Tuberculosis

Introduction:
In the Philippines, tuberculosis ranks sixth in the leading cause of
morbidity (2002) and mortality (2002). The estimated incidence rate of all TB
cases in the Philippines is 243/100,000 population/year (WHO Report 2006). The
country ranks ninth among the 22 high burdened countries under the WHO watch
list.
Tuberculosis (TB) is considered as the world’s deadliest disease and
remains as a major health problem in the Philippines.

Definition:
TB is a highly infectious chronic disease caused by tubercle bacilli. It is
primarily a respiratory disease but can also affect other organs of the body and is
common among malnourished individuals living in crowded areas. It often occurs
in children of underdeveloped and developing countries in the form of primary
complex especially after about of a debilitating childhood disease such as
measles.

Causative Agent:
Mycobacterium tuberculosis and M. Africanum primarily from human,
and M. Bovis primarily from cattle. Other mycobacterium occasionally produces
disease clinically indistinguishable from tuberculosis; the etiology agents can be
identified only by culture of the microorganisms. At present (year 2000), there are
23 new strain of TB bacilli found in the United States. Therefore, TB is no longer
considered to be disease of the past but of the present.

Signs and symptoms:

• Cough of two weeks or more

• Fever
• Chest or back pains not referable to any musculo-skeletal disorders
• Hemoptysis or recurrent blood-streaked sputum
• Significant weight loss
• Other sings and symptoms such as sweating, fatigue, body malaise and
shortness of breath.

Mode of Transmission:
• Airborne droplet method through coughing, singing or sneezing
• Direct invasion through mucous membranes or breaks in the skin may
occur, but is extremely rare
• Bovine tuberculosis results from the exposure to tuberculosis cattle,
usually by ingestion of unpasteurized milk or dairy products.
Extrapulmonary tuberculosis, other than laryngeal, is generally not
communicable, even if there is a draining sinus
Period of Communicability:
As long as viable tubercle bacilli are being discharged in the sputum. Some
untreated or inadequately treated patients may be sputum-positive intermittently for
years. The degree of communicability depends on the numbers of the bacilli discharged,
the virulence of the bacilli, adequacy of ventilation, exposure of the bacilli to sun or UV
light and opportunities for their aerosolization by coughing, sneezing, talking or singing.
Effective antimicrobial chemotherapy usually reduces communicability to insignificant
levels within days to a few weeks. Children with primarily tuberculosis are not infectious.

Methods of Control:
Preventive Measure
• Prompt diagnosis and treatment of infectious cases
• BCG vaccination of newborn, infants and grade I/school entrants
• Educate the public in mode of spread and methods of control and the importance
of early diagnosis.
• Improve social conditions, which may increase the risk of becoming infected,
such as overcrowding.
• Make available medical, laboratory and x-ray facilities for examination of
patients, contact and suspects, and facilities for early treatment of cases and
person at risk of infection and beds for those needing hospitalization.
• Provide public health nursing and outreach services for home supervision of
patients to supervise the therapy directly and to arrange for examination and
preventive treatment of contacts.

Treatment
Category Type of TB Patient Treatment Regimen
Intensive Phase Continuation Phase
I New smear-positive PTB, 2 HRZE 4 HR
New smear-negative PTB
with extensive parenchymal
lesions on CXR as assessed
by the TBDC
EPTB, and
Severe concomitant HIV
disease
II Treatment Failure 2 HRZE/ 1 HRZE 5 HRE
Relapse
Return after Default
Other
III New smear-negative PTB 2 HRZE 4 HR
with minimal parenchymal
lesions on CXR as assessed
by the TBDC
IV Chronic (still smear-positive Refer to specialized facility or DOTS Plus
 after supervised re-treatment) Center Refer to Provincial/City NTP
Coordinator

Dosage per Category of Treatment Regimen

a. Fixed-Dose Formulation (FDC)
The number of tablets of FDCs per patient will depend on the body weight.
Hence, all patients must be weighed (using kilogram as a unit) before treatment is started.

Treatment Regimen for Categories I and III: 2 HRZE/4 HR (FDC)

Body Weight (kg) No. of tablets per day No. of tablets per day
Intensive Phase Continuation Phase
(2 months) (4 months)
FDC-A (HRZE) FDC-B (HR)
30-37 2 2
38-54 3 3
55-70 4 4
>70 5 5

Treatment Regimen for Category II: 2 HRZES/4 HRE (FDC)

Body Intensive Phase Continuation Phase
Weight (kg) First two months Third month FDC-B E
FDC-A Streptomycin FDC-A (HR) 400 mg
(HRZE) (HRZE)
30-37 2 0.75 g 2 2 1
38-54 3 0.75 g 3 3 2
55-70 4 0.75 g 4 4 3
>70 5 0.75 g 5 5 3

b. Single Drug Formulation (SDF)

Simply add one tablet of INH (100 mg), PZA (500 mg), and E (400 mg) each for
the patient weighing more than 50 kg before treatment initiation. Modify drug dosage
within acceptable limits according to patient’s body weight, particularly those weighing
less than 30 kg at the time of diagnosis.

