Overview of Tuberculosis 07

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Welcome! Welcome!


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Overview of Overview of Tuberculosis Tuberculosis

Michigan Department of Community HealthMichigan Department of Community Health American Lung Association of Michigan American Lung Association of Michigan


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History of M. tuberculosisHistory of M. tuberculosisPhthisis (Greek) known since ancient timesPhthisis (Greek) known since ancient timesOften thought of as a hereditary conditionOften thought of as a hereditary condition1854 first sanatorium1854 first sanatorium

1882 Koch demonstrated relationship between1882 Koch demonstrated relationship betweengerm and diseasegerm and disease1895 Roentgen discovery of diagnostic x1895 Roentgen discovery of diagnostic x--ray ray

19401940ss--19501950s chemotherapy s chemotherapy


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Around the World Around the World An estimated 1.58 million deaths occurred in An estimated 1.58 million deaths occurred in2005 from TB disease2005 from TB disease8.8 million new TB cases estimated for 20058.8 million new TB cases estimated for 2005

1/3 of world population has TB infection1/3 of world population has TB infection


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Estimated TB incidence rate, 2005Estimated TB incidence rate, 2005

No estimate

0-24

50-99

100-299

300 or more

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Estimated new TBcases(all forms) per 100 000population

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health

Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

WHO 2006. All rights reserved


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High Burden Countries (WHO)High Burden Countries (WHO) Afghanistan Afghanistan

BangladeshBangladeshBrazilBrazilCambodiaCambodiaChinaChina

Democratic RepublicDemocratic Republicof the Congoof the Congo

EthiopiaEthiopiaIndiaIndiaIndonesiaIndonesiaKenyaKenyaMozambiqueMozambique

MyanmarMyanmar

NigeriaNigeriaPakistanPakistanPhilippinesPhilippinesRussian FederationRussian Federation

South AfricaSouth Africa Thailand ThailandUgandaUgandaUnited Republic of TanzaniaUnited Republic of Tanzania

Viet Nam Viet NamZimbabweZimbabwe


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Tuberculosis Cases Tuberculosis CasesMichigan, 1955Michigan, 1955 -- 20052005

01000

2000

30004000

5000

6000

7000

55 60 65 70 75 80 85 90 95 00 03 04 05Year Reported

T B C a s e s


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246246

2.5/100,000 population

20052005

221221272272243243315315





20062006200420042003200320022002

Reported TB Cases and Rates,Reported TB Cases and Rates,Michigan, 2002Michigan, 2002 -- 20062006


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TB Cases by National Origin TB Cases by National OriginMichigan, 1997Michigan, 1997 20062006

299 287

242

196 210 194

142 164 147129

53

96 107 91120 120

101 109 99 92

050

100

150

200

250

300

350

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year Reported

# o

f T B C a s e s

USForeign


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Percentage of Total TB Cases in ForeignPercentage of Total TB Cases in Foreign --bornbornPersons, Michigan, 1994Persons, Michigan, 1994 --20062006

0

5

10

1520

25

30

35

40

45

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year Reported

% o

f T B

C a s e s


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TB by Race, Michigan, 2005 TB by Race, Michigan, 2005 --20062006

81

108

3 1

52

78 86

1 1

55

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

White Black MultipleRaces

AmIndian/AL

Native

Asian orPacific

Islander200 6 Cases

200 5 Cases


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Countries of Birth for ForeignCountries of Birth for Foreign --bornbornPersons Reported with TBPersons Reported with TB

Michigan, 2006Michigan, 20065%

4%

53%

20%

8%

10% Mexico

VietnamIndia

33 Other

Yemen

Phillipines


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Transmission and Pathogenesis


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PathogenesisPathogenesisInhale droplet nucleiInhale droplet nucleiBacteria multipliesBacteria multipliesMacrophages consume bacteria, then dieMacrophages consume bacteria, then die

Travel through the bloodstream, lymph system Travel through the bloodstream, lymph systemContainmentContainment --infectioninfection

MultiplicationMultiplication

--diseasedisease


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Generation of TB Droplet NucleiGeneration of TB Droplet NucleiOne cough produces 500 dropletsOne cough produces 500 droplets

The average TB patient generates 75,000 The average TB patient generates 75,000droplets per day before therapy droplets per day before therapy

This drops to 25 infectious droplets per This drops to 25 infectious droplets perday within 2 weeks of effective therapy day within 2 weeks of effective therapy


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Factors Affecting TBFactors Affecting TB Transmission Transmission

