TB

1. Tuberculosis
DR.JEEVAN YADAV
Professor,
Community Medicine,
D. Y. Patil Medical College, Kolhapur

2. •India –
•Highest ТВ burden Country in the world and
• accounts for nearly 1/5th (20%) of global burden
• 2/3rd (33%)cases in SEAR are from India.

3. •Every year,
•approx 1.8 million persons develop tuberculosis
•of which about 0.8 million are new smear
positive highly infectious cases.

4. •Annual risk of becoming infected with ТВ is 1.5% and
once infected there is 10% life-time risk of developing
ТВ disease.
•2 out of 5 Indian-are infected with ТВ bacillus
•Every day about 5,000 people develop the disease.
•Patients with infectious pulmonary tuberculosis disease
can infect 10-15 persons in a year.

5. •Today, India's DOTS programme against tuberculosis
recognized as the fastest expanding programme.
•Launched in March 1997 it has covered the whole
country by March 2006
•More than 7.3 million patients are on DOTS
treatment so far, and about 1.4 million additional lives
have been saved.

6. •Death rate under RNTCP have been cut 7-folds from
29 % to around 4 %in smear positive cases.
•In the year 2006, the programme had achieved a case
detection rate of 66 % as against global target of 70 %
•Treatment success achieved consistently is about 85 %

7. TB Burden in India
• Prevalence of Infection: 30%
• Incidence of infection: 1-2%
• Prevalence of Disease: 4/1000
• Incidence of disease: 1.7/1000
• Everyday 20,000 infected, >5000 develop TB,
>1000 die of TB
• Simply every minute 2 become sputum smear
+ve & almost 1 killed.

8. Epidemiological indices
a) Prevalence of infection :
• It is the percentage of individuals who show a positive
reaction to the standard tuberculin test.
b) Incidence of infection : (Annual Infection Rate) :
• It is the percentage of population under study who will be
newly infected by Myco. tuberculosis among the non infected
of the preceding survey during the course of one year.
•It reflects the annual risk of being infected (or reinfected) in a
given community.
• In other words, it expresses the attacking force of tuberculosis
in a community.

9. •In developing countries,
•every 1% of annual risk of infection is said to
correspond to 50 new cases of smear-positive
pulmonary tuberculosis, per year for 100,000 general
population .
•Also known as "tuberculin conversion" index,
•this parameter is considered one of the best
indicators for evaluating the tuberculosis problem
and its trend.

10. C) Prevalence of disease or case rate : It is percentage of
individuals whose sputum is positive for tubercle bacilli on
microscopic examination. It is the best available practical
index to estimate the number of infectious cases or "case
load" in community.
(d)Incidence of new cases : It is the percentage of new
tuberculosis cases (confirmed by bacteriological
examination) per 1000 popul occurring during one year.

11. e) Prevalence of "suspect" cases : This is based on X-ray
examination of chest. For diagnosis of tuberculosis of
bacteriological origin confirmation is needed.
(f) Prevalence of drug-resistant cases : It is the prevalence of
patient excreting tubercle bacilli resistant to anti-tuberculosis
drugs.
(g) Mortality rate : In the past, tuberculosis mortality rate, i.e.
number of deaths from tuberculosis every year per 1,000 or
100,000 population was used as index of tuberculosis problem in
community.

12. Some definitions of tuberculosis cases and treatment
Case of tuberculosis : A patient in whom tuberculosis has
been confirmed by bacteriology or diagnosed by clinician.
Sputum smear examination - Laboratory technique to
screen sputum for tuberculosis, where acid fast bacilli
(AFB) are stained red by the Ziehl Neelsen method, and
then identified and counted using microscopy.

13. Smear positive tuberculosis - At least two initial
sputum smears positive for AFB or one AFB positive
smear and one positive culture, or one sputum smear -
positive for AFB & radiographic abnormalities
consistent with active pulmonary tuberculosis.
Smear negative tuberculosis - At least three negative
smears, but tuberculosis suggestive symptoms and
X-ray abnormalities or positive culture.

