overview of tuberculosis 07
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Welcome! Welcome!
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Overview of Overview of Tuberculosis Tuberculosis
Michigan Department of Community HealthMichigan Department of Community Health American Lung Association of Michigan American Lung Association of Michigan
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History of M. tuberculosisHistory of M. tuberculosisPhthisis (Greek) known since ancient timesPhthisis (Greek) known since ancient timesOften thought of as a hereditary conditionOften thought of as a hereditary condition1854 first sanatorium1854 first sanatorium
1882 Koch demonstrated relationship between1882 Koch demonstrated relationship betweengerm and diseasegerm and disease1895 Roentgen discovery of diagnostic x1895 Roentgen discovery of diagnostic x--ray ray
19401940ss--19501950s chemotherapy s chemotherapy
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Around the World Around the World An estimated 1.58 million deaths occurred in An estimated 1.58 million deaths occurred in2005 from TB disease2005 from TB disease8.8 million new TB cases estimated for 20058.8 million new TB cases estimated for 2005
1/3 of world population has TB infection1/3 of world population has TB infection
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Estimated TB incidence rate, 2005Estimated TB incidence rate, 2005
No estimate
0-24
50-99
100-299
300 or more
25-49
Estimated new TBcases(all forms) per 100 000population
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
WHO 2006. All rights reserved
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High Burden Countries (WHO)High Burden Countries (WHO) Afghanistan Afghanistan
BangladeshBangladeshBrazilBrazilCambodiaCambodiaChinaChina
Democratic RepublicDemocratic Republicof the Congoof the Congo
EthiopiaEthiopiaIndiaIndiaIndonesiaIndonesiaKenyaKenyaMozambiqueMozambique
MyanmarMyanmar
NigeriaNigeriaPakistanPakistanPhilippinesPhilippinesRussian FederationRussian Federation
South AfricaSouth Africa Thailand ThailandUgandaUgandaUnited Republic of TanzaniaUnited Republic of Tanzania
Viet Nam Viet NamZimbabweZimbabwe
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Tuberculosis Cases Tuberculosis CasesMichigan, 1955Michigan, 1955 -- 20052005
01000
2000
30004000
5000
6000
7000
55 60 65 70 75 80 85 90 95 00 03 04 05Year Reported
T B C a s e s
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246246
2.5/100,000 population
20052005
221221272272243243315315
2.2/100,000 population
2.7/100,000 population
2.4/100,000 population
3.2/100,000 population
20062006200420042003200320022002
Reported TB Cases and Rates,Reported TB Cases and Rates,Michigan, 2002Michigan, 2002 -- 20062006
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TB Cases by National Origin TB Cases by National OriginMichigan, 1997Michigan, 1997 20062006
299 287
242
196 210 194
142 164 147129
53
96 107 91120 120
101 109 99 92
050
100
150
200
250
300
350
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year Reported
# o
f T B C a s e s
USForeign
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Percentage of Total TB Cases in ForeignPercentage of Total TB Cases in Foreign --bornbornPersons, Michigan, 1994Persons, Michigan, 1994 --20062006
0
5
10
1520
25
30
35
40
45
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year Reported
% o
f T B
C a s e s
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TB by Race, Michigan, 2005 TB by Race, Michigan, 2005 --20062006
81
108
3 1
52
78 86
1 1
55
0
2 0
4 0
6 0
8 0
1 0 0
1 2 0
White Black MultipleRaces
AmIndian/AL
Native
Asian orPacific
Islander200 6 Cases
200 5 Cases
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Countries of Birth for ForeignCountries of Birth for Foreign --bornbornPersons Reported with TBPersons Reported with TB
Michigan, 2006Michigan, 20065%
4%
53%
20%
8%
10% Mexico
VietnamIndia
33 Other
Yemen
Phillipines
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Transmission and Pathogenesis
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PathogenesisPathogenesisInhale droplet nucleiInhale droplet nucleiBacteria multipliesBacteria multipliesMacrophages consume bacteria, then dieMacrophages consume bacteria, then die
Travel through the bloodstream, lymph system Travel through the bloodstream, lymph systemContainmentContainment --infectioninfection
MultiplicationMultiplication
--diseasedisease
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Generation of TB Droplet NucleiGeneration of TB Droplet NucleiOne cough produces 500 dropletsOne cough produces 500 droplets
The average TB patient generates 75,000 The average TB patient generates 75,000droplets per day before therapy droplets per day before therapy
