Tuberculosis: What you need to know!

Gini Orthner RN, BScNTB Nurse Clinician

TB Control Saskatchewan – Regina Office

History of TB in Saskatchewan

Saskatchewan Anti-TB League was founded in 1911 (TB was out of control with nearly 1000 new cases every year and 1-2 deaths each day).

First TB Sanitorium was built in 1917 at Fort Qu Appelle (Fort San).

Saskatoon Sanitorium was built in 1925.

Prince Albert Sanitorium was built in 1930.

In 1929 Saskatchewan became the first jurisdiction in North America to provide TB treatment at no cost to the patient – it remains this way!

In 1948 Dr. John Orr introduced prophylactic use of antibiotics in the treatment of children under 5 with positive Mantoux tests.

1957 a centralized patient record system was introduced. This database attracted international attention. We continue to use a form of this database – now a computerized version.

Prince Albert Sanitorium closed in 1961.

Fort San closed in 1972.

Saskatoon Sanitorium closed in 1978.

In 1987 the responsibility for TB was transferred from the Anti-TB League to the provincial government.

Directly observed therapy (DOT) was started in 1990.

In 2007 responsibility for TB was transferred to the Saskatoon Health Region.

The Encyclopedia of Saskatchewan

Current TB Control

3 stationary clinics (Saskatoon, Regina, Prince Albert)

Mobile clinics in northern Sask. Staff consists of

4 physicians6 nurses6 administrative support staff4 TB medication workers

Our Partners

General Practitioners/Specialists

First Nations and Inuit Health

First Nations Bands and Staff

Immigration Canada

Correctional Institutions

Communicable Disease Programs

General Public

What is Tuberculosis (TB)

an Acid Fast Bacilli (AFB) known as Mycobacterium Tuberculosis Complex (MTBC)

an airborne organism that most commonly affects the lungs, but can affect any part of the body

Active TB

Active Pulmonary – affects the lungs and connective airways, can be infectious or non-infectious

Active Non–Pulmonary – affects other parts of the body (lymph nodes, CNS, meninges, ocular, pericardial, abdominal, bones/joints, genitourinary, miliary, great vessels, bone marrow), non-infectious

How is TB Spread?

mostly through inhalation of droplet nuclei. (coughing, sneezing, singing, etc)

very rarely through ingestion (mostly in the past with unpasteurized milk)

Active Pulmonary TB Disease

Infectious or non-infectiousInfectious Non-Infectious

Smear positive -isolation x 2 weeks

Smear negative

Culture positive Culture positive

May have an Abnormal CXR

May have an Abnormal CXR

Start Treatment ASAP Start Treatment ASAP

Latent TB Infection (LTBI)

Inactive TB – Infection, NO DiseaseMantoux is positive (> 10mm)CXR is usually normalProphylaxis treatment offered and encouraged

for <15 years old as most susceptible age group

Latent TB Infection (LTBI)

Treatment determined on case by case basis for 15-35 years old

>35 years old encouraged to monitor for top three signs & symptoms of early TB disease as benefits of treatment do not outweigh the risks (i.e. medication induced hepatitis, thrombocytopenia)

Symptoms of TB

Early Signs of TB Cough for more than 1

month Unexplained fever for

more than 1 week Recurring pneumonia

that does not respond to antibiotics

Signs of Advanced TB Night sweats Weight Loss Fatigue Rash

Diagnostic Tests

Sputum and/or other body fluids for AFBMantoux skin test – gold standard for

diagnosing LTBIChest X-rayCT ScansIGRA (Interferon-Gamma Release Assays)

Mantoux Tests

Also called:Tuberculin Skin Tests (TST)TB Skin TestPPD Test

Mantoux Tests

Indicates TB infection only – does not mean person has TB disease

Elicits cellular immune response to PPD antigen, causing a delayed hypersensitivity reaction.

