Training PPT for counselors for TB Helpline

1. MCF COUNSELORS
TRAINING FOR TUBERCULOSIS
HELPLINE
VENUE:MCF OFFICE, PUNE
5TH NOV 2012 TO 9TH NOV 2012
www.mcf.org.in 1

2. Why helpline for TB?
Tuberculosis (TB) remains a major global health
problem.
It causes ill-health among millions of people each
year
TB ranks as the second leading cause of death
from an infectious disease worldwide, after HIV1
Tuberculosis is a treatable and preventable disease.
What is needed is knowledge about the disease.
Stigma, discrimination and fear : TB has all as HIV
Strong referral services available
So helpline for TB makes sense
www.mcf.org.in 2

3. What is tuberculosis?
• TB is a chronic bacterial infection.
• The great majority of infections in people are caused
by Mycobacterium tuberculosis (M. Tuberculosis or
tubercle bacilli).
• M. tuberculosis and seven very closely related
mycobacterial species like M. bovis and others
together comprise what is known as the M.
tuberculosis complex.
• M. Bovis can cause TB in people who drink
unpasteurised milk from infected cows.
www.mcf.org.in 3

4. TB: Global Scenario
• About 1 in 3 of the world’s population is infected with
tubercle bacilli.
• There were an estimated 12 million prevalent cases in 2011
• 170 cases per 100 000 population
• Incidence: 90 lakh new cases
• Someone is newly infected every second
• Mortality: Nearly 14 lakh TB deaths every year
www.mcf.org.in 4

5. • About 95% of the world’s cases of TB occur
in South East Asia, sub-Saharan Africa and
the Western Pacific.
• The five countries with the largest number
of incident cases in 2011 were India (approx
2.0 million), China (approx–1 million),
South Africa (approx 0.5 million),
Indonesia (approx 0.5 million) and
Pakistan (approx 0.4 million).
• India and China alone accounted for 26%
and 12% of global cases, respectively.
www.mcf.org.in 5

6. TB in India
Nearly 40% of the Indian population is infected with the
MTB bacillus
Approx 30 million people in India are infected with TB
In 2011, with 2 million cases of TB, India alone accounted
for 26% of global cases.
4 lakh deaths occur from TB every year.
Everyday 5000 develop TB disease and 1000 people die of TB
TB kills more adults in India than any other infectious
disease.
(2 deaths every 3 minutes).
www.mcf.org.in 6

7. Who are getting infected?
Of the 9 million incident cases in 2011
 1 million (13%) were among people living with HIV
 0.5 million were children
 3 million were women.
TB affects mostly adults in the economically productive
age groups.
www.mcf.org.in 7

8. Drug resistant TB
Globally, 3.7% of new cases and 20% of previously
treated cases are estimated to have MDR-TB.
Estimated 310 000 of MDR-TB cases in 2011.
Almost 60% of these cases were in India, China and
the Russian Federation
Of MDR-TB cases, Extensively drug-resistant XDR-TB
is 9.0%
Treatment success rate of MDR TB is 50%
www.mcf.org.in 8

9. Microbiology
Rod-shaped bacterium of 2-4 x 0.2-0.5 μm.
Obligate aerobe found in the well-aerated
lungs.
Slow growing (dividing only every 16-20
hours)
Lives within tissue macrophages.
Humans are the only reservoir of M.
Tuberculosis
www.mcf.org.in 9

10. Microbiology
• Peculiar cell wall that consists of peptidoglycan and
complex lipids.
• The cell wall is a major factor in the virulence of the
organism.
• Once stained (e.g. with carbol fuchsin: Z N Staining), it
retain dyes when treated by acidified organic compounds.
• Therefore, it is classified as an “acid–fast” bacterium.
www.mcf.org.in 10

11. How is TB transmitted?
Nearly all TB infection is
acquired by inhalation of
respiratory droplets from
people with TB in the
lungs or throat.
Air droplets 3-5 μm
diameter are coughed,
sneezed or spat-out by an
“open” case of TB.
www.mcf.org.in 11

