Vaccine BCG

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BRIEF ALL WE MUST DO TO CONTROL TB
FIND TARGETS-gt CASE FINDING WITH SPUTUM SMEAR
BLACK LIST THEM-gtREGISTERED TARGETS
HIT THEM WITH GOOD WEAPON-gt CURE THEM WITH
ANTI-TB DRUGSDOT
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TUBERCULOSIS

• Infectious disease from Mycobacterium spp TB
  complexM.Tuberculosis M.Bovis,M.Africanum
• 99 cause by M.Tuberculosis
• Most are pulmonary TB

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Transmission

• TB is spread by airborne particles that contain
  Mycobacterium tuberculosis called droplet nuclei.
  
• Droplet nuclei are expelled when a person with
  infectious TB coughs or sneezes.
• Higher infectivity is associated with cavitary
  disease, laryngeal TB, frequent cough.
• Close contact is the most important risk factor
  for acquiring infection.
• Casual transmission also occurs but is less
  common.
• Persons with TB infection, but no disease, are
  not infectious.

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Natural History of Tuberculosis
70 NON INFECTED
10-30
Infection
Exposure
HIV 40-50
PEOPLE
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90 NO DISEASE
Disease
Infectious
50 of smear positive
5 IN 2 YEARS 5 Reactivation TB
Death
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Differences Between TB Infection and TB Disease
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Tuberculosis Risk Factors
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Conditions that Increase the Risk of Progression
to TB Disease

• HIV infection
• Substance abuse (esp. drug injection)
• Recent infection with MTB
• Chest radiograph suggesting of previous TB in a
  person untreated or inadequately treated
• Diabetes mellitus
• End Stage Renal Disease
• Prolonged corticosteriod therapy (equivalent to
  gt 15 mg/d prednisone for gt 1 month)
• Other immunosuppressive therapy (e.g. persons on
  infliximab/Remicade or other anti-TNF apha drugs)
  
• Severe malnutrition (gt 10 under ideal body
  weight)
• Silicosis
• Gastrectomy/ jejuno-ileal bypass

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Annual Risk of Tuberculosis in Individuals with a
Positive Skin Test

• HIV 3-10
• PPD Converters 2-5
• Abnormal CXR 2-4
• IDU 1
• ESRD 1
• Diabetes 0.3
• No Risk Factor 0.01-0.1 
• Risk of Developing Tuberculosis for TB-Infected
• HIV infected 8-10/year
• HIV Non-infected 5-10 lifetime

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World situation

• Estimated TB cases 16-20 millions
• 810 millions-gthighly infectious
• Estimated 8.3 million new cases in 2000 (
  137/100,000 population ) (95in developing
  countries)
• Annual rate of increase 6
• dead1.8 million (98in poor countries)
• 1 / 3 of world population-gtinfected cases

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Thailand Situation

• estimated cases 86,000 cases
• about 38,000 cases-gt infectious
• die every year about 5000 - 7000 cases
• 30-40of population-gt infected with TB
• most are in labor age group15-44 years
• incidence of HIV infection in TB about 13-14

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TYPES OF TUBERCULOSIS

• PULMONARY TB
• EXTRAPULMONARY TBLYMPH NODE, MENINGES, KIDNEY,
  BONE AND JOINT, SKIN

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SYMTOMS

• COUGH gt 2 WEEKS
• HEMOPTYSIS
• CHRONIC FEVER gt 3 WK.
• CHEST PAIN gt 3 WK.

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SYMTOMS AND SIGNS

• GENERAL FATIQUE,ANOREXIA,WEIGHT LOSSFEVER IN
  EVENNING,NIGHT SWEAT
• SYMTOM RELATED TO LUNGDRY COUGH ,HEMOPTYSIS,
  DYSPNEA,CHEST PAIN
• EXTRAPULMONARY TB RELATED TO THE ORGAN INVOLVED

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PRINCIPLES OF TB CONTROL

• 1.PREVENTION BY BCG VACCINE
• 2.CASE FINDING
• 3.PROPER TREATMENT TO CUT OFF CHAIN OF
  TRANMISSION
• 4TREATMENT OF LATENT INFECTION
• 5. HEALTH EDUCATION AND PUBLIC RELATION