This drops to 25 infectious droplets per This drops to 25 infectious droplets perday within 2 weeks of effective therapy day within 2 weeks of effective therapy
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Factors Affecting TBFactors Affecting TB Transmission Transmission
Characteristics of theCharacteristics of thesource casesource case
EnvironmentEnvironmentFactors increasing risk Factors increasing risk
for contactsfor contacts
sourcesource
contactcontact
environmentenvironment
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Classification System for TB
No TB exposureNot infected
No history of exposureNegative reaction to tuberculin skin test
TB exposureNo evidence of infection
History of exposureNegative reaction to tuberculin skin test
TB infectionNo disease
Positive reaction to tuberculin skin testNegative bacteriologic studies (if done)No clinical, bacteriological, or radiographicevidence of active TB
TB, clinically active M. tuberculosis cultured (if done)Clinical, bacteriological, or radiographicevidence of current disease
TBNot clinically active
History of episode(s) of TBor
Abnormal but stable radiographic findingsPositive reaction to the tuberculin skin testNegative bacteriologic studies (if done)
andNo clinical or radiographic evidence ofcurrent disease
TB suspected Diagnosis pending
Class Type Description
0
1
2
3
4
5
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RememberRemember
TB disease is reportable to the State Health TB disease is reportable to the State HealthDepartment TB Control Program on the ReportDepartment TB Control Program on the Report
Verified Case of Tuberculosis (RVCT) Verified Case of Tuberculosis (RVCT)
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INFECTIOUSINFECTIOUSNOT INFECTIOUSNOT INFECTIOUS
Case of TBCase of TBNot a Case of TBNot a Case of TB
Positive Sputum CulturePositive Sputum CultureNegative Sputum CultureNegative Sputum Culture
SymptomsSymptomsNo SymptomsNo Symptoms
CXR: AbnormalCXR: AbnormalCXR: NormalCXR: Normal
TB Disease TB Disease TB Infection TB Infection
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Risk Factors for the Development of Risk Factors for the Development of TB Disease TB DiseaseHow many time higher is
Risk factors the risk of TB disease?
Acquired immunodeficiency 170syndrome (AIDS)
HIV infection 113
Recent TB infection 15(within past 2 years)
Certain medical conditions 2 3 - 162Compared to the risk for people with no known risk factors
For example, diabetes, certain types of cancer, orimmunosuppressive therapy
Excerpt from CDCs Self-Study Modules on Tuberculosis, Module 1, March 1995
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Signs/SymptomsSigns/SymptomsProductive cough 3 weeks or longerProductive cough 3 weeks or longerShortness of breathShortness of breathChest painChest pain
HemoptysisHemoptysisNight sweats/fever/chillsNight sweats/fever/chillsUnexplained weight lossUnexplained weight lossFatigueFatigue
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TB can be found in all parts of TB can be found in all parts of your body your body
Brain EyeLymph node Throat
Lung Bone
Spine Kidney
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Suspect TB:Suspect TB: Chest x-ray
Location of the infiltrate
Presence of a cavity
Hollow areas, dense areas, fluid onthe lung or at margins
Normal x-ray = usually no infectiousTB disease
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Chest Radiograph Abnormalities often seen in apical
or posterior segments of upperlobe or superior segments oflower lobe
May have unusual appearance inHIV-positive persons
Cannot confirm diagnosis of TB
Arrow points to cavity in
patient's right upper lobe.
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Sputum CollectionSputum Collection Sputum specimens are essential to
confirm TB Sputum: mucus from within the lung, not
saliva 3 specimens on 3 different days
Spontaneous morning sputum moredesirable than induced specimens
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AFB Smear Results AFB Smear ResultsPositive
Need at least 10,000 bacilli per mlPositive in about half those with TB diseaseSignal a very infectiouspersonOther mycobacteria may
make the smear a false positive
Negative
Too few bacilli to be seendirectly under themicroscopeProvides somereassurance that patient isless infectiousto others
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AFB Smear: AFB (shown in red) are tubercle bacilli
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CulturesCultures Use to confirm dx of TB
Culture all specimens, even if smear
Result in 4-14 days when liquid medium
systems used Susceptibility testing-
essential
Colonies of M. tuberculosis growing on media
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Drug susceptibility testing on solid media. Upperleft contains no drugs.