12. Other modes of transmission
Ingestion of the organisms leads to development of
tonsillar or intestinal tuberculosis. This mode of infection
of human tubercle bacilli is from self-swallowing of
infected sputum of an open case of pulmonary
tuberculosis, or ingestion of bovine tubercle bacilli from
milk of diseased cows.
Inoculation of the organisms into the skin may rarely
occur from infected pus tissue.
Transplacental route results in development of
congenital tuberculosis in foetus from infected mother
and is a rare mode of transmission.
www.mcf.org.in 12

13. How is TB not transmitted?
People cannot get infected with TB bacteria through
Handshakes
Sitting on toilet seats
Sharing dishes , mattresses with someone who has
TB.
From insect bites
From touching surfaces that are contaminated with
M. tuberculosis.
www.mcf.org.in 13

14. Factors that determine transmission risk
www.mcf.org.in 14

15. Characteristics of a Patient with TB Disease that
Are Associated with Infectiousness
www.mcf.org.in 15

16. Environmental Factors that Enhance the
Probability that M. tuberculosis Will Be
Transmitted
www.mcf.org.in 16

17. Proximity and Length of Exposure Factors that
Can Affect Transmission of M. tuberculosis
www.mcf.org.in 17

18. What happens when TB bacilli is
inhaled?
 Between 70-90% of individuals exposed to TB will not
develop the infection. This is because
• inhale too few organisms to cause infection
• have sufficient immunity to prevent an infection
becoming established
 Any factor associated with impaired immunity, such as
extremes of age, malnutrition and HIV/AIDS will
increase the risk of developing infection.
No infection in 70 to 90 % exposed people
www.mcf.org.in 18

19. What happens when TB bacilli is
inhaled?
In those 10-30% who develop infection,
TB infection begins when the
mycobacterium reach the lung alveoli.
In the alveoli, TB enters macrophages
and with other cells form a shell called
granuloma.
 The granuloma prevents dissemination
of the mycobacteria.
Bacteria inside the granuloma can
become dormant, resulting in a latent
infection.
It may remain latent lifelong or may
reactivate to active TB when immunity
fails.
Of the 10 to 30% of the exposed who
develop infection, 90% people have
latent infection
www.mcf.org.in 19

20. What happens when TB bacilli is
inhaled?
Active TB Infection
Active TB disease occurs if the
immune system cannot keep the
tubercle bacilli under control.
Bacilli begin to multiply rapidly
and break free from the shell of
granuloma.
Active clinical disease can be
pulmonary or may be systemic
( Brain Larynx Lymph node Lung
Spine Kidney , etc)
www.mcf.org.in 20

21. What are the likely outcomes
Pathogenesis
5
following exposure to open
TB? Exposure to TB
No infection Infection
(70-90%) (10-30%)
Dormant TB (90%) Active TB (10%)
• well • ill and likely to die if
• no TB disease untreated
• not infectious to • infectious
others
Activation of infection
results in disease
www.mcf.org.in 21

22. Clinical stages or states of
Mycobacterium tuberculosis infection
www.mcf.org.in 22

23. www.mcf.org.in 23

24. Who is at risk of TB infection?
Contacts Low body weight
Children  Certain medical treatments
Elderly (such as corticosteroid
treatment
All household
Prisons
Workplace
Urban slum
HIV
Poor areas
Previous TB
Migrants
Malnourished
Drug abusers
Smokers
Diabetics
www.mcf.org.in 24

25. Distribution of tuberculosis cases by
anatomical site in HIV-negative patients.
www.mcf.org.in 25

26. Distribution of tuberculosis cases by
anatomical site in HIV-positive patients
www.mcf.org.in 26

27. Clinical features of lung TB
Cough That Last For
More Than Two Weeks
Chest pain
Breathlessness
Coughing up blood
www.mcf.org.in 27

28. HIV AND TB
www.mcf.org.in 28

29. Miliary TB
Extensive TB
May present
only as fever
and weight loss
www.mcf.org.in 29

30. Common symptoms with TB at any
site
Weight Loss
Loss Of Appetite
Fever
Night Sweats
Weakness
www.mcf.org.in 30

31. TB lymphadenitis
Painless nodes in
neck commonly
Non-tender,
matted together
and rubbery
May ulcerate and
discharge.
www.mcf.org.in 31

32. Abdominal TB
Weight loss
Diarrhoea or
constipation
Abdominal distension
(from ascites) or
chronic intestinal
obstruction
Enlarged abd lymph
nodes may be palpable
as multiple intra-
www.mcf.org.in 32

