2. Contents…
• Introduction
• Problem statement
• Natural history of TB
• Modes Of Transmission
• Control of TB
• Chemotherapy
• Childhood TB
• BCG vaccination
• Chemoprophylaxis
• NTP
• Stop TB strategy
• TB and HIV
• Epidemiological impact
• Yoga
• Research
3.
4. INTRODUCTION
Specific infectious diseases
Caused by-M. tuberculosis
Primary effect on lungs-pulmonary tuberculosis
Also affects intestine,meninges,bones,
joints,lymph nodes,etc.
5. Cont…
It affects also animals like cattles
Known as “Bovine tuberculosis”
May communicated to man
6. Problem statement
Distribution-worldwide
WHO estimates that about 9.2 million new cases
of TB occurred in 2006
Of these cases, 4.1 million were new smear
positive cases
This includes 789,000 tuberculosis with HIV co-infected
cases
There were 14.4 million prevalent cases
An estimated 1.7 million people died from TB
which 231,000 were those co-infected with HIV
7. 31.8 million new and relapse cases and
15.5 million smear positive case were
notified by DOTS Programme between
1995-2006
8. India
India is the first rank in incidence
1/5th of global burden of TB
1.8 million persons develop TB of which
0.8 million are new smear positive (highly
infectious)
0.37 million people die every year
DOTS program was launched in March
1997
9. TB estimates for India
Population 1151 million
Global rank (by estimated number of cases) 1
Incidence (all cases/1 lakh population/year) 168
Incidence (new smear +ve cases/lakh population/year) 75
Prevalence (smear +ve cases/lakh population) 299
TB mortality/1 lakh population/year 28
% of new TB cases HIV positive 1.2
% of new case multidrug resistance 2.8
Previously treated TB cases multidrug resistance (%) 17
10. It is mainly a disease of the poor
Majority of victims are migrant laborers, slum
dwellers, residents of backward areas and tribal
pockets
11. History of TB
TB has affected humans
for millennia
Historically known by a
variety of names,
including:
Consumption
Wasting disease
White plague
TB was a death sentence
for many
Vintage image circa 1919
Image credit: National Library of Medicine
12. History of TB
Scientific Discoveries in 1800s
Until mid-1800s, many
believed TB was
hereditary
1865 Jean Antoine-
Villemin proved TB was
contagious
1882 Robert Koch
discovered M.
tuberculosis, the bacterium
that causes TB
Mycobacterium tuberculosis
Image credit: Janice Haney Carr
13. History of TB
Before TB antibiotics,
many patients were sent to
sanatoriums
Patients followed a
regimen of bed rest, open
air, and sunshine
TB patients who could not
afford sanatoriums often
died at home
Sanatorium patients resting outside
14. Breakthrough in the Fight Against
TB
Drugs that could kill TB
bacteria were discovered
in 1940s and 1950s
Streptomycin (SM) discovered
in 1943
Isoniazid (INH) and
p-aminosalicylic acid (PAS)
discovered between 1943 and
1952
15. M. tuberculosis causes most
TB
Mycobacteria that cause TB:
M. tuberculosis
M. bovis
M. africanum
M. microti
M. canetti
Mycobacteria that do not
cause TB
e.g., M. avium complex
M. tuberculosis
TB Transmission
Types of Mycobacteria
16. Natural history of TB
Agent factor
M.tuberculosis is a intracellular parasite
Ingested by phagocytes but resistant to
intracellular killing
Indian tubercle bacillus is said to be less virulent
then the European bacillus
17. Source of infection
Two source of infection
Human source-person whose sputum is
positive for tubercle bacilli
Discharge of bacilli in their sputum
Bovine source-infection is usually by milk
Not a problem in India because of the practice of
boiling milk before consuption
18. Modes Of Transmission
Mainly by droplate infection and droplate nuclei
generated by sputum positive patient
Particle should be fresh enough to carry
Coughing generates all size of droplates
Notes-not transmitted by fomites
21. PATHOGENESIS
Susceptible
Or
Mycobacterium
Tuberculosis
Latent
Infection
Recovery
Reactivation
Active
tuberculosis
Miliary
tuberculosis
Extrapulmonary
Tuberculosis
PULMONARY
TUBERCULOSIS
22. Contribution of Mycobacterial Cellular
Envelope to Pathogenesis
Resistance to Drying and Other Environmental Factors
- Thick, waxy nature of cellular envelope protects M. tuberculosis
from drying, alkali conditions, and chemical disinfectants
- Hinders entrance of antimicrobial agents
Entry into Host Cells
- Lipoarabinomannan (LAM) binds to mannose
receptors on alveolar macropages leading to
entry into the cell
Interference of Host Immune Response
- Glycolipids and sulfolipids decrease the effects of oxidative
cytotoxic mechanism
- Inhibition of phagosome and lysosome fusion inside macrophage
- Waxy cellular envelope prevents acidification of the bacteria inside
the phagosome
23. Common Symptoms of TB Disease
