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ID: 10-4-169
Incubation Period
From infection to development of a primary lesion (the incubation period) or
significant TST reaction or positive IGRA is approximately 2 to 12 weeks. The risk
for developing active disease is the highest in the first two years after infection
and development of a positive TB skin test reaction.

Cycle of infection
Causative agent

The main cause of TB is Mycobacterium tuberculosis, a small, aerobic, nonmotile bacillus. The
high lipid content of this pathogen accounts for many of its unique clinical
characteristics. It divides every 16 to 20 hours, which is an extremely slow rate compared with other
bacteria, which usually divide in less than an hour. Mycobacteria have an outer membrane lipid
bilayer. If a Gram stain is performed, MTB either stains very weakly "Gram-positive" or does not retain
dye(acid fast) as a result of the high lipid and mycolic acid content of its cell wall. MTB can withstand
weak disinfectants ,anti microbials and survive in a dry state for weeks. In nature, the bacterium
can grow only within the cells of a host organism, but M. tuberculosis can be cultured in the

In cases of pulmonary TB, 3 forms are present:

Rapid multipliers; near the walls of pulmonary cavity sensitive to


Slow multipliers; intercellular form, sensitive to Pyrazinamide

Intermittent multipliers; persisters responsible for relapses, sensitive to


Humans are the only known reservoir for M. tuberculosis. Reservoirs are
pulmonary TB cases with positive sputum for acid fast bacilli.

Source of infection:
Sputum positive for tubercle bacilli who either received no treatment or not fully
treated ( can discharge the bacilli in their sputum for years)
Entry and Exit
Nose and Mouth
Mode of transmission

When people with active pulmonary TB cough, sneeze, speak, sing, or spit, they
expel infectious aerosol droplets 0.5 to 5.0 m in diameter. A single sneeze can
release up to 40,000 droplets. Each one of these droplets may transmit the
disease, since the infectious dose of tuberculosis is very low (the inhalation of
fewer than 10 bacteria may cause an infection)
A number of factors make people more susceptible to TB infections. The most
important risk factor globally is HIV; 13% of all TB cases are infected by the
virus.This is a particular problem in sub-Saharan Africa, where rates of HIV are
high. Of people without HIV who are infected with tuberculosis, about 510%
develop active disease during their lifetimes; in contrast, 30% of those
coinfected with HIV develop the active disease.
Tuberculosis is closely linked to both overcrowding and malnutrition, making it
one of the principal diseases of poverty. Those at high risk thus include: people
who inject illicit drugs, inhabitants and employees of locales where vulnerable
people gather (e.g. prisons and homeless shelters), medically underprivileged
and resource-poor communities, high-risk ethnic minorities, children in close
contact with high-risk category patients, and health care providers serving these
Chronic lung disease is another significant risk factor. Silicosis increases the risk
about 30-fold. Those who smoke cigarettes have nearly twice the risk of TB than
Other disease states can also increase the risk of developing tuberculosis. These
include alcoholism and diabetes mellitus (threefold increase).

Certain medications, such as corticosteroids and infliximab (an anti-TNF

monoclonal antibody) are becoming increasingly important risk factors,
especially in the developed world.
There is also a genetic susceptibility. This disease was more prevalent in families
with a previous history of TB. Further support for this notion was provided by
patients with a group of rare disorders called Mendelian Susceptibility to
Mycobacterial Diseases (MSMD). These patients have rare genetic defects, which
results in severe infections caused by non-pathogenic mycobacteria.

Immunity is cell mediated. It is of two types

Natural active immunity following natural infection
Artificial active immunity following BCG vaccinations.
Newborns DO NOT acquire passive natural immunity from mothers.
Period of communicability
A person is able to spread TB from an assigned date of 3 months prior to
symptom onset or a positive lab report. An individual is considered no longer
communicable after effective treatment has been demonstrated for 2 weeks
causing a significant reduction in symptoms.
TB has moderate communicability measured by secondary attack rate(48%). It is
affected by certain factors which are:
Case characteristics: Clinical type, cough frequency, sputum amount, personal
Contacts: Resistance, age, proximity to case
Environmental factors: Overcrowding, ventilation, measures of disinfection

Avoid close contact or spending prolonged time with known active TB

patients while infectious.