33. Pleural effusion
Extrapulmonary
Pain,
breathlessness,
cough
www.mcf.org.in 33

34. Brain TB
Meningitis or
intracranial
tuberculomas
Headache, neck
stiffness, altered
mental status,
and cranial nerve
abnormalities,
convulsions.
www.mcf.org.in 34

35. TB spine
Especially seen
in young children
Presents as a
pain and/or
swelling on the
back or neck
Loss of limb
function
www.mcf.org.in 35

36. Pericardial TB
Patient presents
with
breathlessness
and chest pain.
Chest x-ray
shows cardio-
megaly and
pleural effusion
 Changes on
ECG are common.
www.mcf.org.in 36

37. Diagnosis of TB: Latent and
Active
www.mcf.org.in 37

38. Diagnosis of active TB
Sputum Examination for pulmonary TB
Examination of ascitic fluid, pleural fluid, CSF,
joint fluid, pus, etc for type of cells and AFB
Culture for AFB
NAAT for TB
ADA test
Urine test: LAM
Antibody tests
Breath tests
www.mcf.org.in 38

39. Sputum Smear Examination for
pulmonary TB
Sputum is a thick fluid that is produced in the lungs
Sample of sputum is usually collected by the person coughing.
Earlier 3 morning sputum samples were recommended, but
now two spot specimens are collected on the same day.
To do the test a very thin layer of the sample is placed on a
glass slide, and this is called a smear.
A series of special stains ( Zeihl Neelson or ZN stain) are then
applied to the sample, and the stained slide is examined
under a microscope for signs of the TB bacteria.
Ziehl-Nielsen stain demonstrates the presence of the acid and
alcohol fast bacilli (AFB).
www.mcf.org.in 39

40. How to collect sputum?
Patient is instructed to inhale deeply two to three times
with his/her mouth open, cough out deeply from the
chest, open the container, spit out the sputum into it and
close the container tightly
The health worker or the laboratory technician should
stand behind the patient.
 If a patient coughs out only saliva, (s)he should be asked
to try again to bring out sputum.
If a specimen cannot be sent to laboratory immediately, it
should be stored in a refrigerator or in another cool place.
Sputum specimens should be examined immediately
whenever possible and not late than a week after
collection.
www.mcf.org.in 40

41. Sputum Smear Examination for
pulmonary TB
 Simple, inexpensive, requires minimum training
 High specificity
 High reliability with low inter-reader variation
 Can be used for diagnosis, monitoring and defining cure
 Results are available quickly
 Feasible at peripheral health institutions
 Correlates with infectivity in pulmonary TB cases
But the sensitivity though is only about 50-60%. I.e. the
test is often falsely negative in patients with TB.
When positive, the patient is “smear-positive” or “open
TB” and the risk of transmission of infection to others is
very high.
The yield of the test is higher in patients with lung
www.mcf.org.in 41

42. Sputum-smear microscopy with
LED=light-emitting diode
 Instead of simple
microscope, benefits of low
cost, durability, faster and
ability to use without a
darkroom.
WHO issued a policy
statement recommending
that conventional microscopy
should be replaced by LED
microscopy
www.mcf.org.in 42

43. How is sputum smear test
interpreted?
www.mcf.org.in 43

44. www.mcf.org.in 44

45. Sputum culture
Culturing is a method of studying bacteria by growing
them on media containing nutrients.
It provides a definitive diagnosis of TB and can
significantly increase the number of cases found.
Culture can also provide drug susceptibility testing,
showing which TB drugs a person's bacteria is
resistant to.
www.mcf.org.in 45

46. Sputum culture
Solid culture medium
Egg-based Lowenstein
Jensen (LJ medium) or
Agar-based medium
Diagnosis can take 4
weeks to get a
conclusive result with
another 4-6 weeks to
produce drug
susceptibility results.
www.mcf.org.in 46

47. Liquid culture medium
BACTEC MGIT
960.This can detect
growth of
mycobacteria as
early as 4 days from
inoculation and
drug susceptibility
will be available in
21-28 days.
www.mcf.org.in 47