Treatment Regimen for Categories I and II: 2 HRZE/4 HR (SDF)

Anti-TB Drugs No. of tablets per day No. of tablets per day
Intensive Phase Continuation Phase
(2 months) ( 4 months)
Isoniazid (H) 1 1
Rifampicin (R) 1 1
Pyrazinamide (Z) 2
Ethambutol (E) 2
Treatment Regimen for Category II: 2 HRZES/1 HRZE/5 HRE
Anti-TB Drugs No. of tablets/vial per day No. of tablets per day
Intensive Phase Continuation Phase
(3 months) (5 mnoths)
First 2 months 3rd month
Isoniazid (H) 1 1 1
Rifampicin (R) 1 1 1
Pyrazinamide (Z) 2 2
Ethambutol (E) 2 2 2
Streptomycin (S) 1 vial/day*
*56 vials for two months

Drug Dosage per Kg Body Weight

Drug Dosage per kg body weight and minimum
dose
Isoniazid 5 (4-6) mg/kg, and not to exceed 400mg
daily
Rifampicin 10 (8-12) mg/kg, and not to exceed 600mg
daily
Pyrazinamide 25 (20-30) mg/kg, and not to exceed 2g
daily
Ethambutol 15 (15-20) mg/kg, and not to exceed 1.2g
daily
Streptomycin 15 (12-18) mg/kg, and not to exceed 1g
daily
What is tuberculosis?

Tuberculosis (TB) is an infectious disease caused by bacteria whose scientific name is

Mycobacterium tuberculosis. It was first isolated in 1882 by a German physician named
Robert Koch who received the Nobel Prize for this discovery. TB most commonly affects
the lungs but also can involve almost any organ of the body. Many years ago, this disease
was referred to as "consumption" because without effective treatment, these patients
often would waste away. Today, of course, tuberculosis usually can be treated
successfully with antibiotics.

There is also a group of organisms referred to as atypical tuberculosis. These involve

other types of bacteria that are in the Mycobacterium family. Often, these organisms do
not cause disease and are referred to as "colonizers" because they simply live alongside
other bacteria in our bodies without causing damage. At times, these bacteria can cause
an infection that is sometimes clinically like typical tuberculosis. When these atypical
mycobacterium cause infection, they are often very difficult to cure. Often, drug therapy
for these organisms must be administered for one and a half to two years and requires
multiple medications.

How does a person get TB?

A person can become infected with tuberculosis bacteria when he or she inhales minute
particles of infected sputum from the air. The bacteria get into the air when someone who
has a tuberculosis lung infection coughs, sneezes, shouts, or spits (which is common in
some cultures). People who are nearby can then possibly breathe the bacteria into their
lungs. You don't get TB by just touching the clothes or shaking the hands of someone
who is infected. Tuberculosis is spread (transmitted) primarily from person to person by
breathing infected air during close contact.

How does a doctor diagnose tuberculosis?

TB can be diagnosed in several different ways, including chest X-rays, analysis of

sputum, and skin tests. Sometimes, the chest X-rays can reveal evidence of active
tuberculosis pneumonia. Other times, the X-rays may show scarring (fibrosis) or
hardening (calcification) in the lungs, suggesting that the TB is contained and inactive.
Examination of the sputum on a slide (smear) under the microscope can show the
presence of the tuberculosis-like bacteria. Bacteria of the Mycobacterium family,
including atypical mycobacterium, stain positive with special dyes and are referred to as
acid-fast bacteria (AFB). A sample of the sputum also is usually taken and grown
(cultured) in special incubators so that the tuberculosis bacteria can subsequently be
identified as tuberculosis or atypical tuberculosis. Several types of skin tests are used to
screen for TB infection. These so-called tuberculin skin tests include the Tine test and the
Mantoux test, also known as the PPD (purified protein derivative) test. In each of these
tests, a small amount of purified extract from dead tuberculosis bacteria is injected under
the skin. If a person is not infected with TB, then no reaction will occur at the site of the
injection (a negative skin test). If a person is infected with tuberculosis, however, a raised
and reddened area will occur around the site of the test injection. This reaction, a positive
skin test, occurs about 48-72 hours after the injection. When only the skin test is positive,
or evidence of prior TB is present on chest X-rays, the disease is referred to as "latent
tuberculosis." This contrasts with active TB as described above, under symptoms. If the
infection with tuberculosis has occurred recently, however, the skin test can be falsely
negative. The reason for a false-negative test with a recent infection is that it usually
takes two to 10 weeks after the time of infection with tuberculosis before the skin test
becomes positive. The skin test can also be falsely negative if a person's immune system
is weakened or deficient due to another illness such as AIDS or cancer, or while taking
medications that can suppress the immune response, such as cortisone or anticancer
drugs.