14. Adherence - Person takes appropriate drug
regimen for required time (also known as
compliance).
New case - A patient with sputum positive
pulmonary tuberculosis who has never had
treatment for tuberculosis or has taken anti-
tuberculosis drugs for less than 4 weeks.

15. Relapse - A patient who returns smear positive having previously
been treated for tuberculosis and declared cured after the
completion of his treatment.
Failure case - A patient who was initially smear positive, who
began treatment and who remained or became smear positive
again at five months or later during the course of treatment.
Return after default - A patient who returns sputum smear
positive, after having left treatment for at least two months.

16. Transfer in - A patient recorded in another administrative area register and
transferred into another area to continue treatment (treatment results should be
reported to the district where the patient was initially registered).
Transfer out - A patient who has been transferred to another area register and
treatment results are not known.
Cured - Initially smear positive patient who completed treatment and had negative
smear result on at least two occasions (one at treatment completion).
Treatment completed - Initially smear negative patient who received full course of
treatment, or smear positive who completed treatment, with negative smear at the
end of initial phase, but no or only one negative smear during continuation and
none at treatment end.
Cohort - A group of ТВ patients ….

17. NATURAL HISTORY OF TUBERCULOSIS
Agent Factors
(a) AGENT : M. tuberculosis
• is a facultative intracellular parasite i.e.it is readily
ingested by phagocytes & resistant to intracellular killing .
• Of importance to man are the human and bovine strains.
• human strain is responsible for majority of cases.

18. • recently, a number of "atypical" mycobacteria have been
isolated from man are
• (i) photochromogens (ii) scotochromogens
(iii) non-photochromogens and. (iv) rapid growers
• Diseases attributed to them have resembled pulmonary
tuberculosis and chronic cervical lymphadenitis.
• Non-specific infections have been reported to be widely
prevalent in the southern part of India.

19. (b) SOURCE OF INFECTION : -
• 2 sources - human and bovine,
(i) Human source :
• The most common is the human case whose sputum is
positive for TB Bacilli either received no treatment or not
been treated fully.
• An estimated annual average of 10-15 persons contract
infection from one case of infectious pulmonary ТВ.
• Such sources discharge the bacilli in their sputum for yrs.
• TB bacilli in a human case are usually a mixed group –
• some multiply very rapidly and some slowly.
• The more rapidly bacillary multiplies the more susceptible

20. •The slow multipliers are the source of persister or dormant
bacilli, they can remain alive for years without causing harm to the
host, but when conditions are favorable they may start multiplying
again and cause active disease. That is, they are the seeds of a
future relapse.
(ii) Bovine source:
•The bovine source of infection is usually infected milk.
•There is no definite evidence that bovine tuberculosis is a
problem in this country because of the practice of boiling milk
before consumption.

21. (C) COMMUNICABILITY :
• Patients are infective as long as they remain untreated.
• Effective anti-microbial treatment reduces infectivity by 90%
within 48 hours .

22. Host factors
(a) AGE :
• Tuberculosis affects all ages.
• In India, from 1 % in "under five", infection index
climbs to about 30 % at 15 yrs.
(b) SEX : More prevalent in males than in females.
(c) HEREDITY :
•Tuberculosis is not a hereditary disease.
•Twin studies indicate that inherited susceptibility is
important risk factor.

23. (d) NUTRITION:
•Malnutrition is indirectly believed to
predispose to tuberculosis.
•Studies in India at TB Chemotherapy Centre,
Chennai showed that diet had no discernible
influence on the recovery of patients in the
context of potent anti-TB drugs.

24. (e) IMMUNITY :
•Man has no inherited immunity against tuberculosis.
• It is acquired as a result of natural infection or BCG
vaccination.
•Both delayed hypersensitivity and acquired
resistance to tuberculosis are cell-mediated
responses.
•In most cases, the cellular immunity proves adequate
to limit further multiplication and spread of bacilli.

25. Social factors:
• Tuberculosis is a social disease with medical aspects.
• It has also described as a barometer of social welfare.
• All these factors are interrelated and contribute to the
occurrence and spread of tuberculosis.
• In fact, tuberculosis began decline in the western world
long before the advent of chemotherapeutic drugs.
• This has been attributed to improvements in the
quality of life.