Cough (2-3 weeks or more)
Coughing up blood
Chest pains
Fever
Night sweats
Feeling weak and tired
Losing weight without trying
Decreased or no appetite
If you have TB outside the lungs, you may have
other symptoms
24. Host Factor
AGE
Affects all ages
In India under 5 age group-1%
At the age of 15years-30%
25. SEX
More prevalent in male then female
HEREDITY
It is not a hereditary disease
26. NUTRITION
Malnutrition is believed to predispose to TB
Diet had no effect on the recovery of patient
IMMUNITY
No inherited immunity against TB
Acquired after natural infection or BCG
vaccination
27. Social factor
TB is a disease with both social and
medical aspects
Social factors includes
Poor quality of life
Poor housing
Population explosion
Early marriages
Lack of awareness of causes of disease
28. TB Infection vs. TB Disease
There is a difference between TB “infection” and
TB “disease”
TB infection: TB germs stay in your lungs, but
they do not multiply or make you sick
You cannot pass TB germs to others
TB disease: TB germs stay in your lungs or move
to other parts of your body, multiply, and make
you sick
You can pass the TB germs to other people
29. LTBI vs. TB Disease
Latent TB Infection (LTBI) TB Disease (in the lungs)
Inactive, contained tubercle bacilli
Active, multiplying tubercle bacilli
in the body
in the body
TST or blood test results usually
positive
TST or blood test results usually
positive
Chest x-ray usually normal Chest x-ray usually abnormal
Sputum smears and cultures
negative
Sputum smears and cultures may
be positive
No symptoms Symptoms such as cough, fever,
weight loss
Not infectious Often infectious before treatment
Not a case of TB A case of TB
30. Progression to TB Disease
Risk of developing TB disease is highest the first 2
years after infection
People with LTBI can be given treatment to prevent
them from developing TB disease
Detecting TB infection early and providing treatment
helps prevent new cases of TB disease
31. Progression to TB Disease
Some conditions increase probability of LTBI
progressing to TB disease
Infection with HIV
Chest x-ray findings suggestive
of previous TB
Substance abuse
Recent TB infection
Prolonged therapy with
corticosteroids and other
immunosuppressive therapy,
such as prednisone and tumor
necrosis factor-alpha [TNF-α]
antagonists
Organ transplant
Silicosis
Diabetes mellitus
Severe kidney disease
Certain types of cancer
Certain intestinal conditions
Low body weight
32. Progression to TB Disease
People Exposed to TB
Not
TB Infected
Latent TB
Infection (LTBI)
Not
Infectious
Positive TST or
QFT-G test result
Latent TB
Infection
May go on to
develop TB
disease
Not
Infectious
Negative TST or
QFT-G test result
No
TB Infection
33. TB Classification System
Based on pathogenesis of TB
Class Type Description
0 No TB exposure
Not infected
No history of TB exposure
Negative result to a TST or IGRA
1 TB exposure
No evidence of
infection
History of TB exposure
Negative result to a TST (given at least 8-
10 weeks after exposure) or IGRA
2 TB infection
No TB disease
Positive result to a TST or IGRA
Negative smears and cultures (if done)
No clinical or x-ray evidence of active
TB disease
34. TB Classification System
Based on pathogenesis of TB
Class Type Description
3 TB,
clinically
active
Positive culture (if done) for M. tuberculosis
Positive result to a TST or IGRA, and clinical,
bacteriological, or x-ray evidence of TB disease
4 Previous
TB disease
(not
clinically
active)
Medical history of TB disease
Abnormal but stable x-ray findings
Positive result to a TST or IGRA
Negative smears and cultures (if done)
No clinical or x-ray evidence of active TB
disease
5 TB
suspected
Signs and symptoms of TB disease, but
evaluation not complete
35. Sites of TB Disease
Bacilli may reach any part of the body, but common sites
include:
Brain
Lymph node
Pleura
Lung
Spine
Larynx
Bone
Kidney
36. Sites of TB Disease
Location Frequency
Pulmonary TB Lungs Most TB cases are
pulmonary
Extrapulmonary TB Places other than
lungs such as:
• Larynx
• Lymph nodes
• Pleura
• Brain
• Kidneys
• Bones and joints
Found more often in:
• HIV-infected or
other
immunosuppressed
persons
• Young children
Miliary TB Carried to all parts
of body, through
bloodstream
Rare
37. Diagnosis and Treatment for Latent & Active TB
Tools for Diagnosing TB Infection
Mantoux skin test (PPD)
Chest x-ray
Sputum cultures
38. TUBERCULIN TEST
Discovered by Von Pirquet(1907)
Three main test are currently in use
Mantoux intradermal test
Heaf test
Tine multiple puncture test
39. Diagnosis and Treatment for Latent & Active TB
Tools for Diagnosing TB Infection
Chest X-Ray
A chest x-ray is ordered when a
person presents a recent skin test
conversion and is suspected of
having TB.
