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TUBERCULOSI

GROUP 4

Bernardo, Alexandra Marisse

Cayetano, Joann Shaira A.

Cristales, Immareign D.

Doria, Christianne Nikkie Lauren Q.

Orillaza, Jezeia-ann

Nayan,Marian Charity S.

Salud, Joan Allain

Solidum, Acey Chad

Valmonte, Justine Dominique L.


DCD 412 DGE

TUBERCULOSIS

Tuberculosis (TB) is an infectious disease caused by the bacillus Mycobacterium tuberculosis. It typically
affects the lungs (pulmonary TB), but can also affect other sites (extra pulmonary TB). The disease is
spread when people who are sick with pulmonary TB expel bacteria into the air, for example by
coughing.

A relatively small proportion (5–10%) of the estimated 1.7 billion people infected with M. tuberculosis
will develop TB disease during their lifetime. However, the probability of developing TB disease is much
higher among people infected with HIV; it is also higher among people affected by risk factors such as
undernutrition, diabetes, smoking and alcohol consumption.

Overall, about 90% of cases occur among adults, with more cases among men than women. The male:
female ratio among adults is approximately 2:1.

NATIONAL EPIDEMIOLOGY OF TUBERCULOSIS (PHILIPPINES)

a. Diagnosis of Tuberculosis disease

1. Chest X-ray

 For participants who consented to have a chest X-ray taken, the radiology technologist ensured
that all necessary preparations for the procedure were observed according to the chest X-ray SOP.
For all participants who declined or were not eligible for X-ray imaging, the field team leader
probed the reasons for refusal and, where applicable, tried once more to persuade the participant
to have the procedure done. Those who refused chest X-ray imaging were directed to the sputum
collection station, where they were asked to submit sputum specimens, regardless of the
presence of signs and symptoms suggestive of TB.
 Chest X-ray reading by the off-site radiologist

■ Abnormality detected—not TB. Chest X-ray images where the radiologist detects some
abnormality but considers it not clinically significant in relation to PTB.

■ Pulmonary abnormality detected—not tuberculosis. Chest X-ray images where the radiologist
detects a significant lung abnormality and considers this as non-tuberculosis.

■ Pulmonary abnormality detected—suspicious for tuberculosis. Chest X-ray images that show
abnormalities usually associated with PTB.
The following classification for chest X-rays, as adapted from the WHO Handbook [WHO 2011]
were used by the off-site radiologists:
* House-to-house interviews

This was done to ensure participation from eligible individuals with physical limitations that
prevented them from going to the survey site. Eligible individuals who had not yet participated in the
survey were also reminded to go to the survey site. Eligible individuals who refused to go to the
survey site but consented to participate were interviewed at home

2. Sputum collection in the Field

S1—the first collection of a spot specimen at the field survey site


S2—an early morning specimen (usually collected the next day)
S3—an additional spot specimen shortly after the early morning specimen was submitted for
examination. This was collected whenever the previous sputum specimens given had a volume of less
than 3 mL
- The sputum specimens from the field site were transported to the designated laboratory in coolers (2–
8ºC) at least twice a week.

Laboratory Procedures:

1. Fluorescence microscopy
2. Mycobacterial culture
3. Xpert MTB/RIF test
The Diagnostic and Medical Panel

 Composed of two pulmonologists, two infectious disease specialists, a senior radiologist, the
laboratory coordinator, one data manager from the data management unit, and the deputy
director of the Central Technical Unit.
 The main function of the Diagnostic and Medical Panel was to decide on the survey classification
of positive cases and to give clinical recommendations and feedback to the municipal health
officers (MHOs) and/or NTP coordinators of the respective clusters.
 Each case for discussion was presented with the following information: barcode, ID, age and sex,
household number, symptoms, history of treatment, history of diabetes mellitus and smoking,
Xpert, direct sputum smear microscopy (DSSM) and culture results including quantification,
chest X-ray images and the interpretation of the radiograph by the central senior radiologist.

Quality management procedures

 The QM unit undertook quality assurance and quality control processes and procedures to
ensure satisfactory achievement of project objectives.
 The QM Coordinator (Epidemiology) and QM Coordinator (Laboratory) implemented and
supervised quality management activities (quality audits and monitoring of process performance
metrics).
 Quality assurance and quality control activities were performed in coordination with the field
teams and the participating laboratories. The QM unit in collaboration with NTPS project
directors and unit heads implemented QM recommendations (preventive and corrective
actions) to ensure that all processes complied with project and organizational standards

Distribution of Tuberculosis disease

Frequency of Tuberculosis disease

 Philippines have suffered enormously from the health and socioeconomic consequences of
tuberculosis (TB). The World Health Organization (WHO) estimates that 1.8 million people living
in the Western Pacific Region developed active tuberculosis (TB) in 2016, and of these, 573 000
(32%) lived in the Philippines.

