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  2. 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. 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. 3
  4. 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. 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. 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. 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. 8
  9. 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. 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”. 10
  11. 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. 11
  12. 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. 12
  13. 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. 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.. 14
  15. 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. 15
  16. 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). 16
  17. 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 17
  18. 18. EPIDEMIOLOGICAL TRIAD Epidemiological Triad of Tuberculosis A) Agent B) Host C) Environment 18
  19. 19. AGENT 19 Fig: Mycobacterium Tuberculosis
  20. 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. 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. 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. 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. 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. 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. 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. 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. 28. PROBABILITY THAT TB WILL BE TRANSMITTED DEPENDS UPON  Environment in which exposure occurs  Length of exposure  Virulence of Mycobacterium Tuberculosis 28
  29. 29. RISK FACTOR OF TB 29
  30. 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. 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. 31 2/9/2023
  32. 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. 32 2/9/2023 Persons who have been Recently Infected with TB Bacteria
  33. 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, 33 2/9/2023
  34. 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. 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. 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. 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. 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. 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. 39 2/9/2023
  40. 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. 41. 2) TB Disease Has symptoms that may include : 2/9/2023 41
  42. 42. CONT…. 2/9/2023 42 Weakness or fatigue Coughing up blood or Blood in sputum
  43. 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. 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. 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. 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
  48. 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. 49. DIAGNOSIS OF TB  Case finding tools in tuberculosis : • Sputum microscopy : Method of choice • Sputum culture • Mass miniature radiography • Tuberculin test 49
  50. 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. 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. 52. SOME TERMINOLOGIES  New Case  Relapse  Treatment Failure  Defaulter  Cured 52
  53. 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. 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. 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.
  58. 58. 58
  59. 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. 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. 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. 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. 63. DRUG RESISTANT TB  Multi Drug Resistant TB (MDR TB)  Extensively Drug Resistant TB (XDR TB) 63
  64. 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. 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. 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. 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. 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. 69
  70. 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. 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. 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. 73. PREVENTION AND CONTROL Based on level of prevention  Primordial prevention  Primary prevention  Secondary prevention  Tertiary prevention 73
  74. 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. 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 75
  76. 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 76
  77. 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. 77
  78. 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. 78
  79. 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. 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 80
  81. 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 81
  82. 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. 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
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Notas do Editor

  • 4 types
  • In 1882, when Robert Koch announced that he had isolated the tubercle bacillu
  • Ending the TB epidemic by 2020 is among the health targets of the Sustainable Development Goals and priority area of MDG too.
  • including actions to address stigma, discrimination, marginalization and overcome barriers to access care.
  • 1. India
  • WhO End TB stretagy , adopted by the World Health Assembly in 2014, aims to end the global TB epidemic as part of the newly adopted Sustainable Development Goals.
    It serves as a blueprint for countries to reduce TB incidence by 80%, TB deaths by 90%, and to eliminate catastrophic costs for TB-affected households by 2030.
  • Persons who work or reside with people who are at high risk for TB in facilities or institutions such as hospitals, homeless shelters, nursing homes, and residential homes for those with HIV.
  • , which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease.
  • 260 Page vivek Jain
  • Kathmandu, Biratnagar, Nepalgunj
  • WHO developed the End TB Strategy, which was endorsed by the Sixty-seventh World Health Assembly in 2014. The strategy envisions a world free of TB, with zero deaths, disease and suffering due to the disease. Further, the strategy ambitiously proposes to “end the global TB epidemic” by 2035. The strategy targets a 90% reduction in patients suffering from TB, and a 95% reduction in deaths from TB by 2035 — all while protecting families from catastrophic costs that push them further into poverty.