If a chest x-ray is normal, further
diagnostic testing may not be
necessary.
40. Diagnosis and Treatment for Latent & Active TB
Tools for Diagnosing TB Infection
Sputum
A sputum specimen is necessary to
confirm that the TB bacteria is present in
the lung.
The sputum specimens should:
-come from deep within the lungs;
-be obtained from the first coughed up
sputum of the day, for 3 consecutive days
-may be obtained through special
respiratory therapy procedures.
41. Control of TB
Reduction in prevalence and incidence
WHO defines control as prevalance of natural
infection in the age 0-14yrs is of the order of 1%
In india it is about 40%
Control measure consists of
Curative component-case finding and treatment
Preventive component-BCG vaccination
42. Case finding tools
Sputum examination
Sputum smear examination
Who also have problems like
persistant cough of about 3-4weeks
Continous fever
Chest pain
haemoptysis
43. Chemotherapy
Indicated for every case of active TB
Objectives are
Elimination of both the fast and slow multiplying
bacilli
Mainly elimination of bacilli from patients sputum
Available for free of charge
44. Anti-tuberculosis drugs
An anti-tuberculosis drug should follow some
criteria's like
Free from side effects
Highly effective
Easy to administrate
Reasonably cheap
45. Classification of drugs
Currently used drugs are classified in to
Bactericidal drugs-kills the bacteria
Bacteriostatic drugs-inhibits the multiplication of the
bacilli and leads to destruction by the immune
mechanism of the host
46. Bactericidal drugs
Rifampicin(RMP)
Powerful Bactericidal drugs
Permeates all tissue membrane
Only Bactericidal drugs active against the dormant
bacilli
Only oral drug
10-12mg/kg body weight
May feel nausea,gastritis,purpra
47. INH
Most powerful drug
Can penitrate the cell membrane
Active against intracellular and extracellular bacilli
It can also pass BBB,present in CSF
4-5gm/kg body weight
48. Streptomycin
Act on rapidly multiplying bacilli
Less active on slow multiplying bacilli
No action on persisters
Non-permeate cell wall
0.75-1gm in a single injection
49. Pyrazinamide
Active against slow-multiplying intracellular
bacilli
Drug given orally
Usual dose 30gm/kg body weight
Recommended in tuberculous meningitis
50. Bacteriostatic drugs
Ethambutol
Used in combination to prevent the
emergence to the drugs
Given orally
Side-effect-retro-bulbar neuritis
15mg/kg body weight given in 2-3 doses
51. Thioacetazone
Companion drug to INH
Adult dose-2mg/kg body weight
Side-effect includes gastrointestinal
disturbances, blurring of vision, haemolytic
anaemia
52. Two-phase chemotherapy
Consist of two phase of effective treatment
Short aggressive or intense phase
Lasting 1-3months
Three or more drugs are combined to kill initialy
Continuation phase
Aimed to sterilizing the smaller number of
dormant
Not less then 18 months
If rifampcin and pyrazinamide applied,then it can
reduced to 6-9 months
53. Treatment during pregnancy
Streptomycin can cause permanent deafness in
the baby
So ethambutol should be used instead of
streptomycin,
Isoniazid, rifampicin, pyrazinamide and
ethambutol are safe to use
Second line drugs should not be used because
these are teratogenic
(flouroquinolomes,ethionamide)
54. Childhood TB
TB in children present between 10-20% of all TB
Source is usually adult
Frequency of childhood TB depends
Number of infectious case
Closeness of contact with an infectious case
Age of the child when exposed to TB
55. Childhood TB is mainly due to failure in control
of TB in adult
Under 5 age group-20%
The commonest age-1-4years
56. BCG vaccination
Calmette and guerin in 1919 discovered bacille
Calmette guerin(BCG)
Avirulent for man while retaining its capacity to
induce an immune response
During 1921-1925-given orally
After 1927-intradermal technique
1948-it is accepted by TB workers
57. AIM
Induce benign artificial primary infection
By stimulating an acquired resistance
58. Vaccine
Widely used live bacterial vaccination
Derived from an attenuated bovine stain of
tubercle bacilli
WHO has recommended the “Danish 1331” stain
for production of BCG vaccination
59. Types of vaccination
Two types of BCG vaccination
Liquid vaccination(fresh)
Freeze-dried vaccination(stable)
60. BCG is stable for several weeks in a tropical
climate and for up to 1 year if kept away from
direct light and stored in cool environment
preferably refrigerator at a temperature below 10
deg C
Normal saline is recommended for diluent for
reconstituting the vaccine
61. Dosage
For vaccination the usual strength is 0.1 g in 0.1
ml volume
For new born (below 4 weeks) 0.5 ml, because
the skin of the new born is thin
62. Administration
Inject the vaccine intradermally using a
tuberculin syringe (recommended by WHO)
If injected subcutaneously an abscess is likely to
develop
The site of injection should be above the insertion
of deltoid
63. Phenomena after vaccination
After 2-3 weeks a papule develops at the site of
vaccination
It increases slowly in the diameter about 4-8 mm
in 5 weeks
Healing occurs within 6-12weeks
Round scar is formed
64. complication
Prolonged severe ulceration
Supractive lymphadenitis
Osteomyelitis
Death
65. Revaccination
Even 80 years after the development of the vaccine, it is
not known whether booster doses are indicated or
advisable
Contraindication
Generalized eczema, infective dermatosis,
hypogammaglobulinaemia, to those with a history of
deficient immunity
Patient under immunosuppresent treatment and in
pregnancy
66. Direct BCG vaccination
Vaccination without a prior tuberculin test has been
adopted as a National policy in many developing
countries including India
No adverse effects have been reported even if
BCG is given to tuberculin – positive reactors
67. Impact
BCG is less effective than the chemotherapy
BCG vaccination and HIV infection
A single dose of BCG vaccine should be given to
all healthy infants as soon as possible after birth
unless the child presented with symptomatic HIV
infection
68. Combined vaccination
BCG may be given at the same time as OPV.