26. Social factors:
• These include many non-medical factors like-
 poor quality of life,
 poor housing, and
 overcrowding,
 population explosion,
 under nutrition,
 lack of education,
 large families,
 early marriages,
 lack of awareness of causes of illness, etc.

27. TUBERCULIN TEST-
• Discovered by Von Pirquet in 1907.
• A positive reaction to test generally accepted
as evidence of past or present infection by M.
tuberculosis.
• Tuberculin test is only means of estimating
prevalence of infection in population

28. TUBERCULIN TEST- 3 tests currently in use :
 Mantoux intradermal test -The Mantoux is favoured
when a more precise measurement of tuberculin sensitivity is
required.
 Heaf test - The Heaf test is usually preferred for testing
large group of people because it is quick and easy to perform,
reliable and cheap.
 Tine multiple puncture tests - The Tine test is
considered by some authorities as unreliable, therefore not
recommended.

29. Tuberculin:
•Test material or antigen is known as tuberculin.
•There are two major antigens –
•the old tuberculin (ОТ),
• and the purified protein derivative (PPD).
•Since PPD is a purer preparation , widely used.
•One TU is equal to 0.01 ml of ОТ or 0.00002 mg PPD.
•The WHO advocates a PPD tuberculin as "PPD-RT-23 with Tween 80".
DOSAGE : The dosages of PPD in vogue are :
•(a) first strength or 1 TU,
•(b) intermediate strength or 5 TU and
•(c) the second strength or 250 TU.
•For routine testing, the vaccinating teams in India use 1 TU,
in some countries 5 TU are used.
•Nearly all truly infected persons react to 1 to 5 tuberculin units.
•Stronger doses elicit a higher proportion of false +ve.

30. MANTOUX TEST :
•Test used for estimating prevalence of infection in
population
•Gives evidence of past or present infection by MTB.
•Discovered by Von Pirquet in 1907.
•Mantoux test is carried out by injecting intradermally on
flexor surface of forearm 1 TU of PPD in 0.1 ml.
•WHO advocates preparation -"PPD-RT-23 with Tween 80”.
The result of the test is read after 72 hours (3rd day).

31. Interpretation:
•Look for erythema and induration.
•Since erythema is sometimes difficult to measure,
•Induration alone more specific & is measured (horizontal
transverse diameter of induration in mm, by transparent plastic
ruler/ calipers.
•Reactions > 10 mm are considered "positive".
•Those < 6 mm are considered "negative"'.
•Those between 6 and 9 mm are considered "doubtful", i.e., the
reaction may be due to M. TB or atypical mycobacteria.
•< 5 mm- more risk of contracting TB

32. •This test only indicates that person is infected with MTB.
•This does not mean that the person is diseased
•A positive tuberculin test in paediatric population
below 2 yrs is an indirect evidence of an active lesion in their
body and should be interpreteted with caution
•False positive test-
•Non-tuberculous mycobacteria
•Recent BCG vaccination

33. •False negative test-
•Immunocompromised
•Infants less than 6 months
•Recent live virus vaccination e.g.measles within 4-6 wks
•Early phase of infection
•Drawbacks-
•Lack of specificity due to errors in mode of administration, test
material, interpretation, cross reaction by other mycobacterium.
•Lack of sensitivity due to infection with atypical mycobacterium,
repeat test exerting booster effects etc.

34. Transmission: Tuberculosis is
transmitted mainly by droplet infection
and droplet nuclei generated by
sputum-positive patients with pulmonary
tuberculosis.
Resp route – inhalation of airborne
droplets following coughing, sneezing
and speaking where organism remain
airborne and infectious for period of

35. Incubation period:
The time from receipt of infection to development of
a positive tuberculin test ranges from 3 to 6 weeks,
and thereafter,
the development of disease depends upon the
closeness of contact, extent of the disease and
sputum positivity of the source case (dose of
infection) and host-parasite relationship.
Thus the incubation period may be weeks, months
or years

36. • Pulmonary
• Extra-pulmonary

37. The primary stage of the disease may be
symptom-free, or the individual may experience a
flu-like illness.This is called the “inactive stage.”
Within the active stage of the disease, there might
be a slight fever, night sweats, weight loss, fatigue.
The symptoms my vary depending on what type
of tuberculosis you contract.