Treatment of LTBI (latent TB infection) reduces the risk that TB infection

will progress to active TB disease. Immunocompromised persons and
children <5 years old are at high risk for developing active TB disease
once infected. Every effort should be made to begin appropriate and
complete appropriate treatment for LTBI.

All active cases of TB disease require direct observed therapy (DOT)

BCG vaccination: The only currently available vaccine as of 2011 is

bacillus CalmetteGurin (BCG) which, while it is effective against
disseminated disease in childhood, confers inconsistent protection against
contracting pulmonary TB. Nevertheless, it is the most widely used
vaccine worldwide, with more than 90% of all children being vaccinated.
However, the immunity it induces decreases after about ten years. As
tuberculosis is uncommon in most of Canada, the United Kingdom, and the
United States, BCG is only administered to people at high risk.

Basic measures preventing respiratory diseases

Improve socioeconomic conditions.

Control program of TB

Control measures for cases

The best is Case Finding and Chemotheraphy

A. Case finding

Sputum examination: direct smear ( direct microscopy ) of sputum of

suspected cases for two consecutive specimens is sufficient to detect most
infectious cases. Its the method of choice because:
i) Reliable( detects those excreting TB in their sputum)
ii) Easy and cheap


Sputum culture: required to;

i) Confirm diagnosis in cases whose sputum smear is negative
ii) Detect sensitivity of bacilli to drugs especially in resistant case
The limitations are; difficult, needs special training, tedious(slow
process), lengthy, expensive

B. Chemotherapy
Direct observation therapy with short course chemotherapy( DOTS)is
recommended for TB case control. According to WHO, The most costeffective way to stop the spread of TB in communities with a high
incidence is by curing it. The best curative method for TB is known as
DOTS. DOTS has five main components:

Government commitment (including political will at all levels, and

establishment of a centralized and prioritized system of TB
monitoring, recording and training).

Case detection by sputum smear microscopy.

Standardized treatment regimen directly of six to eight months

observed by a healthcare worker or community health worker for at
least the first two months.

A regular, uninterrupted drug supply.

A standardized recording and reporting system that allows

assessment of treatment results.

Criteria for potent DOTS


Short course therapy, duration of drug intake is 6 months, observed

by health care worker at home or in specialized health facility

Four drugs( INH, rifampicin , Pyrazinamide, ethambutol) for the

initial TWO months, followed by two drugs( INH , Rifampicin) for the
remaining FOUR month as a continuation phase.

Priority for DOTS is cases with positive pulmonary smear

Monitor treatment with sputum smear at the end of initial phase

and at the end of course.

Advantages of DOTS
Rapid cure; eliminate rapid & slow multipliers
Low failure rate
Reduce emergence of drug resistant straint

Improved compliance
Second line
The second line drugs are considered as the reserved therapy for tuberculosis
treatment. These drugs are often used in special conditions. When situations like
resistance to first line therapy, extensively drug-resistant tuberculosis (XDR-TB)
or multidrug-resistant tuberculosis (MDR-TB) arise, the second-line drugs are
implemented for the treatment of tuberculosis. There are six classes of secondline drugs (SLDs) used for the treatment of TB. A drug may be classed as secondline instead of first-line for one of three possible reasons: it may be less effective
than the first-line drugs (e.g., p-aminosalicylic acid); or, it may have toxic sideeffects (e.g., cycloserine); or it may be unavailable in many developing countries
(e.g., fluoroquinolones):

aminoglycosides: e.g., amikacin (AMK), kanamycin (KM);

polypeptides: e.g., capreomycin, viomycin, enviomycin;

Fluoroquinolones: e.g., ciprofloxacin (CIP), levofloxacin, moxifloxacin


thioamides: e.g. ethionamide, prothionamide

cycloserine: e.g., closerin


C. Other measures
Isolation : isolate at home if condition permits, otherwise hospitalization
is required
Concurrent and terminal disinfections of the patients sputum
Rehabilitation : help the patient integrate himself into society within his
limited physical ability.








pg 29-32 Tuberculosis, Essentials of Community Medicine 2012-2013,

Faculty of Medicine Alexandria University.