 The Philippines has one of the highest TB incidence rates in the Region, estimated at 554 cases
per 100 000 in 2016, a rate that has not declined significantly since 2007.

 Half (52%) of the population of the Philippines is under 25 years of age, compared to a regional
average of 43%. Age influences TB risk in a variety of biological and social ways, and TB
epidemiology changes with population age structure as nations undergo demographic shifts.

 Children under 5 years of age are at high risk of developing clinical TB after infection and are
prone to developing severe forms of TB such as TB meningitis and disseminated TB, particularly
if not protected by Bacillus Calmette-Guérin (BCG) vaccination.

 In contrast, adolescents and young adults (“young people,” aged 10–24 years) more often
develop infectious pulmonary TB. Young people who attend educational institutions or reside in
institutional settings may have multiple extended respiratory contacts per day. Furthermore,
recent research suggests that young people may be at increased risk of discontinuing TB
treatment before completion.

 aged ≥15 years residing in clusters from four strata:


o stratum 1—National Capital Region, Region 3 and 4A;
o stratum 2—the rest of Luzon;
o stratum 3—Visayas; and
o stratum 4— Mindanao.
 The survey covered 57 provinces from the 18 regions of the Philippines. Nine cities from NCR
were also included
 based on age (≥15 years old) and residency criteria (having spent at least the last two weeks in
the cluster or slept in the household >50% of the time in the past month).
 Of the 61,466 eligible individuals, 46,689 (76%) participated in the survey.
 Survey participants were screened by symptom questionnaire and digital chest X-ray imaging.
 A total of 18,597 individuals (39.8%) are eligible for sputum sample collection, out of whom
16,242 (87.3%) provided at least one sputum sample.
 Two sputum samples were collected from those with screening symptoms (cough ≥2 weeks
and/or hemoptysis) and/or a chest X-ray suspicious for TB.
 Samples were tested with smear microscopy, MTB culture, and Xpert MTB/RIF.
 A bacteriologically confirmed pulmonary TB case was defined as a participant with sputum
samples positive on culture for MTB and/or Xpert MTB/RIF.
Pattern of Tuberculosis disease according to:

b. Person

 Based on the prevalence survey findings, the estimated prevalence of smear- positive
and bacteriologically confirmed pulmonary TB in those ≥15 years was 434 per 100,000
(95% C.I. 350–518) and 1,159 per 100,000 (95% C.I. 1,016–1,301),
 The highest number of cases was in the age group 45−54 years (22.1%), while the lowest
proportion of cases was in the age group 25–34 years (14.6%).
 There were more cases of TB among men (1.5%) than women (0.6%), with a 3:1 ratio
(P<0.001).
c. Place

 Stratum 1, which had twice the required sample size as the other clusters, had the
highest number of PTB cases (40%),
 followed by stratum 3 (24%) and stratum 4 (20%).
 Stratum 2 had the least number of cases (16%).
 The proportion of TB cases was greater in the urban areas (1.1%) compared to the rural
areas (0.9%) (P=0.006).
d. Time

 Incidence of tuberculosis (per 100,000 people) Incidence of tuberculosis is the estimated


number of new and relapse tuberculosis cases arising in a given year, expressed as the
rate per 100,000 population. All forms of TB are included, including cases in people
living with HIV.

Determinants of Tuberculosis
disease

e. Risk factors
 age (highest in the age group ≥ 65
 Previous TB treatment
 Diabetes mellitus
 Urban residents
 Men with more than 5 pack years smoking history
 Women with 1-5 pack-years of smoking
 Malnourished
 HIV
e. Modes of transmission
 How does a person get TB?
o primarily from person to person through infected air during close contact
o The bacteria get into the air when someone infected with TB of the lung coughs,
sneezes, shouts, or spits
o A person can become infected when they inhale minute particles of the infected
sputum from the air
 If a person is exposed to someone with active TB disease, can he/she transmit TB to
others?
o Only persons with active TB disease (i.e. those who also show signs and symptoms of
the disease) can spread TB to others.
o People with latent TB infection (i.e. people who have the TB bacteria but do not show
any symptoms) cannot spread TB bacteria to others.
o A person exposed to someone with active TB disease, may become infected with the
TB bacteria, but would not be able to spread the infection unless he or she starts
showing symptoms of the disease.
o People who have latent TB infection can, however, be treated to prevent them from
developing active TB

