
This is the initial phase lasts for 2 months; a combination of 3 or 4 drugs
are given: During this phase a combination of three or more drugs are
used to kill off as many bacilli as possible.
CONTINUOUS PHASE
This is the maintenance phase lasts for 4-6 months under short course
chemotherapy in which a combination of 2 or 3 Durga are given.

27. DRUG ADMINISTRATION IN DIRECTLY OBSERVED
TREATMENT SHORT COURSE CHEMOTHERAPY (DOTS)
 In intensive phase of treatment a health worker or trained person
closely watches the patient swallowing the drug in his presence.
 During continuation phase the patient is issued 1 week medicine in a
multiblister combipack.
The first dose is swallowed by the patient in front of health worker
 The drug consumption in the continuation phase is counter-checked
by retrun of empty multiblister combipack while collecting the drugs
for next week.

28. The drugs are provided in patient wise boxes with sufficient shelf life.
Tuberculosis cases are divided in to three categories for the sake of
putting them under different regimens based on specific criteria
 INTERPRETATION OF THE NUMBERS AND LETTERS PLACED IN THE
REGIMENS
 Prefix number indicates the number of months for that regimen
 Suffix number indicates the frequency of administration in a week
 No suffix means given daily
 R- Rifampicin
 I- Isoniazid

29.  S- Streptomycin
 Z- Pyrazinamide
BCG VACCINATION
 BCG vaccination was invented by calmette and Guirin, French
scientists. BCG stands for Bacilli of Calmette and Guerin. It is a widely
used live bacterial vaccine. It is a widely used live bacterial vaccine.
There are two types of BCG vaccine: Liquid and freeze dried. Freeze
dried is more stable.
 The vaccine is stored below 10°c.
 The vaccine must be protected from exposure to sunlight.
 It comes in freeze-dried powder from in ampoule. It is reconstituted
with 1mL normal saline (Distilled water is not

30. used since it causes irritation )
 strength is 0.1 mg in 0.1 mL
 The dose for newborns aged below 4 weeks in 0.05 mL
 It is advised to clean the site using saline swab before
administering the vaccine
 Using tuberculin syringe BCG is administered intradermally
in left upper arm just above the insertion of deltiod muscle.
 When properly Administered, the injection should
produce a wheal measuring 5 mm in diameter.

31. CHEMOTHERAPY
This preventive treatment is administered to contacts: INH for 1 year
or INH and Ethambutol are given for 9 months.
SURVEILLANCE
This focuses on the continuous monitoring and measurement. It
closely monitors and measures the rates of incidence, prevalence and
other rates like TB death rates. It helps the epidemiologist to have
current knowledge about what is happening and what he has to do to
control the diseases.

32. REVISED NATIONAL TUBERCULOSIS PROGRAM
In the year 1992 Govt. Of India, WHO and world bank together
reviewed the national Tuberculosis program (NTP). After the revision it
is revision it is referred to " Revised national Tuberculosis program
(RNTCP)
The main objectives of RNTCP:
 To achieve the cure rate of not less than 85% through short course
chemotherapy.

33. CONCLUSION
Tuberculosis infection and disease remain common in populations
characterized by poor housing condition,drug use,and HIV
infection.

34. THANK YOU