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Alternative Techniques Alternative Techniques BACTEC can confirm TB growth
within one week, by indirectlymeasuring TB bacilli growth in
special bottles and medium Other tests can confirm TB by
amplifying DNA and other methodsthat look for the TB bacilli genes
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Potential Chains of TuberculosisPotential Chains of Tuberculosis
Transmission Before and After DNA Transmission Before and After DNA Fingerprinting of IsolatesFingerprinting of Isolates
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DIVERSITY OF RFLPDIVERSITY OF RFLP
PATTERNSPATTERNS# # # ##
d d l l l f
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Individual TB CDC Cluster totals forIndividual TB CDC Cluster totals for OutstateOutstateMichiganMichigan
and theand the City of DetroitCity of Detroit 1996 to 2000.1996 to 2000.OutstateOutstate 6464 cluster totals:cluster totals:SizeSize Freq.Freq. %%
2 person2 person 4242 65 %65 %3 person3 person 77 10.9 %10.9 %4 person4 person 77 10.9 %10.9 %5 person5 person 11 1.6 %1.6 %6 person6 person 22 3.1 %3.1 %7 person7 person 11 1.6 %1.6 %8 person8 person 1 1.6 %1 1.6 %
9 person9 person 11 1.6 %1.6 %10 person10 person 11 1.6 %1.6 %31 person31 person 11 1.6 %1.6 %
DetroitDetroit 5353 cluster totals:cluster totals:SizeSize Freq.Freq. %%
2 person2 person 2525 47.2 %47.2 %3 person3 person 66 11.3 %11.3 %4 person4 person 44 7.5 %7.5 %5 person5 person 55 9.4 %9.4 %
6 person6 person 33 5.7 %5.7 %7 person7 person 22 3.8 %3.8 %8 person8 person 11 1.9 %1.9 %
10 person10 person 11 1.9 %1.9 %
13 person13 person 11 1.9 %1.9 %18 person18 person 11 1.9 %1.9 %58 person58 person 11 1.9 %1.9 %70 person70 person 11 1.9 %1.9 %
D i CDC 00027
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Detroit CDC 00027Detroit CDC 00027
70 cases70 cases68% Male, 90% Black 68% Male, 90% Black 99% US citizens99% US citizens76% Pulmonary76% Pulmonary29%29% CavitaryCavitary4 cases prior TB4 cases prior TB17% HIV+17% HIV+
10% Homeless10% Homeless7% Long term care7% Long term care13% Injecting drugs13% Injecting drugs11% Non11% Non --injecting drugsinjecting drugs20% Alcohol abuse20% Alcohol abuse51% Unemployed51% Unemployed89%89% -- Ages 30 to 54 Ages 30 to 54
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Treatment
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fT f L
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Treatment of Latent Treatment of Latent TB Infection (LTBI) TB Infection (LTBI)
Consists of 9 months of daily isoniazid(INH)
Substantially reduces the infectedpersons risk of developing clinical TB
Monitor patient at least monthly forsymptoms of toxicity and adherence
T i TB DiT i TB Di
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Treating TB Disease: Treating TB Disease:General PrinciplesGeneral Principles
Always treat with multiple drugs Never add a single drug to a failing regimen
Treatment course depends on drugs selected.Usually 6 months, sometimes 9 months:
Four drugs for two monthsFour drugs for two monthsINHINH --RIFRIF--EMBEMB--PZAPZA
Two drugs for four or seven months Two drugs for four or seven monthsINHINH --RIFRIF
H ill k if hH ill k if th
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How will we know if theHow will we know if thetreatment is effective?treatment is effective?
The symptoms improve
Sputum smears become negative
Sputum cultures change to negative,usually within 2 3 months
The chest x-ray improves (importantfor kids)
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NonNon --adherenceadherence A very serious problem
Failure to take all the prescribed TBtreatment is the single mostimportant reason for tuberculosistreatment failure
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NonNon --adherence (2)adherence (2) The non-adherent patient risks
Continuing transmission of TBinfection
Development of drug resistantTB bacilli
Increasing disability and death
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InfectiousnessInfectiousnessPatients should be considered infectious if they
Are coughing Are undergoing cough-inducing or aerosol-generating procedures, or
Have sputum smears positive for acid-fast bacilliand they Are not receiving therapy
Have just started therapy, orHave poor clinical response to therapy
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Infection ControlInfection Control Administrative Administrative--reducereduce
risk of exposurerisk of exposure
Alert to S/S of MTB Alert to S/S of MTBPrompt therapy withPrompt therapy withsuspectsuspect
Alert for undiagnosed Alert for undiagnosedpulmonary illness withpulmonary illness withHIV HIV
Engineering Engineering --prevent spread,prevent spread,reduce conc. of dropletreduce conc. of dropletnucleinuclei
Neg. pressure isolation roomNeg. pressure isolation roomFiltration systemFiltration system
Personal protectionPersonal protection --use inuse inareas of increased exposureareas of increased exposure
Client (surgical mask) to mask Client (surgical mask) to mask outsideoutside
HCW (NHCW (N --95) to mask inside95) to mask inside