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Vaccine BCG

• BACILLUS CALMETTE GUERIN
• (Lived attenuated vaccine)
• repeated cultureM.bovis 230 times
• Efficacy to prevent pulmonary TB 0-80 (overall
  protection 50)
• Disseminated TB 78 TB meningitis 64
• EPI at Birth since 1977

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1951 ??????????? BCG solution---gt dried
BCG seed strain - Danish strain 1331 (????
9 - 12 ?????) 1967 Direct BCG vaccination NB
?????????? 1977 EPI programme 1987
---gt ???????? ??? Tokyo strain 172 (???? 24
?????) Efficacy of BCG not related to strain
/ manufacturer
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Recommendation
WHO 1980 - TB inf. In children 10 - 14 yr. Old 5
BCG at birth 2 - 5 BCG at school entry lt
2 BCG at 12 - 14 yr. old now BCG at
birth if prevalence TB gt 40/100,000
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BCG

• 20-100 millions lived bacilli /cc.( Live
  attenuated vaccine)
• 10 doses/vial mixed with 1 cc. Sterile water
• 20 doses/vial mixed with 2 cc. Sterile water
• Store at 4-8 celcius can keep about 1 year
• Can keep for 2 hours after mixed.

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• 0.1 cc. -gt intracutaneous injection at deltoid
• Induration about 0.6 cm width and disappear after
  1 hour
• 2-3 weeks red induration at injected site
• 3-4 weeks forming repeated(off and on) abscess
• 2 months -gt immunity

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REACTION

• BCG scar .
• No scar 20 - 50

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BCG Contraindication
- HIV inf. - Congenital immunodeficiency -
Leukemia, Lymphoma, Generalized malignancy -
receiving high dose steroid Rx - receiving
radioactive Rx
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Adverse reaction dose,depth,immunity,site

• Local abscess ---gt keloid
• Suppurative Lymphadenitis 3 - 6 month after
  injection some with abscess
• Disseminated. BCG in immunodef. - rare
• Osteitis - very rare

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Rx Of Adverse Reaction
Reassurance to parents - benign course self
limited Pressure from parents s anxiety - use
antibiotic ? - INH 2- 4 wk.
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CASE FINDING

• SUGGESTIVE SYMTOMS AND SIGNS
• MOST IMPORTANT -gt SPUTUM FOR AFB
• CHEST X-RAY

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Sputum Examination

• Staining method Ziehl Neelsenacid fast
  bacillus stained with (alkali) dye and can not
  wash out with acid
• Culture with Solid media
• Drug sensitivity test

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Sputum stained most important

• Definite diagnosis -gt pulmonary TB
• Most contagious( AFBve 1 case can infect other
  about10 cases/year)
• follow up

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AFBve result depend on

• Patient Cavity lesion, much bacilli in
  sputum large amount sputum
• technician Correct staining method
  Number of examination

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SPUTUM COLLECTION

• Spot sputum at first visit exam
• collected sputum in the morning sputum
• Ratio of AFBve spot collected 13
• spotcollectedspot culture

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FATE OF SMEAR POSITIVE CASES ACCORDING TO
TREATMENT5 years follow up
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DRUG TREATMENT PRINCIPLES

• USE MORE THAN 2 DRUGS
• Correct dose of each drug
• Good compliance of patient
• proper duration of Rx

In case of failure the regimen should be
changed not add 1 drug to old regimen
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Drugs for Rx of Tuberculosis

• Isoniazid and rifampicin most powerful
  bactericidal drugs, active against all
  populations of TB bacilli.
• Rifampicin most potent sterilizing drug
  available.
• Pyrazinamide and streptomycin bactericidal
  against certain populations of TB bacilli.
  Pyrazinamide active only in an acid environment.
• Streptomycin is bactericidal against rapidly
  multiplying TB bacilli.
• Ethambutol and thioacetazone in association with
  more powerful drugs to prevent the emergence of
  resistant bacilli.