48. Microscopic observation of drug
susceptibility assay (MODS)
MODS has been described for the early detection
of M. tuberculosis growth in liquid medium,
allowing a more timely diagnosis and drug
susceptibility testing.
The method is based on the observation of the
characteristic cord formation of M.tuberculosis
visualized microscopically in liquid medium with
the use of an inverted Microscope
Sensitivity of MODS (92 %)
Turnaround time of nine days.
www.mcf.org.in 48

49. NAATs=nucleic acid
amplification tests (MTB PCR)
Currently available NAA tests are
not sufficiently sensitive (detecting
50%--80% of AFB smear-negative,
culture-positive pulmonary TB
cases) to exclude the diagnosis of
TB in AFB smear-negative patients
suspected to have TB
NAATs have high specificity.
Cannot be used for treatment
monitoring.
Culture, supported by microscopy,
still remains the gold standard
www.mcf.org.in 49

50. Xpert MTB/RIF
It is rapid NAAT test
Uses PCR technique for diagnosis of Mycobacterium
tuberculosis and rifampicin resistance
Xpert MTB/RIF has the advantage of detecting TB with
equivalent sensitivity to culture on solid media and of
simultaneously detecting rifampicin resistance with high
sensitivity (95%) and specificity (98%)
Turnover time less than 2 hours
 Another advantage is that it performs equally well among
HIV-negative and HIV-positive individuals.
It is therefore a useful tool to improve early case detection
of MDR-TB and HIV-associated TB.
www.mcf.org.in 50

51. CDC recommendations For
NAAT
www.mcf.org.in 51

52. Serological (antibody) detection tests for
pulmonary and extrapulmonary tuberculosis
Commercial serological tests (Ig G, Ig M
tests) for both pulmonary and
extrapulmonary tuberculosis produce
highly inconsistent estimates of sensitivity
and specificity
None of the assays do well enough to
replace microscopy.
www.mcf.org.in 52

53. ADA for tuberculosis pleuritis,
pericarditis, peritonitis
Measurement of ADA concentrations in
pleural, pericardial, and ascitic fluid has high
Sensitivity and specificity for extrapulmonary
tuberculosis.
www.mcf.org.in 53

54. Diagnosis of latent
tuberculosis
www.mcf.org.in 54

55. Mantoux or tuberculin skin test (TST)
or TT or PPD TEST
0.1 ml PPD is injected
intradermally and the
injection site is inspected
48-72 hours later.
Erythema and induration
at the site signify an
immune response and,
therefore, previous
exposure to mycobacteria.
www.mcf.org.in 55

56. Mantoux or tuberculin skin
test (TST) or TT or PPD TEST
False positive: a skin reaction in people who do
not have TB because of exposure to non-
pathogenic mycobacteria and also due to the
immune response following BCG immunisation
False negative: a negative result in a person with
TB in early primary infection or because they are
immunocompromised – for example, due to
HIV/AIDS, malnutrition or people who develop
disseminated TB.
www.mcf.org.in 56

57. Mantoux or tuberculin skin test
(TST) or TT or PPD TEST
Individuals who had received BCG vaccination
are more likely to have a positive TST
The effect of BCG on TST results is less after 15
years
Positive TST with indurations of >15 mm are more
likely to be the result of tuberculosis infection
than of BCG vaccination.
Non tuberculous mycobacterial infection can
cause positive test, esp in areas where MTB is less.
www.mcf.org.in 57

58. IGRAs=interferon-γ release
assays.
T-SPOT.TB Test, QuantiFERON-TB Gold test
IGRAs have excellent specificity (higher than the
TST), and are unaffected by previous BCG
vaccination.
IGRA sensitivity varies across populations and
tends to be lower in high-endemic countries and
in HIV-infected individuals.
www.mcf.org.in 58

59. Diagnosis of drug-resistant
tuberculosis
The INNO-LiPA Rif assay
GenoType MTBDR assays
CRI=colorimetric redox indicator method
NRA=nitrate reductase assays
MODS=microscopically observed drug susceptibility
Xpert MTB/RIF
www.mcf.org.in 59

60. Different tests for drug
resistance
The INNO-LiPA Rif assay is a highly sensitive and
specific test for the detection of rifampicin resistance
in culture isolates. The test has lower sensitivity when
used directly on clinical specimens.
GenoType MTBDR assays have excellent sensitivity
and specificity for rifampicin resistance, even when
directly used on clinical specimens.
www.mcf.org.in 60