Characteristics of theCharacteristics of thesource casesource case

EnvironmentEnvironmentFactors increasing risk Factors increasing risk

for contactsfor contacts

sourcesource

contactcontact

environmentenvironment


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Classification System for TB

No TB exposureNot infected

No history of exposureNegative reaction to tuberculin skin test

TB exposureNo evidence of infection

History of exposureNegative reaction to tuberculin skin test

TB infectionNo disease

Positive reaction to tuberculin skin testNegative bacteriologic studies (if done)No clinical, bacteriological, or radiographicevidence of active TB

TB, clinically active M. tuberculosis cultured (if done)Clinical, bacteriological, or radiographicevidence of current disease

TBNot clinically active

History of episode(s) of TBor

Abnormal but stable radiographic findingsPositive reaction to the tuberculin skin testNegative bacteriologic studies (if done)

andNo clinical or radiographic evidence ofcurrent disease

TB suspected Diagnosis pending

Class Type Description

0

1

2

3

4

5


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RememberRemember

TB disease is reportable to the State Health TB disease is reportable to the State HealthDepartment TB Control Program on the ReportDepartment TB Control Program on the Report

Verified Case of Tuberculosis (RVCT) Verified Case of Tuberculosis (RVCT)


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INFECTIOUSINFECTIOUSNOT INFECTIOUSNOT INFECTIOUS

Case of TBCase of TBNot a Case of TBNot a Case of TB

Positive Sputum CulturePositive Sputum CultureNegative Sputum CultureNegative Sputum Culture

SymptomsSymptomsNo SymptomsNo Symptoms

CXR: AbnormalCXR: AbnormalCXR: NormalCXR: Normal

TB Disease TB Disease TB Infection TB Infection


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Risk Factors for the Development of Risk Factors for the Development of TB Disease TB DiseaseHow many time higher is

Risk factors the risk of TB disease?

Acquired immunodeficiency 170syndrome (AIDS)

HIV infection 113

Recent TB infection 15(within past 2 years)

Certain medical conditions 2 3 - 162Compared to the risk for people with no known risk factors

For example, diabetes, certain types of cancer, orimmunosuppressive therapy

Excerpt from CDCs Self-Study Modules on Tuberculosis, Module 1, March 1995


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Signs/SymptomsSigns/SymptomsProductive cough 3 weeks or longerProductive cough 3 weeks or longerShortness of breathShortness of breathChest painChest pain

HemoptysisHemoptysisNight sweats/fever/chillsNight sweats/fever/chillsUnexplained weight lossUnexplained weight lossFatigueFatigue


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TB can be found in all parts of TB can be found in all parts of your body your body

Brain EyeLymph node Throat

Lung Bone

Spine Kidney


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Suspect TB:Suspect TB: Chest x-ray

Location of the infiltrate

Presence of a cavity

Hollow areas, dense areas, fluid onthe lung or at margins

Normal x-ray = usually no infectiousTB disease


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Chest Radiograph Abnormalities often seen in apical

or posterior segments of upperlobe or superior segments oflower lobe

May have unusual appearance inHIV-positive persons

Cannot confirm diagnosis of TB

Arrow points to cavity in

patient's right upper lobe.


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Sputum CollectionSputum Collection Sputum specimens are essential to

confirm TB Sputum: mucus from within the lung, not

saliva 3 specimens on 3 different days

Spontaneous morning sputum moredesirable than induced specimens


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AFB Smear Results AFB Smear ResultsPositive

Need at least 10,000 bacilli per mlPositive in about half those with TB diseaseSignal a very infectiouspersonOther mycobacteria may

make the smear a false positive

Negative

Too few bacilli to be seendirectly under themicroscopeProvides somereassurance that patient isless infectiousto others


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AFB Smear: AFB (shown in red) are tubercle bacilli


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CulturesCultures Use to confirm dx of TB

Culture all specimens, even if smear

Result in 4-14 days when liquid medium

systems used Susceptibility testing-

essential

Colonies of M. tuberculosis growing on media


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Drug susceptibility testing on solid media. Upperleft contains no drugs.


