Tuberculosis Huminis et bovis

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Tuberculosis Huminis et Bovis
Dr. S. K. Jindal www.jindalchest.com
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TUBERCULOSIS a global emergency

• H. Nakajima
• World Health (ed) 1993

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Tuberculosis A Global Emergency

• TB kills 5,000 people a day 2 million each year
• One third of the worlds population is infected
  with TB
• More than 100,000 children will die needlessly
  from TB this year
• Hundreds of thousands of children will become TB
  orphans this year
• HIV and MDR TB will make the TB epidemic much
  more severe unless urgent action is taken

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India is the highest TB burden country globally
accounting for one fifth of the global incidence
Globally 9 million new TB cases occur annually
Source WHO Geneva WHO Report 2006 Global
Tuberculosis Control Surveillance, Planning and
Financing
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TB is the leading single infectious cause of
death in India
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The National Problem

• Large pool of patients
• Renewed and perpetuated
• Difficult to approach
• Difficult to find, hold and treat
• Shortage of beds

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TB in India

• Per year Per Day
• Infection gt 7 million gt 20000
• Disease gt 2 million gt 5000
• Death gt 4 lacs gt 1000
• Children forced 3 lacs -
• to leave school
• Women losing 1 lac -
• status

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TB research in IndiaIndian contribution

1. Supreme importance of bacteriology in diagnosis
   and control
2. Hospitalization not essential
3. Principles of chemotherapy intermittent is as
   good

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• All countries benefit from the fruits of Indian
  research all countries except India.
• H. Maher, D.G. WHO
• (Quoted by Grzybowski. Tuberc Lung Dis, Ed, 1993)

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HIV Infection TB Risk

• Annual risk about 10
• Life Time Risk of TB
• w.r.t. HIV status
• - Negative 5-10
• - Positive 50

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ECONOMIC BURDEN Per Year

• Total costs Rs. 12000 crores
• (US 3 b)
• Loss of work days 17 crores
• At a cost of 700 crores

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Classification of mycobacteria

• Group 4
• Non- or rarely pathogenic
• Mycobacterium gordonae
• Mycobacterium smegmatis
• Group 5
• Animal pathogens
• Mycobacterium paratuberculosis
• Mycobacterium lepraemurium

• Group 1
• Obligate pathogens
• Mycobacterium tuberculosis
• Mycobacterium leprae
• Mycobacterium bovis
• Group 2
• Skin pathogens
• Mycobacterium marinum
• Mycobacterium ulcerans
• Group 3
• Opportunistic pathogens
• Mycobacterium kansasii
• Mycobacterium avium intracellulare (MAIC)

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Mycobacterium bovis

• Subset of mycobacteria
• Include M. tuberculosis
• M. africanum
• M. microti
• (Live attenuated strains of M.
  bovis is used in BCG)

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M.bovis TB in Humans

• Transmission from animals/human
• Inhalation route
• Unpasteurized milk
• Karlson et al (Ann Int Med 1970)
• Lab primates
• Renner et al (ARRD, 1974)
• Commercial elk herds
• Fanning (Lancet 1991)
• Persistence of M. bovis in US
• Dankner et al (Med 1993)

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The public health importance of animal TB

• WHO Report of the Expert Committee on
  Tuberculosis 1950
• "The committee recognizes the seriousness of
  human infection with bovine tuberculosis in
  countries where the disease in cattle is
  prevalent. There is the danger of transmission of
  infection by direct contact between diseased
  cattle and farm workers and their families, as
  well as from infected food products."

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Bovine tuberculosis occurrence, in Asia
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Control measures for bovine tuberculosis based on
test-and-slaughter policy and disease
notification, Asia
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Risk Factors of Bovine TB

• Unpasteurized milk of infected cattle
• Sharing of the same micro-environment and
  dwelling premises by humans and animals
• Immuno-compromised patients
• HIV infection (BCG vaccination in patients with
  AIDS)
• Leukaemias, Malignancies
• Ranch workers, veterinarians
• Common watering place (for live stock)

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• Currently, the BTB in humans is becoming
  increasingly important in developing countries,
  as, especially in rural areas. At present, due to
  the association of mycobacteria with the HIV/AIDS
  pandemic and in view of the high prevalence of
  HIV/AIDS in the developing world and
  susceptibility of AIDS patients to tuberculosis
  in general, the situation change is most likely
  (Amanfu, 2006). This diseases presence in humans
  has been reduced as a result of the

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Zoonotic TB - Elephants

• A report from India (July 5, 2009)
• (TB in domesticated elephants from Kerala,
  Karnataka, TN, Andaman Nicobar)
• Temple elephants 16 of 63 (25.4)
• Individual owners 24 of 160
  (15.0)
• Forest department 10 of 164 (6.1)
• Total 50 of 387
  (12.9)
• (Transmission from humans)

