TB CONTROL PROGRAMME KZN WTBD Media Session What is TB 22nd March 2011 WHAT IS TB • Tuberculosis or TB is a curable, infectious disease caused by a germ called Mycobacterium tuberculosis, that attacks any part of the body, but mostly the lungs • TB of the lungs is called Pulmonary TB (PTB) • TB outside the lungs is called Extra Pulmonary TB (EPTB) and can be in the skin, bones, lymph nodes, stomach etc. HOW IS TB SPREAD • The TB germs are spread into the air when a person who has TB coughs, sneezes or spits • The germs float in the air, and can be breathed in by people who come into contact with the infected air • The TB germs now infect the lungs (PTB ) • The TB germs can also spread to other parts of the body ( EPTB ) • TB germs are so small they can only be seen under a microscope Number and Size of Organisms Liberated Number of Organisms Liberated: Talking 0 – 200 Coughing 0 – 3 500 Sneezing 4500 – 1 000 000 Jennison [1942] WHO Definition of exposure: Contact between persons in sufficient proximity to carry on a conversation OR within confined spaces where ventilation is poor SIGNS & SYMPTOMS OF TB • A persistent cough that lasts for 2 weeks or longer • • • • • Shortness of breath, and chest pain Coughing up blood Loss of appetite, and loss of weight A general feeling of illness Tiredness and weakness of the body, and loss of motivation • Night sweats and fever, even when it is cold HOW IS TB DIAGNOSED • Firstly, TB is suspected by observing the clinical signs and symptoms • Secondly, by obtaining 2 sputum specimens from the patient which are tested in the laboratory under a microscope to identify the TB bacillus ( Smear Positive Case ) • Thirdly, if the patient does not prove positive on sputum examination, x-rays and cultures can be done to confirm diagnosis PATIENT CATEGORIES • New patient – a patient who has not had TB or been treated before • Re-treatment patient – a patient who has been treated for TB before (5yrs) however, now a move to 2yrs • MDR TB patient – a patient who does not respond to the normal TB drugs TB Drugs First Line • • • • • R – rifampicin - tablet H – isoniazid - tablet Z – pyrazinamade - tablet E – ethambutol - tablet S – streptomycin – injection First Line Drugs Blue in use Rifampicin New Patient Isoniazid New Patient Pyrazinamide New Patient Ethambutol New Patient Streptomycin Added to above for ReTreatment Patients TB Treatment cont. • Fixed Dose Combinations – makes it easier for the patient to take the tablet • 4 in 1 = all 4 intensive phase drugs in 1 tablet • 2 in 1 = all 2 continuation phase drugs in 1 tablet TB REGIMENS • New patient – 6 months treatment – 2 months intensive phase with 4 drugs ( RHZE ), followed by 4 months continuation phase with 2 drugs ( RH ) • Re-treatment patient – 8 months treatment – 3 months intensive phase with 5 drugs ( RHZES ) for first 2 months and 4 drugs ( RHZE ) for third month, followed by 5 months continuation phase with 3 drugs ( RHE ) • TB treatment is taken 7 days a week MDR/XDR TB Case Definition • MDR TB is defined as TB that is resistant to both the 2 main first line drugs Rifampicin and Isoniazid (INH) with or without resistance to other drugs • XDR-TB is defined as resistance to at least rifampicin and isoniazid, (MDR-TB), in addition to any fluoroquinolone, and at least one of the three following injectable drugs capreomycin, kanamycin, and amikacin (WHO) MDR / XDR TB Drugs Second Line Drugs Blue in use for MDR TB / Green are new drugs for XDR TB Category Drug(s) Aminoglycosides Kanamycin Amikacin Thioamides Ethionamide Prothionamide Polypeptides Capreomycin Fluoroquinolones Ofloxacin Ciprofloxacin Cycloserine / Terizidone Cycloserine / Terizidone PAS PAS MDR Treatment • Intensive phase – Minimum 6 months – 5 drugs – at least 6 x per week • Aminoglycoside ( 5 x weekly) (Kanamycin/Amikacin) • PZA • Ofloxacin • Ethionamide • Terizidone/Cycloserine • Ethambutol • Pyridoxine (B6) - 150mg daily with Terizidone/Cycloserine • Continuation Phase – Minimum 18 months – Drugs at least 6 x per week • Ethionamide • Ofloxacin • Terizidone/Cycloserine • Continue PZA DOTS • DOTS = Directly Observed Treatment Short Course Strategy (6mths) – Political Commitment / sustained TB programme activities – Sputum smear microscopy for diagnosis of infectious cases – Standardised short course anti-TB treatment with directly observed treatment – Uninterupted supply of TB drugs – Standardised reporting and recording system that allows assessment of treatment outcomes • DOT = Directly Observed Treatment • In other words all TB patients should have a treatment supporter to help them to complete their full 6 months of treatment, as remembering to take your treatment every day for 6 months is not easy • however • Move towards focus on patient education TB Indicators • Bacterial coverage = % of PTB patients diagnosed by sputum – target 90% • Smear conversion rate = % of smear + patients converted to negative at end of intensive phase treatment – target 85% • Cure rate - % of patients smear negative at end of treatment, and also on at least one other occasion during treatment – target 85% • Default / Interruption rate = % of patients stopped taking treatment for longer than 4 weeks – target <5% TB Infection Control Remember • • • • Number of Organisms Liberated: Talking 0 – 200 Coughing 0 – 3 500 Sneezing 4500 – 1 000 000 TB Infection Control Simply put • Cough Hygiene • Open Window policy = good ventilation At facility • Both of the above • Staff baselines • N95 Respirators • Triaging of patients • Mechanical ventilation / UV lights