How is tuberculosis treated?

A person with a positive skin test, a normal chest X-ray, and no symptoms most
likely has only a few TB germs in an inactive state and is not contagious. Nevertheless,
treatment with an antibiotic may be recommended for this person to prevent the TB from
turning into an active infection. The antibiotic used for this purpose is called isoniazid
(INH). If taken for six to 12 months, it will prevent the TB from becoming active in the
future. In fact, if a person with a positive skin test does not take INH, there is a 5%-10%
lifelong risk that the TB will become active. Taking isoniazid can be inadvisable
(contraindicated) during pregnancy or for those suffering from alcoholism or liver
disease. Also, isoniazid can have side effects. The side effects occur infrequently, but a
rash can develop, and the individual can feel tired or irritable. Liver damage from
isoniazid is a rare occurrence and typically reverses once the drug is stopped. Very rarely,
however, especially in older people, the liver damage (INH hepatitis) can even be fatal. It
is important therefore, for the doctor to monitor a patient's liver by periodically ordering
blood tests called "liver function tests" during the course of INH therapy. Another side
effect of INH is a decreased sensation in the extremities referred to as a peripheral
neuropathy. This can be avoided by taking vitamin B6 (pyridoxine), and this is often
prescribed along with INH. A person with a positive skin test along with an abnormal
chest X-ray and sputum evidencing TB bacteria has active TB and is contagious. As
already mentioned, active TB usually is accompanied by symptoms, such as a cough,
fever, weight loss, and fatigue. Active TB is treated with a combination of medications
along with isoniazid. Rifampin (Rifadin), ethambutol (Myambutol), and pyrazinamide are
the drugs commonly used to treat active TB in conjunction with isoniazid (INH). Four
drugs are often taken for the first two months of therapy to help kill any potentially
resistant strains of bacteria. Then the number is usually reduced to two drugs for the
remainder of the treatment based on drug sensitivity testing that is usually available by
this time in the course. Streptomycin, a drug that is given by injection, may be used as
well, particularly when the disease is extensive and/or the patients do not take their oral
medications reliably (termed "poor compliance"). Treatment usually lasts for many
months and sometimes for years. Successful treatment of TB is dependent largely on the
compliance of the patient. Indeed, the failure of a patient to take the medications as
prescribed is the most important cause of failure to cure the TB infection. In some
locations, the health department demands direct monitoring of patient compliance with
therapy. Surgery on the lungs may be indicated to help cure TB when medication has
failed, but in this day and age, surgery for TB is unusual. Treatment with appropriate
antibiotics will usually cure the TB. Without treatment, however, tuberculosis can be a
lethal infection. Therefore, early diagnosis is important. Those individuals who have been
exposed to a person with TB, or suspect that they have been, should be examined by a
doctor for signs of TB and screened with a TB skin test.

What is DOTS?

Tuberculosis is completely curable through short-course chemotherapy. Treating

TB cases who are sputum-smear positive (and who can therefore spread the disease to
others) at the source, it is the most effective means of eliminating TB from a population.
DOTS or Directly Observed Treatment Short course is the internationally recommended
strategy for TB control that has been recognized as a highly efficient and cost-effective
strategy.

Is TB Curable?

In more than nine of out of ten patients, tuberculosis can be cured with
appropriate treatment. Treatment for tuberculosis usually combines several different
antibiotic drugs that are given for at least six months, sometimes for as long as 12
months. A tuberculosis cure relies on close cooperation between the patient and doctor
and other healthcare workers in order to make sure that the right amount of medicine is
taken for the right amount of time. If too little medicine is taken, or the right amount is
taken for a shorter period of time, a cure is less likely. Furthermore, there is a greater
chance a person will develop drug-resistant TB, a condition that is more difficult to cure.

Prevention
Generally, tuberculosis (TB) is a preventable disease. Prevention measures focus on:

• Preventive treatment in people who have a positive TB test without symptoms of

tuberculosis (latent tuberculosis)
• Precautions at hospitals and clinics
• BCG vaccine
• Reducing exposures when a person is infectious.

In the United States, healthcare providers try to identify people infected with tuberculosis
as early as possible, before they have developed active tuberculosis. These people can
then be treated and cured before they become contagious.

Anyone who has been exposed to a person with TB should be tested for latent
tuberculosis .This disease is especially dangerous for children and people with HIV
infection. If infected with TB bacteria, these people need medicine right away to keep
from developing an active case.