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Relative Risk for Developing Active TB by
selected clinical conditions
Clinical Condition Relative Risk
Silicosis 30
Diabetes mellitus 2.0 4.1
Chronic renal failure/hemodialysis 10.0 25.3
Gastrectomy 2 5
Jejunoileal bypass 27 63
Solid organ transplantation
Renal 37
Cardiac 20-74
Carcinoma of head or neck 16
Note Relative to Control Population, independent of tuberculin-test status. Note Relative to Control Population, independent of tuberculin-test status.
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Clinical Features

• Indistinguishable from M. tuberculosis huminis
• Accounts for about 3.1 of all forms of TB 2.1
  of pulmonary and 9.4 of extra-pulmonary forms.
• Pulmonary
• Extrapulmonary
• Cervical adenitis
• Abdominal TB
• Skin (Lupus vulgaris)
• Disseminated infection
• (esp. in children)

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TB control efforts in India

• 1997 RNTCP started as a national programme
• 1998 Large scale RNTCP expansion began
• Early 2000 135 million population covered
  Monitoring Mission conducted
• Sept 2003 741 million population covered
• Monitoring Mission appreciates rapid expansion
• and overall quality
• Mar 2006 100 population covered
• Next 5-year plan approved with additional
  activities, such as DOTS-Plus

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DOTS Strategy

• A strategy to ensure treatment completion in
  which
• Treatment observer (DOT provider) must be
  accessible and acceptable to the patient and
  accountable to the health system
• DOT provider administers the drugs
• in intensive phase.
• Ensures that the patient takes medicines
• correctly in continuation phase.
• Provides the necessary information
• and encouragement for completion of treatment.

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RNTCP treatment guidelines
CATEGORY I New smear Seriously ill smear negative Seriously ill extra- pulmonary TB 2 H3R3Z3E3 / 4H3R3
CATEGORY II Previously treated smear- positive ( relapse, failure, treatment after default) 2 H3R3Z3E3S3/ 1 H3R3Z3E3 / 5H3R3E3
CATEGORY III New smear negative and extra pulmonary TB, not seriously ill 2 H3R3Z3 / 4H3R3
ALL TREATMENT THRICE WEEKLY. CAT I AND CAT II
EXTENDED by ONE MONTH IF SMEAR POSITIVE AT THE
END OF INITIAL INTENSIVE PHASE
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Impact of RNTCP

• Cure rate More than doubled and 85 global
  target achieved
• Case detection Almost at the target of 70 (72
  in 2004, 66 in 2005)
• Case fatality Reduced from 29 to 4 in NSP
  cases, and deaths due to TB from 500,000 to
  lt370,000 a year
• Treatment Over 6 million patients initiated on
  DOTS
• TB incidence and prevalence Early signs of start
  of decline.

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India has already implemented most of the
additional components of the Stop TB Strategy
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VISION A world free of TB

• GOAL
• - To reduce dramatically the global burden of TB
  by 2015 in line with the Millennium Development
  Goals (MDGs) and the Stop TB Partnership targets
• OBJECTIVES
• - To achieve universal access to high-quality
  diagnosis and patient-centred treatment
• - To reduce the suffering and socioeconomic
  burden associated with TB
• - To protect poor and vulnerable populations from
  TB, TB/HIV and MDR-TB
• - To support development of new tools and enable
  their timely and effective use
• TARGETS
• MDG 6, Target 8
• - TB halted by 2015 and begun to reverse the
  incidence
• - Targets linked to the MDGs and endorsed by the
  Stop TB Partnership

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Millennium Development Goal 6

• Millennium Development Goal (MDG) 6, Target 8
  Halt and begin to reverse the incidence of TB by
  2015
• Targets linked to the MDGs and endorsed by the
  Stop TB Partnership
• by 2005 detect at least 70 of new sputum
  smear-positive TB cases and cure at least 85 of
  these cases
• by 2015 reduce TB prevalence and death rates by
  50 relative to 1990
• by 2050 eliminate TB as a public health problem
  (1 case per million population)

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Components of the strategy and implementation
approaches

• Pursue high-quality DOTS expansion and
  enhancement
• a. Political commitment with increased and
  sustained financing
• b. Case detection through quality-assured
  bacteriology
• c. Standardized treatment, with supervision and
  patient support
• d. An effective drug supply and management system
• e. Monitoring and evaluation system, and impact
  measurement
• Address TB/HIV, MDR-TB and other challenges
• a. Implement collaborative TB/HIV activities
• b. Prevent and control MDR-TB
• c. Addressing issues concerning prisoners,
  refugees and other high-risk groups and
  situations
• Contribute to health system strengthening
• a. Actively participate in efforts to improve
  system-wide policy, human resources, financing,
  management, service delivery and information
  systems
• b. Share innovations that strengthen systems,
  including the Practical Approach to Lung Health
  (PAL)

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Components of the strategy and implementation
approaches (Contd.)

