EPIDEMIOLOGY OF TUBERCULOSIS

TB

MK SHAMBESH
 Definition:
TB is an endemic and specific communicable
disease
caused by (Mycobacterium tuberculosis
complex)
which usually affects the pulmonary (75%)
more than the extra pulmonary (25%) systems,
and
the disease can be acute or chronic, local or
general.
 Historically,
the disease is of great antiquity, •
‫• العصر القديم العظيم‬
Lesions have been found in the vertebrae of •
the Neolithic man in Europe: and in the
Egyptian mummies,
perhaps as early as 3700 BC, •
the disease increased disastrously during the •
industrial revolution,
 Diminished probably
as a result of the •
increasing standard of living. •
improved medical services •
chemotherapy, •
BCG Vaccination •
•
 Magnitude of the disease problem

• Worldwide there were an estimated 8.8 million

new TB cases in 2005,
• of which 7.4 million were in Asia and sub Saharan
Africa.
• In 2005, the TB incidence rate was stable or in
decline in all six WHO regions.
• However, the total number of new TB cases was
still rising slowly – because the case – load
continued to grow in the African, Eastern
Mediterranean and south East Asian regions.
How to measure the magnitude of
the problem?
• The most important and sensitive
measurement is the incidence of infection or
(Tuberculin conversion rate) –
• the percentage of those newly infected in
one year based on tuberculin testing
 In Libya,
• fortunately the disease is not very common.
The estimated prevalence is
• 0.013/10,000. The distribution of the
disease is patchy, there seems to be more
• concentration in some areas than others.
 70
60/100.000
60

50
Aids related
40
15/100.000
30

20

8/100.000
10

0
73 77 81 85 89 93 97 2001 2005
75 79 83 87 91 95 99 2003 2007

YEAR

Fig. 1.Reported annual incidence of TB (All forms) per 100.000 population

in Libya 1973-2007.
Epidemiological factors that influence
the development of the disease:
•
The Agent: •
Mycobacterium tuberculosis is classified into •
( human and bovine + the Atypicals) •
all are Acid Fast Baccili (AFB), •
the single most important investigation is •
sputum obtained in the morning and stained •
using the Ziehl-Neelsen method.
On few occasions Fluorescent microscopy, •
culture and Serological and DNA tests.
 Tuberculosis
• Causative organism:
1. Mycobacterium tuberculosis.
2. Mycobacterium bovis.
3. Mycobacterium avium Complex (MAC).
Pathogenesis of tuberculosis
The tubercle bacilli

Bacilli
Acid fast, alcohol fast
Aerobic or microaerophilic
Non spore forming
Non motile
Slightly bent rods
2-4 um long
0.2-0.5um wide
Evenly stained or beaded & granular
Tend to be in parallel
Form long threads or cords
 AGENT
The bacilli can survive in the dark for months •
or years
but they are highly susceptible to direct •
sunlight which kills them within minutes.
Also heat can rapidly destroy them within 20 •
minutes at 600 C.
 MDR--agent
Some mycobacterium strains are more •
virulent than others.

Moreover, WHO estimates that 50 million •

people are already infected with multi-drug
resistant (MDR) tuberculosis
which can be very costly for management . •
 Host:
• man is the reservoir of the human type, and

• one positive case may infect

• 10% of contacts (children) as primary TB (+ve
TubeculinTest).
• 5% develop the disease within 2 years of
infection,
• and 5% within 5 years of infection
• the rest during the remainder of their life time.i.e
up to 15% of infected persons develop the
disease.
•
 Period of infectivity:
TB is communicable as long as the •
bacilli are excreted by the (infected sick
host)
which may be months to a few years. •

On treatment: •
Three weeks of effective chemotherapy. •
The progression or development of
the disease may depend on:
• 1. Genetic susceptibility – weak association
with (HLA).
• 2. Physiological – age extremes, gender,
pregnancy, etc.
• 3. Immunological – the effect of primary
infection in childhood, BCG vaccination, HIV
infection, malnutrition, transplant recipients,
diabetes, partial gastrectomy, etc.
• 4. Environmental factors – living conditions,
overcrowding, occupation, etc.
• 5. Miscellaneous – alcohol, tobacco, etc.
Primary lesion Gohn's lesion which may remain quiescent
or initiate pulmonary tuberculosis.