61. CRI=colorimetric redox
indicator method
Colorimetric methods are sensitive and specific for
the detection of rifampicin and isoniazid resistance in
culture isolates.
CRIs use inexpensive non-commercial supplies
and equipment and have a rapid turnaround time (7
days).
www.mcf.org.in 61

62. NRA=nitrate reductase assays
NRA has high accuracy when used to detect
rifampicin and isoniazid resistance in culture isolates.
NRA is simple and inexpensive
Turnaround time 7–14 days
www.mcf.org.in 62

63. MODS=microscopically observed drug
susceptibility
MODS for rapid detection of rifampicin and isoniazid
resistance
MODS has high accuracy when testing for rifampicin
resistance, but shows slightly lower sensitivity when
detecting isoniazid resistance.
 MODS seems to do equally well with use of direct
patient specimens and culture isolates.
MODS uses non-commercial supplies and equipment,
and has a rapid turnaround time (10 days) compared
with conventional methods.
www.mcf.org.in 63

64. Diagnosis using urine sample
Urine-Based Assay for Lipoarabinomannan (LAM)
Urine LAM test detects a subset of TB patients who have
severe TB, advanced AIDS, and are not detected by
sputum smear microscopy
The combination of smear and LAM (either positive = TB)
detects about 75% of TB cases
Urine LAM test is promising for use in conjunction with
smear microscopy in settings of HIV high prevalence
Lacks infection control issues of blood, sputum
www.mcf.org.in 64

65. The tuberculosis diagnostics pipeline
www.mcf.org.in 65

66. Prevention of Tuberculosis
www.mcf.org.in 66

67. Patients are more likely to be
infectious if they:
Have TB of the lungs or throat
Have a cavity in the lung
Are coughing or undergoing cough-inducing
procedures
Are not covering their mouth when coughing
Have acid-fast bacilli on the sputum smear
Are not receiving adequate treatment
www.mcf.org.in 67

68. What care a TB case should take
to prevent transmission of TB?
The most important thing is to take REGULAR medicine.
TB patients who may be infectious should be instructed to
cover their mouth and nose with a tissue when coughing or
sneezing. Put the tissue in a closed bag and throw it away.
Adequate (ventilated and sunny) site for sputum collection,
preferentially outdoors
Avoiding the use of ceiling fans
Use of a standing fan either to direct the air flow towards
the window (or door) or to produce an air "barrier" between
the contacts and the patient
www.mcf.org.in 68

69. What care a TB case should
take to prevent transmission
of TB?
Avoid going to work or school.
 Sleep in a bedroom away from other family
members.
If in a hospital and also in home if possible, TB
patient must be given a separate room, with the door
closed and windows that can be opened.
This is to be followed for a period of 2 weeks after
starting TB treatment after which infectiousness
appears to decline very rapidly.
Close contacts should wear N99 masks, if available.
www.mcf.org.in 69

70. BCG Vaccine
Bacille Calmette-Guerin is an live vaccine available
for TB.
BCG appears to reduce the risk of serious childhood
forms of TB, including miliary TB and
extrapulmonary TB
BCG does not seem to be highly effective as people
move into adulthood.
www.mcf.org.in 70

71. BCG Vaccine
WHO recommends that BCG be given to infants and
young children in countries where TB is common.
It should not be given during pregnancy or to
children with symptomatic HIV infection.
If you were vaccinated with BCG, you may have a
positive reaction to a TB skin test. This reaction may
be due to the BCG vaccine itself or to a real TB
infection.
www.mcf.org.in 71

72. Treatment of Active TB
http://www.lifehugger.com/doc/2224/RNTCP_Current_gu
www.mcf.org.in 72

73. Anti-Tuberculosis Therapy
First-Line Drugs
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
www.mcf.org.in 73

74. High
INH
А
Continuous
(RIF, SM)
growth Special bacterial
population
hypothesis
PZ RIF and action of the
Speed of
bacteria
A specific drugs
growth
B C (From Mitchison, 1985)
D Acid Spurts of
Dormant inhibition metabolism
Low
(No cure)
Mitchison, Tubercle 66: 219-226
www.mcf.org.in 74