38. = Group of People at high risk for MTB
** HIV infected persons
** Close contact (eg, family members) of patients infected with MTB
** underlying medical condition that increase risk of acquiring MTB
** Alcoholic IVDU
** H.C.W.
** Long term care facilities, nursing homes, etc.
= Several months of exposure needed to get infection with MTB, however,
close contacts of infected persons puts others at risks of acquiring infections.

39. = Degree of contagiousness of a patient depends on:
** Number of organism in sputum (open TB)
** Cavitary lung disease
** Amount of coughing
** Length of time on anti TB Rx
** Others
= Clinical Syndromes
** Primary infection ** Latent infection
** Reactivation TB ** P. TB and E.P. TB

40. DIAGNOSIS OF T.B.

41. SPECIMENS USED
1. Pulmonary T.B.- Sputum
2. TB Meningitis- C.S.F.
3. Renal T.B.- Urine
4. Bone and joint T.B.- Aspirated fluid
5. Tissue- Biopsy

42. DIRECT MICROSCOPY
• Sputum collection- 2 samples of sputum are
collected
• Early morning sample and on the spot
samples are collected

43. 1- Sputum smears stained by Z-N stain
Three morning successive mucopurulent sputum
samples are needed to diagnoise pulmonary TB.
Advantage: - cheap – rapid
- Easy to perform
- High predictive value > 90%
- Specificity of 98%
Disadvantages:
- sputum ( need to contain 5000-10000 AFB/ ml.)
- Young children, elderly & HIV infected persons
may not produce cavities & sputum containing AFB.

44. CULTURE
• Very sensitive method
• Solid medium is LJ medium in which growth
takes 6-10 weeks.
• MGIT is a liquid medium in which growth
occurs in 4-6 weeks.
• Smear is prepared from these cultures.

45. SEROLOGY
• USED FOR DETECTION OF ANTIMICROBIAL
ANTIBODIES.
• TESTS PERFORMED ARE- ELISA
- RIA
- LATEX AGGLU.
• MOLECULAR METHODS- PCR
• CHROMATOGRAPHIC METHODS

46. NEWER TESTS
• A) LPA:- LINE PROBE ASSAY- this gives the
diagnosis with in the 48hrs.
• B) CBNAAT- Citrate based nucleic acid antigen
testing- it is an expensive method but
diagnosis is made with in 2 hrs.
• It is a gene expert technique.

48. THE CONTROL OF TUBERCULOSIS
•Control means reduction in prevalence & incidence
of TB in community.
•WHO defines tuberculosis "control" to be
achieved when prevalence of natural infection in
age group 0-14 years is of 1 %
•This is about 40% in India.
•It means we have to go long way to reach WHO
goal of control .

49. •The control measures consist of -
•curative component - namely case
finding and treatment -
the most powerful weapon and
•preventive component - namely
BCG vaccination.

50. Case finding
a. THE CASE
•First step in TB control programme is early detection
of sputum-positive cases.
•A ‘case of tuberculosis’ is a patient who sputum is
positive for tubercle bacilli.
•Sputum negative suspects diagnosed based on clinical
and X-ray.

51. Case finding
b. TARGET GROUP
•C/F: Patients of pulmonary TB have one or more c/o
* persistent cough (usually with sputum, sometimes blood stained)
•fever,
•chest pain for 3 wks.
*Other constitutional symptoms are lethargy,
lassitude, loss of appetite and weight loss.
•Many of them (over 60 per cent) seek medical advice on their
own initiative. This is the most fertile group for case finding.