Localized Disease In the presence of reasonable resistance, the

disease does not advance beyond the
respiratory system.
Disease Progress In case of poor resistance , the disease
dissemination advances beyond the respiratory system and
involves multiple organs by of bacteria
through blood or lymphatic circulation.
 Incubation period: •
Could be weeks or months •
depending upon
the host agent relationship and •
dose of infection. •
 Environmental factors:
Mortality and morbidity from TB have •
decreased remarkably over the past century
and this decrease antedated any specific
measure for prevention or cure of this disease
as being demonstrated in the Western
communities .
Due to high standard of living •
 In Africa
• TB is increasing why:
• 1. poor standard of living &
• 2. lack of health services
• 3. associated with HIV-Aids
• 4. associated withy other disease like malaria
HIV
• Mode of Transmission:
• 1. droplet infection during
• coughing,
• sneezing or
• even talking.
• 2. By air (indirect)
• 3.Bovine by drinking contaminated milk
Prof.Essam El Sawaf
 Inhaled TB bacilli

Terminal air spaces

Lungs (apical)

Regional lymph
nodes

Early or late spread

Lymph nodes Kidneys Vertebrae CNS Lungs (miliary)

Pathogenesis and clinical syndromes of TB

Prof.Essam El Sawaf
 Treatment and Control of TB is
based on the following principles:

• 1. Case finding
• 2. Isolation and Effective
treatment
• 3. BCG Vaccination
• 4. Chemoprophylaxis
• 5. Health education
Treatment and Control of TB is based
on the following principles:

• 1. Case finding by three techniques:

• A. Sputum examination of smears for TB
bacilli (ZN-stain)
• B. Photofluorography or Mass Miniature
Radiography (MMR),

• C. Tuberculin testing
 MMR
Maternal Mortality Rate •
Measles, Mumps, Rubella •
Mass Miniature Radiography •

30
 Mass Miniature Radiography
• Screening of TB
• Mass type
• University entrance
• Labour
• Still in use in developing countries

31
32
 Tuberculin test
• Purified protein derivative (PPD).
Mantoux test:
• Dosage: 0.1ml or one Tuberculin unit.
• Forearm.
• Read after 72 hours.
 Tuberculin test

- Ve + Ve

Repeat the test Chest X-ray

- Ve + Ve - Ve + Ve

BCG Treatment

chemoprophylaxis
Prof.Essam El Sawaf
Isolation and Effective treatment of •
TB
(General measures such as isolation •
and hospital admission is only
required for the initial intensive
phase of treatment.)
The National Tuberculosis Programme
(NTP)
• When TB was realized a major public health
problem,
• this was followed by building and staffing of
about 20 ambulatory chest units and two
regional chest centres, supported by four
chest and TB hospitals,
• which placed at the most populated areas like
Benghazi, Tripoli, Misrata and Shahat.
 The programme included the
following:

• 1. A uniform national chemotherapy

policy which has been planned and practiced
since 1970.
 2. A legislation prohibiting •
the use or sale of antituberculosis drugs, •
to prevent the abuse and •
hence the emergence of resistant •
mycobacterial strains in the community.
 3. To provide anti-tuberculous •
therapy free of charge to all detected
patients
(Libyans or non-Libyans alike). •
• 4. BCG vaccination of all children at birth,
• in addition to school entry and school
leaving age.
 5. Screening of all •
foreign labour force entering the country for •
work by
chest X-ray and 3 sputum smears for AFB. •
Nonetheless screening has been encouraged •
and sometimes enforced among the high risk
groups in the general population.
 DOTS (Directly observed Treatment
Short-course)
• Objectives of DOTS;

• 1-Augmentation ‫ الزيادة‬of case finding

activities through quality sputum microscopy
to detect at least 70% of estimated cases.