• Engage all care providers
• a. Public-Public and Public-Private mix (PPM)
  approaches
• b. International Standards for Tuberculosis
  Care (ISTC)
• Empower people with TB and communities
• a. Advocacy, communication and social
  mobilization
• b. Community participation in TB care
• c. Patients charter for tuberculosis care
• Enable and promote research
• a. Programme-bases operational research
• b. Research to develop new diagnostics, drugs
  and vaccines

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Health sectors involved in RNTCP

• Medical colleges
• Task forces, Core committees in colleges
  established
• 230 medical colleges involved
• Other Central government departments/PSUs
• Railways, ESI, Mining, Shipping
• NGOs
• More than 2000 NGOs involved
• Private Practitioners
• More than 12,000 private practitioners involved
• Corporate sector
• Nearly 120 corporate houses involved
• Coal India, Tea industry, Steel/Aluminium plants

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Factors influencing nosocomial transmission of
tuberculosis among HCWs

• Related to the health care facility
• Level of exposure
• High vs low exposure areas
• Inadequate isolation of infected patients
• Ennvironmetal
• Inadequate sanitation
• Inappropriate disposal of excreta
• Overcrowding in the wards
• Poor ventilation
• Host factors related to HCWs
• Immune status of an individual
• Co-morbid illnesses
• BCG vaccination status
• General clinical factors
• Delayed suspicion and diagnosis
• Delayed initiation of treatment

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Measures used for control of tuberculosis
transmission in health care workers

• General infection control measures
• Reduction of environmental load by reducing the
  release of mycobacteria
• Use of masks for patients
• Isolation rooms
• Preventing environmental spread
• Negative pressure rooms
• Use of HEPA filters
• Use of ultraviolet radiation
• Individual protection measures
• Inhalation prevention strategies
• Use of simple masks
• Use of respirators HEPA filters/PAPR
• BCG vaccination
• Chemoprophylaxis
• Early detection and treatment
• (HEPA high efficiency particulate air PAPR
  powered air purifying respirator)

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Suggested algorithm for early detection of
tuberculosis in HCWs in resource limited
settings

• Annual screening of HCWs with a
  symptom-questionnaire
• TB Suspect (any HCW with respiratory and/or
  constitutional symptoms,
• not explained by a definitive alternative cause)
• Sputum smear for AFB X3
• Positive
  Negative
• Treat as smear-positive TB Chest X-ray
• Suggestive of TB
  Not suggestive of TB
• -Treat as smear-negative TB TST/IGRAs
• Consider bronchoscopy BAL
• fluid examination for AFB Positive
  Negative

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Prevention of non-tuberculous mycobacteria disease

• Health care-associated NTM disease
• Avoid exposure of injection sites, intravenous
  catheters and surgical wounds and tap water
  derived fluid
• Avoid cleaning of endoscopes with tap water
• Avoid contamination of clinical specimens with
  tap water and ice
• Disseminated MAIC disease
• Patients with AIDS (CD4 T-lymphocyte count lt 50
  cells/?l) or Clarithromycin 100 mg/day or
  Rifabutin 300 mg/day (less well tolerated)

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Control of Bovine TB

• Control/ Eradication program in animals
• Co-ordination with RNTCP
• Treatment with effective drugs
• Pasteurization of milk
• Advances in sanitation and hygiene
• Sustained cooperation of national and private
  veterinary services, meat inspectors, and farmers
  for successful conduct of a test-and-slaughter
  policy, as well as adequate compensation for
  services etc.

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Treatment of Bovine TB

• Innate resistance to Pyrazinamide
• Treatment with 2 or 3 drugs (H,R,E and S) for
  9-12 months
• Standard SCC 2HRZE, 4RH
  (ODonahue et al (ARRD, 1974)
• DOTS strategy Not clearly defined. But type of
  mycobacteria is not distinguished in RNTCP.

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Summary

• India is the highest TB-burden country.
• Nationwide DOTS-coverage is achieved after a
  phase of unprecedented rapid expansion of DOTS.
• With reference to the global targets, the
  Treatment-success has exceeded and case-detection
  is close.
• A wide range of initiatives beyond basic DOTS
  services have been implemented
• The challenge ahead is to sustain good quality
  services over the next few decades in order to
  achieve TB control
• Bovine TB is being recognized as an important
  cause in humans in specific patient populations.
• Control programs for bovine and human TB
  should coordinate for an effective implementation.

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Thank You