52. In extra-pulmonary tuberculosis, symptoms
depend on organ involved -
•Swelling with pus discharge when lymph
nodes affected.
•Pain and swelling of joints if involved.
•Headache, fever, stiffness of neck, mental
confusion-TB meningitis

53. с. CASE FINDING TOOLS
(i) Sputum examination: Sputum smear examination by direct
microscopy is now considered the method of choice.
•Collection of sputum samples- minimum 2 , spot-
early morning

54. Slide reporting

55. False-positive results of sputum smear microscopy
•A false-positive result means that sputum smear result is positive
even though patient does not really have sputum smear-positive PTB.
•This may arise because of the following:
•red stain retained by scratches on the slide;
•accidental transfer of AFBs from positive slide to negative one;
•contamination of the slide or smear by environmental
mycobacteria:
•presence of various particles that are acid-fast (e.g. food
particles, precipitates, other microorganisms).

56. False-negative result of sputum microscopy-
•A false-negative result means that the sputum smear result is negative even though
the patient really does have sputum smear-positive PTB.
•This may arise because of
•problems in collecting (patient provides inadequate sample, inappropriate
sputum container used or sputum stored too long before smear microscopy),
•problems in processing (faulty sampling of sputum for smear or faulty smear
preparation and staining), or
•interpreting sputum smears (inadequate time spent examining smear or
inadequate attention to smear examination), or
•administrative errors (misidentification of patient, incorrect labelling of sample
or mistakes in documentation

57. •Under India's RNTCP the first priority is given to direct
smear examination of sputum of patients who, of their
volition, attend hospitals and health centres with the following
persistent chest symptoms ;
a. persistent cough of about 3 or 4 weeks duration
b. continuous fever
с. chest pain
d. haemoptysis

58. Sputum culture
•Culture examination of sputum is only second in importance in a case-
finding programme.
•It is not only difficult, tedious, lengthy (takes at least 6 weeks) and
expensive but also needs special training and expertise.
•It is therefore offered as a centralized service at district and regional
chest clinic laboratories.
•Only to patients presenting with chest symptoms, whose sputum smear
is negative by direct microscopic examination.
•Culture of sputum is necessary for carrying out sensitivity tests and
monitoring drug treatment.

59. (ii) Mass miniature radiography :
•MMR examinations have been stopped as a general measure of case
finding.
•The short-comings of mass radiography are :
(a) lack of definitiveness, i.e., the mere presence of X-ray shadows is
not indicative of a "case" unless presence of tubercle bacilli
demonstrated;
(b) high cost
(c) high proportion of erroneous interpretation of films, and
(d) very low yield of cases commensurate with the effort involved.
(iii) Tuberculin test : As the diagnostic value of tuberculin test is
invalidated, this test has little value as a case-finding tool.

60. First line drugs
• Rifampicin
• Isoniazid
• Streptomycin
• Pyrazinamide
• Ethambutol
Second line drugs
• Fluoroquinolones
• Ethionamide
• Capreomycin,
• Kanamycin
• Amikacin
• Cycloserine
• Macrolides.

61. DIRECTLY OBSERVED TREATMENT, SHORT COURSE (DOTS)
CHEMOTHERAPY
•DOTS is a strategy to ensure cure by providing
most effective medicine and confirming that it is
taken.
•It is only strategy which has been documented to
be effective worldwide on a programme basis.
•In DOTS, during intensive phase health worker or
trained person watches as patient swallows drug in
his presence.
•Ctd……

62. •During continuation phase, patient is issued
medicine for one week in multiblister combipack,
of which first dose is swallowed by patient in
presence of health worker or trained person.
•The consumption of medicine in the continuation
phase is also checked by return of empty
multiblister combipack, when the patient comes to
collect medicine for the next week.
•The drugs are provided in patient-wise boxes with
sufficient shelf-life.
•In the programme alternate-day treatment is used.

63. Change in TB Treatment Categories (Upto Sept 2016)
Treatment
Group
Type of patient Regimen (Alternate Day) Box
Colour
Intensive(IP) Continuation(CP)
New (Cat I) •New sput Smear +ve
•New sput Smear –ve
•New Extra-pulmonary
•New Others
2(HRZE)3 4(HR)3 Red Box
Previously
treated
(Cat II)
•Smear +ve Relapse
•Smear +ve Failure
•Smear +ve Treatment
after Default
•Others
2(HRZES)3
1(HRZE)3
5(HRE)3 Blue Box
Patient wise drug boxes-
Drugs are supplied in Patient wise boxes (PWB) containing the full
course of treatment, and packaged in blister packs.
•The PWB have a color code indicating 2 regimens- Red for New,
Blue for Previously treated.
•There is no Green box for Cat III regimen now onwards.