• 2-Achievement of 85% cure rate of the smear

positive cases

• 3-To prevent MDR

 DOTS-- treatment strategy of TB
1. direct observation •
2. 6 months treatment •
3. one month in hospital & 5 months out •
side
4. 4 drugs in 1st 2 months & 2 drugs in •
2nd 4 months
Isoniazide
All drugs should be take ½ an hour before
breakfast
Rifampicin
+
Isoniazide
Pyrazinamid
+
e 2 4
months months
+
Rifampicin
Ethambutol

Or
Streptomyci
n

Prof.Essam El Sawaf
BCG vaccine•
 ‫طعم الدرن ‪BCG (Bacille calmete Guerin):‬‬
‫المكونات‪ :‬الطعم مكون من مسحوق (بودرة) ومذيب ‪.‬‬
‫التخزين ‪ :‬من ‪ 2+‬إلى ‪ 8+‬درجة مئوية ال يحتمل الضوء وأشعة الشمس ‪.‬‬
‫مقدار الجرعة‪ 0.05 for neonates, 0.1 for infants :‬مل (سم ‪)3‬‬
‫طريقة إعطاء الطعم ‪ :‬في الجلد ‪ ، Intra dermal‬فوق المرتكز السفلي‬
‫للعضلة الدالية ‪.‬‬
‫مواعيد إعطاء الجرعات (البرنامج الوطني للتحصين)‪:‬‬
‫بعد الوالدة مباشرة‪ ،‬وفي المدارس لمن لم يسبق تطعيمه‪.‬‬
‫اآلثار الجانبية‪ :‬انتفاخ أحمر ‪ ،‬ظهور انتفاخ بسيط خالل ‪ 2‬إلى ‪ 4‬أسابيع ندبة‬
‫قطرها من ‪ 2‬إلى ‪ 10‬مم ‪ ،‬الحقن الخطأ يسبب انتفاخ للعقد الليمفاوية االبطية‬
‫من شهرين إلي ‪ 4‬أشهر ‪.‬‬

‫‪47‬‬
 Microscopic image of the
Calmette-Guérin bacillus. Ziehl-
Neelsen stain (1909).
Magnification:1,000

48
49
 Is BCG protect against TB

Only Against extra pulmonary, bone, •

renal, CNS type

50
 Duration of protection

-The duration of protection of BCG is not clearly

known.
-studies showed that protection waned to 59% -
after 15 years and to zero after 20 years;
-however, a study looking at native Americans -
immunized in the 1930s found evidence of
protection even 60 years after immunization
with only a slight waning in efficacy.

51
 Type of vaccine Live bacterial
Number of doses One

Schedule At or as soon as possible after birth

Booster None

Contraindications Symptomatic HIV infection

Adverse reactions Local abscess, regional lymphadenitis; rarely, distant
spread to osteomyelitis, disseminated disease

Special precautions Correct intradermal administration is essential. A special

syringe and needle is used
for the administration of BCG vaccine

Dosage 0.05ml

Injection site Outer upper left arm or shoulder

Injection type Intradermal

Storage Store between 2°C–8°C(vaccine maybe frozen

52 for long-term storage but not the diluent)
left arm

In insertion:
1. To avoid joint colloid,
To avoid subclavicular LNs.

53
 If BCG is accidentally given
subcutaneously or IM

-then a local abscess may form (a BCG-oma) •

that may ulcerat (suppurative lymphadenitis).
- However, it is important to note that an •
abscess is not always associated with incorrect
administration, and
-it is one of the more common complications •
that can occur with the vaccination.

54
 BCG-oma

-often requires treatment with antibiotics •

- Refer to TB Centre
-the abscess will generally heal spontaneously in
a matter of weeks

55
 What I need to know if giving BCG
1. BCG vaccine and diluent + needle, •
2. Reconstitutation of BCG vaccine, dosage, •
3.The site of injection, •
4-. Injection technique, •
5.After vaccination.

56
1. BCG vaccine and diluent + needle, 2.Reconstitutation of BCG vaccine, 3.The site

of injection, 4-5. Injection technique, 6.After vaccination.

57
58
Disease Duration of isolation

Measles Upto third day of rash

Chicken pox Six days after onset of rash

Cholera, diphtheria Until 48 hrs.

Shegellosis/salmonellosis Until 3 consecutive negative stool samples

Hepatitis A Three weeks

Influenza Three days after onset

Herpes zoster Six days after onset of rash

Mumps Until swelling subsides

Meningococcal meningitis, Six hours of effective antibiotic therapy

strepto pharyngitis

TB(sputum +) Three weeks of effective chemotherapy.



HIB OPV BCG

PENTA 1 OPV1

PENTA 2 OPV2
PENTA 3 OPV3
MMR 1
MMR 2 DPT 4 OPV4
meningitis BCG
DT OPV5
OPV6

Td
 `

Thank u •