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ISONIAZID

• 100 mg. tablet.Body wt.gt 30 kg. 3 tab OD
• side effect Major hepatitis minor 1.
  Peripheral neuropathy(numbness of hand and foot)
  give vit.B6 2.skin reaction-gt itching,
  rash

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RIFAMPICIN

• Capsule dose 150 300 450 600 mgwt.30-39
  kg. 300 mg./daywt..40-49 kg. 450 mg/daywt. gt
  50 kg 600 mg/day

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RIFAMPICIN major side effect

• Hepatitis
• Renal failure
• Shock syndrome
• Acute hemolytic anemia

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RIFAMPICIN minor side effect

• Cutaneous syndrome
• Flu like syndrome fever,chill, myalgia
• Abdominal syndrome abdominal pain,nausea,vomitti
  ng
• Neurologic headache,anxiety

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PYRAZINAMIDE

• Tablet 500 mg.
• 30-39 kg 1000 mg/day 40-49 kg.
  1500 mg/day gt50 ??.2000 mg/day

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PYRAZINAMIDE

• Major side effect hepatitis
• Minor side effecthyperuricemia, arthralgiafever
  rash anorexia nausea

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STREPTOMYCIN

• For injection 1 gram/vial
• 30-39 ?? 0.5 gram 40-49 ??. 0.75 gram gt50
  ??. 1 gram age gt60 y 0.75 gm.

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STREPTOMYCIN

• Major side effectvestibular damage tinitus
  vertigohearing losscontraindicate in pregnancy
• minor side effectpost injection-gtnumbness around
  mouthrash,fever ,vomitting

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ETHAMBUTOL

• tablet 200 400 500 mg. 30-39 kg. 800
  mg/day 40-49 kg. 1000 mg/day gt50 kg.
  1200 mg/day

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ETHAMBUTOL

• Majorblur vision, color blindness red-greenNot
  use in children lt 6 yr.
• minorrash,numbness in hand and foot,
  hallicination

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Advantage of FDC 1 easier to prescribe 2 smaller
numbers of tablets 3 patient can not select
individual drug
Disadvantage 1.excess dose or suboptimal dose 2
health worker -gt not doing DOT 3 poor Rifam
bioavailibity in some FDC
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WHO FDC recommendation
isoniazid rifampicin pyrazinamide tablet 75
mg 150 mg 400 mg isoniazid rifampicin
pyrazinamide ethambutol tablet 75 mg 150 mg
400 mg 275 mg
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Important things to know before start Rx

• Type of TB
• Type of Registration

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The purposes of case definition are

• proper patient registration and case
  notification
• prioritized treatment of sputum smear-positive
  cases, the main sources of infection in the
  community
• allocation of cases to appropriate standardized
  treatment regimens
• evaluation of the proportion of cases according
  to site, bacteriology and treatment history
• cohort analysis of treatment outcomes.

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The four determinants of case definition are
Site of TB disease. Bacteriology (result of
sputum smear). Severity of TB disease.
History of previous treatment of TB.
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TYPES OF TUBERCULOSIS

• 1.PULMONARY TB 1.1 PULMONARY TB WITH SPUTUM
  SMEAR VE 1.2 PULMONARY TB WITH SPUTUM SMEAR -VE
• 2.EXTRAPULMONARY TB

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1. ????????? (Pulmonary TB)

• 1.1) (Pulmonary TB,smear positive)- AT LEAST TWO
  VE SPECIMENS- ONE VE SPECIMEN CHEST X-RAY
  SUGGESTIVE PTB- OR ONE VE SPECIMEN PLUS
  CULTURE VE

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1.2) ???????????????????????????? (Pulmonary TB,
smear negative)
1.at least three sputum specimens Negative for
AFB, and
2.radiographic abnormalities consistent
with active PTB, and
3.no response to a course of broad-spectrum
antibiotics, and decision by a clinician to treat
with a full course of antituberculosis
Chemotherapy.
PTB/TOTAL TB 65 PTB/PTB- 50
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2. ???????????? (Extrapulmonary TB)

• refers to tuberculosis of organs other than the
  lungs, e.g. pleura, lymph nodes, abdomen,
  genitourinary tract, skin, joints and bones,
  meninges. Diagnosis should be based on one
  culture-positive specimen, or histological or
  strong clinical evidence consistent with active
  EPTB

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classification as severe disease if there is a
significant acute threat to life (e.g.
pericardial TB), a risk of subsequent severe
handicap (e.g. spinal TB), or both (e.g.
meningeal TB). Miliary TB
The following forms of EPTB are classified as
severe meningeal, pericardial, peritoneal,
bilateral or extensive pleural effusive, spinal,
intestinal, genitourinary. Lymph node, pleural
effusion (unilateral), bone (excluding spine),
peripheral joint and skin tuberculosis are
classified as less severe.
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category of patient for registration on diagnosis