64. Change in TB Treatment (w.e.f. Sept-2016)
Treatment
Group
Type of patient Regimen (Daily Basis)
Intensive(IP) Continuation(CP)
New •Pt with no prior TB
treatment or taken < 1
month Anti TB drugs
(2)HRZE (4)HRE
Previously
treated
•Recurrent TB case
•Treatment After
Failure
•Treatment after loss
of follow-up
•Other previously
treated pts
(2)HRZES
(1)(HRZE
(5)HRE

65. MDR/RR-TB cases
• Treatment regimen MDR-TB :
• 6-9 month of IP - with Kanamycin, Levofloxacin,
Ethambutol, Pyrazinamide, Ethionamide and
Cycloserine and
• 18 months of CP -with Levofloxacin, Ethambutol,
Ethionamide and Cycloserine.

66. XDR-TB
• XDRTB cases will be treated with the STR for XDRTB
comprising of injection Capreomycin, Moxifloxacin,
Linezolid, PAS, Clofazimine High Dose INH & Co-
Amoxyclav.
• The duration of IP will be for 6-12 months. Only the
injectables will be stopped in CP and the remaining
medicines will continue for another 18 months in CP.
• Treatment regimen given on daily basis under supervision.

67. Treatment during pregnancy
•During pregnancy, streptomycin can cause permanent
deafness in the baby, so ethambutol should be used
instead of streptomycin.
•Isoniazid, rifampicin, pyrazinamide and ethambutol
are safe to use.
•Second-line drugs as fluoroquinolones, ethionamide
and protionamide are teratogenic, should not be used.

68. CHILDHOOD TUBERCULOSIS
•Represent between 10 to 20 per cent of all tuberculosis.
•Source of infection to a child is usually an adult, often a
family member with sputum smear-positive tuberculosis.
•The frequency of childhood ТВ in a given population
depends on :
a) the number of infectious cases;
b) closeness of contact with an infectious case;
c) the age of child when exposed to ТВ; and
d) the age structure of the population.

70. BCG Vaccination:
•Bacille Calmette Guerin or BCG - which was avirulent for man while
retaining its capacity to induce an immune response.
•Recognition of the value of BCG came in 1948 when it was accepted by
tuberculosis workers from all over the world as safe preventive measure.
(1) AIM : The aim of BCG vaccination is to induce a benign, artificial
primary infection which will stimulate an acquired resistance to
possible subsequent infection with virulent tubercle bacilli.
(2) Nature of VACCINE : BCG is the only widely used live bacterial
vaccine. WHO recommended the "Danish 1331" strain for the production
of BCG vaccine.

71. (3) TYPES : Presently vaccines distributed in the freeze-dried form.
(4) Route: Intradermal
(5) Dose: Newborn-0.05 ml, Children- 0.1 ml
(6) Diluent: Normal saline
(7) Administration: Using tuberculin syringe (26G)
(8) Cold chain: Ideal storage temp +2 to +8 deg Celcius
(9) Age: as early as possible or upto 6 wks with DPT & OPV
(10) Protective value: 15 to 20 yrs. Range of protection varies from
0 to 80 %. Highly protective against severe forms of disease, e.g.
TB meningitis, miliary TB, etc. BCG vaccination does not decrease
the spread of TB.

72. (11) Complications: Subcutaneous abscess, ulceration at injection site,
swelling with or without ulceration of regional lymph nodes, systemic
complications
(12) Phenomenon after vaccination: Normal changes occur at
vaccination site after successful vaccination. Normally individual turns
mantoux positive after a period of 8 wks but sometimes 14 wks.
•2-3 wks after injection- Papule
•5 wks- increase in size with diameter of 4 to 8 mm.
•Breaks into shallow ulcer.
•6 to 12 wks- healing occurs.
•Tiny round scar 4 to 8 mm in diameter.