75. Side effects of ATT drugs
No appetite, nausea, Easy bleeding
vomiting Aching joints
Yellowish skin or eyes Dizziness
Hepatitis Blurred or changed vision
Abdominal pain Ringing in the ears
Skin rash Tingling fingers or toes
Patients on Rifampicin or around mouth
can have red colored
urine, saliva, or tears.
www.mcf.org.in 75

76. Principles of Therapy
Insure that patient is taking medication properly
(Directly Observed Therapy).
Therapy
Always use at least 2 drugs to which the
organism is susceptible.
Never add a single drug to a failing regimen.
Monitor clinical response to therapy.
www.mcf.org.in 76

77. What is MDR/XDR TB?
MDR-TB occurs when the TB bacteria are resistant to
at least isoniazid and rifampicin, the two most
powerful anti-TB drugs.
Extensively drug-resistant tuberculosis XDR-TB
is TB that is resistant to any fluoroquinolone, and at
least one of three injectable second-line drugs, in
addition to MDR-TB
www.mcf.org.in 77

78. Criteria to label a patient as
MDR-TB suspect.
A new smear-positive patient remaining smear-
positive at the end of fifth month.
A new smear-negative patient becoming smear-
positive at the end of fifth month.
A patient treated with regimen for previously treated
remaining positive at fourth month
Smear-positive contacts of an established/confirmed
MDR-TB case
www.mcf.org.in 78

79. MDR is more common in
people who
Have spent time with someone with drug-resistant
TB disease
Do not take their medicine regularly
Do not take all of their prescribed medicine
Develop TB disease again, after having taken TB
medicine in the past
www.mcf.org.in 79

80. Contributing Factors for MDR
TB
High prevalence of HIV.
Delayed diagnosis.
Delays in adequate therapy (in part due to unknown
drug susceptibilities).
Inadequate isolation procedures.
www.mcf.org.in 80

81. Deadly Mistakes
Not knowing MTB drug susceptibilities.
Inadequate therapy.
Ineffective drug regimen.
Inadequate length of treatment.
Sub-therapeutic drug level.
Lack of patient monitoring.
DOT.
Clinical Response.
www.mcf.org.in 81

82. ReasonMulti-Drug Resistant TB*
Prevalence of
for Alarm
6 5.5 %
5
4
*The W IUATLD Global Project on Anti-
HO/
3 TB Drug Resistance Surveillance
% (1994-1997)
2 1.6
1 Countries with good TB control = >33%
DOTS coverage.
0
With Good TB With Poor TB
Control Control
82

83. Management of MDR/XDR TB
For MDR
Intensive Phase (IP) of 6 drugs should be given at
least 6 months.
Continuation Phase, 4 drugs are given for 18 months.
For XDR:
At least three to four drugs to which the strain is
sensitive need to be used for effective treatment
Surgery of lung
www.mcf.org.in 83

84. Treatment for Latent
Tuberculosis Infection (TLTBI)
Isoniazid preventive therapy (IPT), is given to people
who have latent TB infection to prevent them from
developing TB disease.
The usual regimen for IPT is isoniazid given daily for
6 months for all patients.
Patients she should be screened for activeTB (current
cough, fever, weight loss or night sweats ) to rule out
active TB before starting IPT.
www.mcf.org.in 84

85. Who should be offered IPT?
ALL HIV patients should be given IPT irrespective of
the degree of immunosuppression, and also to those
on ART, those who have previously been treated for
TB and pregnant women.
IPT is administered to all the children aged 6 years ,
in risk groups such as household contacts, individuals
with chronic renal or respiratory disease
Patients should be clinically evaluated every month
for signs of hepatitis and other adverse reactions like
tingling numbness in legs due to isoniazid.
www.mcf.org.in 85

86. References
www.tuberculosistextbook.com
 Revised National Tuberculosis Control Programme (RNTCP)
Training Module for Medical Practitioners
 Extrapulmonary tuberculosis Indian J Med Res 120, October
2004, pp 316-353
 The Situation of HIV/M. tuberculosis Co-Infection in India. The
Open Infectious Diseases Journal, 2011, 5, (Suppl 1-M5) 51-59
 WHO Policy on TB Infection Control in Health-Care Facilities,
congregate Settings and Households
 Biomarkers and diagnostics for tuberculosis: progress,
needs, and translation into practice( Lancet)
 Questions and Answers About Tuberculosis, CDC 2009
www.mcf.org.in 86