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Alternative Techniques Alternative Techniques BACTEC can confirm TB growth

within one week, by indirectlymeasuring TB bacilli growth in

special bottles and medium Other tests can confirm TB by

amplifying DNA and other methodsthat look for the TB bacilli genes


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Potential Chains of TuberculosisPotential Chains of Tuberculosis

Transmission Before and After DNA Transmission Before and After DNA Fingerprinting of IsolatesFingerprinting of Isolates


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DIVERSITY OF RFLPDIVERSITY OF RFLP

PATTERNSPATTERNS# # # ##

d d l l l f


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Individual TB CDC Cluster totals forIndividual TB CDC Cluster totals for OutstateOutstateMichiganMichigan

and theand the City of DetroitCity of Detroit 1996 to 2000.1996 to 2000.OutstateOutstate 6464 cluster totals:cluster totals:SizeSize Freq.Freq. %%

2 person2 person 4242 65 %65 %3 person3 person 77 10.9 %10.9 %4 person4 person 77 10.9 %10.9 %5 person5 person 11 1.6 %1.6 %6 person6 person 22 3.1 %3.1 %7 person7 person 11 1.6 %1.6 %8 person8 person 1 1.6 %1 1.6 %

9 person9 person 11 1.6 %1.6 %10 person10 person 11 1.6 %1.6 %31 person31 person 11 1.6 %1.6 %

DetroitDetroit 5353 cluster totals:cluster totals:SizeSize Freq.Freq. %%

2 person2 person 2525 47.2 %47.2 %3 person3 person 66 11.3 %11.3 %4 person4 person 44 7.5 %7.5 %5 person5 person 55 9.4 %9.4 %

6 person6 person 33 5.7 %5.7 %7 person7 person 22 3.8 %3.8 %8 person8 person 11 1.9 %1.9 %

10 person10 person 11 1.9 %1.9 %

13 person13 person 11 1.9 %1.9 %18 person18 person 11 1.9 %1.9 %58 person58 person 11 1.9 %1.9 %70 person70 person 11 1.9 %1.9 %

D i CDC 00027


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Detroit CDC 00027Detroit CDC 00027

70 cases70 cases68% Male, 90% Black 68% Male, 90% Black 99% US citizens99% US citizens76% Pulmonary76% Pulmonary29%29% CavitaryCavitary4 cases prior TB4 cases prior TB17% HIV+17% HIV+

10% Homeless10% Homeless7% Long term care7% Long term care13% Injecting drugs13% Injecting drugs11% Non11% Non --injecting drugsinjecting drugs20% Alcohol abuse20% Alcohol abuse51% Unemployed51% Unemployed89%89% -- Ages 30 to 54 Ages 30 to 54


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Treatment


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fT f L


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Treatment of Latent Treatment of Latent TB Infection (LTBI) TB Infection (LTBI)

Consists of 9 months of daily isoniazid(INH)

Substantially reduces the infectedpersons risk of developing clinical TB

Monitor patient at least monthly forsymptoms of toxicity and adherence

T i TB DiT i TB Di


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Treating TB Disease: Treating TB Disease:General PrinciplesGeneral Principles

Always treat with multiple drugs Never add a single drug to a failing regimen

Treatment course depends on drugs selected.Usually 6 months, sometimes 9 months:

Four drugs for two monthsFour drugs for two monthsINHINH --RIFRIF--EMBEMB--PZAPZA

Two drugs for four or seven months Two drugs for four or seven monthsINHINH --RIFRIF

H ill k if hH ill k if th


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How will we know if theHow will we know if thetreatment is effective?treatment is effective?

The symptoms improve

Sputum smears become negative

Sputum cultures change to negative,usually within 2 3 months

The chest x-ray improves (importantfor kids)


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NonNon --adherenceadherence A very serious problem

Failure to take all the prescribed TBtreatment is the single mostimportant reason for tuberculosistreatment failure


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NonNon --adherence (2)adherence (2) The non-adherent patient risks

Continuing transmission of TBinfection

Development of drug resistantTB bacilli

Increasing disability and death


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InfectiousnessInfectiousnessPatients should be considered infectious if they

Are coughing Are undergoing cough-inducing or aerosol-generating procedures, or

Have sputum smears positive for acid-fast bacilliand they Are not receiving therapy

Have just started therapy, orHave poor clinical response to therapy


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Infection ControlInfection Control Administrative Administrative--reducereduce

risk of exposurerisk of exposure

Alert to S/S of MTB Alert to S/S of MTBPrompt therapy withPrompt therapy withsuspectsuspect

Alert for undiagnosed Alert for undiagnosedpulmonary illness withpulmonary illness withHIV HIV

Engineering Engineering --prevent spread,prevent spread,reduce conc. of dropletreduce conc. of dropletnucleinuclei

Neg. pressure isolation roomNeg. pressure isolation roomFiltration systemFiltration system

Personal protectionPersonal protection --use inuse inareas of increased exposureareas of increased exposure

Client (surgical mask) to mask Client (surgical mask) to mask outsideoutside

HCW (NHCW (N --95) to mask inside95) to mask inside

Overview of Tuberculosis 07

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