73. (13) CONTRAINDICATIONS :
•Unless specifically indicated, BCG should not be given to patients suffering from–
 generalized eczema, infective dermatosis.
Hypogammaglobulinaemia ,
 to those with a H/O deficient immunity (symptomatic HIV infection, known
or suspected congenital immunodeficiency, leukaemia, lymphoma or
generalized malignant diseases),
 patients under immunosuppressive treatment (corticosteroids. alkylating
agents, antimetabolites. radiation), and in pregnancy.
The effect of BCG may be exaggerated in these patients.
(14) DIRECT BCG VACCINATION :
Direct BCG vaccination, i.e., vaccination without a prior tuberculin test, has been adopted as a
national policy in many developing countries, including India.

74. Surveillance:
Surveillance is an integral part of any effective tuberculosis programme.
It should be concerned with 2 distinct aspects :
(a) surveillance of the tuberculosis situation, for example, by measuring
the "annual infection rates" which will guide the epidemiologist and
health administrator by indicating whether the ТВ problem is static,
increasing or decreasing;
(b) surveillance of control measures applied such as BCG vaccination
and chemotherapy.

75. Role of hospitals:
•Inspite of effective domiciliary treatment services, some patients
who will be needing hospitalization are :
(a) emergencies as massive haemoptysis & spontaneous
pneumolhorax
(b) surgical treatment
(c) management of serious types of tuberculosis such as
meningeal tuberculosis, and
(d) certain social indications, such as when there is no one to
look after the patient at home.

76. HIV and TB:
HIV infection destroys the immune system
especially lymphocytes
At present, patients with HIV/AIDS are much
more suscptible to many infections, including TB.
With increasing HIV infection in India, the
HIV/TB coinfection is also increasing

77. Diagnosing TB in patients with HIV:
Is a difficult situation for 3 reasons
HIV infected patients are likely to have negative sputum smear
Highly non-specific X-ray abnormalities leading to under
diagnosis
Recurrent pulmonary infection leading to over diagnosis
Treatment:
On the same line as that of HIV negative patient.
DOTS treatment will ensure cure in these patients
Don’t use Thiacetazone due to risk of fatal skin reactions.

78. FUTURE

79. Study Exercises
Long Questions :
(1) Discuss the epidemiology, treatment, prevention and control of
Tuberculosis
(2) Describe the Diagnosis and treatment of TB under RNTCP.
Short Notes :
(1) Sputum Microscopy
(2) Classification of TB patient based on sputum examination and
treatment history
(3) Diagnostic Algorithm of RNTCP
(4) Treatment Regimens under RNTCP
(5) Management of Patients with HIV Infection and Tuberculosis
(6) MDR TB.

80. MCQs:
1. Which disease is known as ‘Captain of the Men of Death’?
(a) Tuberculosis (b) AIDS (c) Plague (d) Cholera.
2. Pulmonary Tuberculosis accounts for over ______ per cent
of the total cases
(a) 50% (b) 60% (c) 70% (d) 80%.
3. Commonest opportunistic infection in patients suffering from AIDS
(a) Candidiasis (b) Pulmonary Tuberculosis (c) Herpes (d) Scabies.
4. The ________ Region has the highest incidence rate
per capita (363 per 1,00,000 population)
(a) Asian (b) American (c) Indian (d) African.
5. _________ is the highest TB burden country in the world
(a) Nigeria (b) South Africa (c) India (d) Bangladesh.

81. 6. It is estimated that a cough can generate _____ (a) 1000
droplet nuclei (b) 2000 droplet nuclei (c) 3000 droplet
nuclei (d) 4000 droplet nuclei.
7. Under RNTCP in reporting of Sputum Smears, 1 - 10 AFB
per oil immersion field is graded as
(a) 1+ (b) 2+ (c) 3+ (d) 4+.
8. All new TB cases known to be HIV positive are treated
with (a) Category I regimen (b) Category II regimen
(c) New regimen (d) None of the above.
9. Multidrug Resistant (MDR) Tuberculosis treatment
involves all drugs expect
(a) Kanamycin (b) Pyrazinamide (c) Rifampicin (d) Ethambutol.
Answers : (1) a; (2) d; (3) b; (4) d; (5) c; (6) c; (7) b; (8) a; (9) c.