DPT vaccine may also be given at the same time
as BCG, but in different arm without reducing the
immune responses or increasing the rate of
complication
69. Chemoprophylaxis
The case against INH chemoprophylaxis rests on
3 points:
It is a costly exercise
It is not strikingly effective
It can induce hepatitis
According to WHO mass treatment is not feasible
In this context, BCG gets priority over
chemoprophylaxis
70. Drugs resistance
All drugs used in TB produce resistance
Resistance may be of two types
Pretreatment resistance
Acquired resistance
71. National Tuberculosis
Programme (NTP)
NTP has been under operation since 1962
The long term goal of NTP is “to reduce the
problem of tuberculosis in the community
sufficiently quickly to the level where it ceases to
be a public health problem”.
72. Revised NTP
The Govt. of India, WHO and World Bank
together reviewed the NTP in the year 1992
The main pillars of the revised strategy are;
Achievement of not less than 85% cure rate amongst
infectious cases of TB, through short course
chemotherapy involving peripheral health
functionary
73. Detecting 70% of the estimated cases – through quality
sputum microscopy
Involvement of NGOs
Direct Observed Therapy Short – term (DOTS) – a
community based TB treatment and care strategy
74. Stop TB strategy
2006- WHO launched
Core of the strategy – DOTS
Indicators used to measure implementation and
impact of TB control:
Case detection
Treatment success
Incidence
Prevalence
Deaths
75. Stop TB partnership target
By 2005
70% of people with sputum smear positive TB will
be diagnosed
By 2015
Global burden of TB will be reduced by 50% relative
to 1990 levels
By 2050
Global incidence of TB will be less then or equal to 1
case/million population/year
76. TB and HIV
HIV virus damages the bodies natural defense
Accelerates the speed at which TB progresses
from a harmful infection to life – threatening
condition
77. Epidemiological impact
Reactivation of latent infection
People who are infected with both TB and HIV are
25-30 times more likely to develop TB than the
people infected with only TB
Recurring infection
People having HIV who have been cured of TB may
be at more risk of developing TB again
In the community
Educate people that TB is curable and the people are
no longer infectious after the first few weeks of
treatment
80. There are 5 layers of existence
1 Annamaya kosha
2 Pranamaya kosha
3 Manomaya kosha
4 Vijanamaya kosha
5 Anadamaya kosha
81. Aims and objectives
Improves immune system
Reduce the infection
Reduce the symptom scores
Giving them a healthy life
Reduce the resistance to the medicine
83. DIET
•Mastery over mind
•Better mastery over appetite & satisfaction
APPETITE SATIETY
84. Tuberculosis is said to be a diseases of
calcium deficiency
Exclusive fresh fruit diet with milk
Banana should be avoided
Give more citrus fruits
Custard apple – effective food
94. complementary role for yoga in the
management of pulmonary tuberculosis
yoga group showed a significant reduction
in symptom scores(88.1%), and an increase
in weight (10.9%), FVC (64.7%) and
FEV(83.6%)
breath awareness group also showed a
significant (paired t-test) reduction in
symptom scores (16.3%), and an increase
in weight (2.1%) and FEV(63.8%)
95. Ten of 13 in the yoga group had negative
sputum culture after 60 days compared
with four of 19 in the breath awareness
group
Improvement in the radiographic picture
occurred in 16/25 in the yoga group
compared to 3/22 in the breath awareness
group on day 60