• NEW
• RELAPSE
• TREAMENT AFTER FAILURE
• TREATMENT AFTER DEFAULT
• TRANSFER IN
• OTHER

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??????????????????????????????
category of patient for registration on diagnosis
New. A patient who has never had treatment for
antituberculosis drugs for less than 1 month.
Relapse. A patient previously treated for TB who
has been declared cured or treatment completed,
and is diagnosed with bacteriologically positive
(smear or culture) tuberculosis.
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category of patient for registration on diagnosis
Treatment after failure. A patient who is started
on a re-treatment regimen after having failed
previous treatment.
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category of patient for registration on diagnosis

• Treatment after default. A patient who returns to
  treatment, positive bacteriologically, following
  interruption of treatment for 2 months or more.
• Transfer in. A patient who has been transferred
  from another TB register to continue treatment.

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??????????????????????????????
category of patient for registration on diagnosis

• Other. All cases that do not fit the above
  definitions. This group includes chronic case, a
  patient who is sputum-positive at the end of a
  re-treatment regimen.

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The aims of treatment of TB are to cure the
patient to prevent death from active TB or its
late effects to prevent relapse of TB to
decrease transmission of TB to others to
prevent the development of acquired drug
resistance.
It is vital to achieve these aims while
preventing the selection of resistant bacilli in
infectious patients.
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DRUG REGIMEN(Category)

• CAT 1 2HRZE/4HRNEW SMEAR VE
  SMEAR -VE SEVERE OR
  EXTENSIVE DISEASE

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DRUG REGIMEN

• CAT 2 2HRZES/HRZE/5HRE
  RELAPSE FAILURE

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DRUG REGIMEN

• CAT 3 2HRZE/4HR NEW
  SMEAR-VE EXTRAPULMONARY TB

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We should use the suggested regimens
reduce errors in prescription thereby reducing
the risk of development of drug resistance
facilitate estimates of drug needs, purchasing,
distribution and monitoring facilitate staff
training reduce costs facilitate regular drug
supply when patients move from one area to
another.
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SPUTUM EXAN FOR MONITORING OF Rx

• AT THE END OF INTENSIVE PHASE- CAT1 , 3 AT THE
  END OF 2ND MNTH- CAT2 AT THE END OF 3ND MNTH
• 2 EXAMS. IN CONTINUATION PHASE AND ONE SHOULD BE
  AT THE END OF Rx

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TREATMENT OUTCOME

• CURE
• COMPLETED
• FAILURE
• DEFAULT
• DIE
• TRANSFER OUT

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TREATMENT OUTCOME
CURE

• Patient who is sputum smear-negative in the last
  month of treatment and on at least one previous
  occasion.

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TREATMENT COMPLETED
Patient who has completed treatment but who does
not meet the criteria to be classified as a cure
or a failure.
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• 3 TREATMENT FAILURE Patient who is sputum
  smear-positive at 5 months or later during
  treatment.
• 4 DefaultPatient whose treatment was interrupted
  for two consecutive months or more.

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• DiePatient who dies for any reason during the
  course of treatment.
• Transfer outPatient who has been transferred to
  another recording and reporting unit and for whom
  the treatment outcome is not known.

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DIRECTLY OBSERVED TREAMENT,SHORT COURSE DOTS

• MOST EFFECTIVE STRATEGY AVAILABLE FOR CONTROLLING
  TB EPIDEMIC TODAY

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Policy package for TB control the expanded DOTS
Framework
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The expanded DOTS framework reinforces the five
essential components of the DOTS strategy
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Directly observed treatment means that an
observer watches the patient swallowing their
tablets, in a way that is sensitive and
supportive to the patient's needs. This ensures
that a TB patient takes the right
antituberculosis drugs, in the right doses, at
the right intervals.
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DOT DIRECTLY OBSERVED TREATMENT

• One component of DOTS
• Treatment Observer(????????????????)Willingly
  Well trainedResponse Accepted by patient

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Who can be treatment observer?

• Health personel
• Health volunteer
• Husband,Wife, relatives
• Community members, leaders

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Treatment observer

• ensures that a TB patient taken right
  antituberculosis drugs, in the right doses, at
  the right intervals.
• Recording DOT CARD
• supportive
• Health education
• Prevent of tranmission