Mantoux Tests

5 units(0.1ml) of Tuberculin (PPD) injected intradermally, 3-4 fingers down from the anticubital space

Mantoux Tests

Measure transverse diameter of induration only (not erythema)

Record in mm

No induration is recorded as 0mm

Interpreting Mantoux Tests

History of BCG is not considered

Significant Reaction if:10mm or greater5mm or greater in contacts to infectious TB,

HIV positive, pre school children

Treatment – In the Early Days

Sunshine & fresh air!

Treatment - Now

1st Line DrugsIsoniazid (INH)Rifampin (RMP)Ethambutol (EMB)Pyrazinamide (PZA)

2nd Line Drugs

• Moxifloxacin

• Levofloxacin

• Amikacin

Other medication used for treatment include: streptomycin, fluoroquinolone, injectable agents (amikacin, kanamycin, capreomycin, ethionamide, clofazamine, para-aminosalicylic acid, cycloserine, PZA, EMB)

Treatment – Active TB (or suspected)

INH and RMP (standard)28 daily doses followed by twice weekly doses

for 8 months Ideal total of 98 doses within 9 month time

frame4 drug therapy if drug resistance suspected

until drug sensitivity results are obtained (2-6 weeks)

Treatment – LTBI

INH and RMP (standard)6 months of twice weekly medication Ideal total of 52 doses within the 6 month time

frame

Treatment in Saskatchewan

All treatment is provided by directly observed therapy (DOT).

WHY? to prevent drug resistance to prevent relapse of TB to ensure treatment completion

Interesting Facts…

After HIV/AIDS, TB kills more people than any other

infectious disease

WHO 2008

Did you know???

1/3 of the world’s population is infected with TB

Canadian Tuberculosis Standards 2007

Prevalence

WORLD9.4 million new cases of active TB in 2008 1.3 million people die each year from TBCANADA 1600 new cases in 2008SASKATCHEWAN 93 new active cases in 2008

WHOPublic Health Agency of Canada

TB in Canada

BC, Ontario and Quebec made up 69% of total cases

Nunavut had the highest rates

PEI reported no cases!

TB in Canada

Foreign born – 62% of cases

Canadian Aboriginal – 21% of cases

Canadian Non Aboriginal – 13% of cases

TB in Saskatchewan - 2009

2 Cases of TB Meningitis

1 death caused by TB – found on autopsy

2 case of multi-drug resistance (INH and RMP)

TB in Saskatchewan

Canadian Aboriginal – 72 cases

Foreign Born – 11 cases

Canadian Non-Aboriginal – 9 cases

Multi-drug resistant (MDR-TB)

TB bacteria resistant to INH and RMP with or without resistance to other first or second line drugs

WHO

MDR-TB World Wide

0.5 million cases of MDR-TB in 2007

27 countries account for 85% of cases (15 countries are in European Regions)

Top 5 countries affected: India, China, Russia, South Africa, Bangladesh

WHO

Extensively Drug Resistant (XDR-TB)

TB bacteria resistant to at least INH and RMP from the first line drugs plus resistance to any fluoroquinolone and at least one of three injectable second line drugs (capreomycin, kanamycin and amikacin)

WHO

XDR-TB

By 2008, 55 countries reported at least 1 case of XDR-TB

WHO

Total Drug Resistance

new term used in an article based on a case in Iran

a case of TB that is essentially resistant to all antibiotics known to effectively treat TB

THINK TB!

Assess for symptoms• Cough with sputum for more than 1 month.

• Unexplained fever for more than 1 week.

• Pneumonia not improving with antibiotic treatment.

THINK TB!

Obtain CXR

Obtain sputum (body fluid) for AFB testing. Send to Provincial Lab.

Contact TB Control with questions and for further instructions

“The most common physical finding in pulmonary TB is a…

totally normal examination.”

Canadian TB Standards, 2007

Questions???

Contact Information

Toll Free Number – 1-866-780-6482

Saskatoon Office – 655-1740/655-1741

Prince Albert Office – 765-4260

Regina Office – 766-4311