Prevention of Tuberculosis
• TB infection control
• Universal use of BCG and Isoniazid Preventive Therapy
 Prevent exposure & infection
For vulnerable populations such as young children (0-4 yo) & people with HIV who are already
exposed or infected: prevent progression to TB disease = IPT for 6 months
 Bacillus Calmette-Guerin (BCG) Vaccine – given at earliest possible age protects the possibility of
TB Meningitis and other TB infections which infants are prone (according to Expanded Program
on Immunization)
• TB infection control at the DOTS Facilities
 Specific measures are provided in the “Guidelines on Infection Control for TB and Other
Airborne Infectious Diseases” issued by DOH
 Administrative control measures include:
o Promptly identifying people with TB symptoms
o Separating or isolating infectious patients
o Controlling the spread of pathogens
o Minimizing the time spent by patients in healthcare facility
o Reducing diagnostic delays
o Early initiation of treatment for TB patients
o Providing a package of prevention, treatment and care interventions for staff,
including HIV prevention, anti-retroviral treatment and IPT for HIV positive staff
• TB infection control measures within the household of TB patients
 The importance of early detection and treatment of TB, and prompt screening of
household contacts
 Methods to reduce exposure:
o Cough etiquette
o Minimizing time spent by infectious TB patients in crowded public places
o Opening windows and removing any obstruction to ventilation in rooms where TB
patient sleeps or spends much time
Treatment of Tuberculosis

TB Disease Registration Groups

Directly Observed Treatment (DOT)

o DOT is a method developed to ensure treatment compliance by providing constant and


motivational supervision to TB patients. DOT works by having a responsible person,
referred to as treatment partner, watch the TB patient take anti-TB drugs every day
during the whole course of treatment.
Management of Cases Who Interrupted Treatment

Treatment Modifications for Special Situations

• Pregnancy

• Breastfeeding

• Oral contraceptives

• Liver disease or History of liver disease

• Established Chronic Liver Disease

• Acute Hepatitis (e.g., Acute Viral Hepatitis)

• Renal Failure

• TB/HIV co-infection
GLOBAL EPIDEMIOLOGY OF TUBERCULOSIS

a. Diagnostic tests for TB disease include:

1. Rapid molecular tests

o The only rapid test for diagnosis of TB currently recommended by WHO is the Xpert® MTB/RIF
assay (Cepheid, USA).
o It can provide results within 2 hours, and was initially recommended (in 2010) for diagnosis of
pulmonary TB in adults.
o Since 2013, it has also been recommended for use in children and to diagnose specific forms of
extra pulmonary TB.
o The test has much better accuracy than sputum smear microscopy.

2. Sputum smear microscopy

o Developed more than 100 years ago, this technique requires the examination of sputum
samples using a microscope to determine the presence of bacteria.

3. Culture-based methods

o These form the current reference standard; they require more developed laboratory capacity
and can take up to 12 weeks to provide results.

* tests for TB that is resistant to first line and second-line anti-TB drugs.

o Xpert MTB/RIF: simultaneously tests for TB and resistance to rifampicin (the most effective first-
line anti-TB drug)
o Rapid line probe assays (LPAs)
a. test for resistance to rifampicin and isoniazid (referred to as first–line LPAs)
b. tests for resistance to fluoroquinolones and injectable anti-TB drugs (referred to as a
second-line LPA)

Distribution of the disease

Frequency of Tuberculosis disease

 Worldwide, Tuberculosis is one of the top 10 causes of death, and the leading cause
from a single infectious agent.
 In 2017, the largest number of new TB cases occurred in the South-East Asia and
Western Pacific regions, with 62% of new cases, followed by the African region,
with 25% of new cases.
 TB caused an estimated 1.3 million deaths with a range of 1.2-1.4 Million among
HIV negative people and 300,000 deaths among HIV positive people.
 Drug-resistant TB continues to be a public health crisis. Worldwide in 2017,
 With Rifampicin being the most effective first line of drug, 558 000 people (range,
483 000–639 000) developed TB that was resistant to rifampicin (RR-TB)
 And of these, 82% had multidrug-resistant TB (MDR-TB)
 Three (3) countries accounted for almost half of the world’s cases of MDR/RR-TB:
India (24%), China (13%) and the Russian Federation (10%).
 3.5% of new TB cases and 18% of previously treated cases had MDR/RR-TB.
 The highest proportions (>50% in previously treated cases) are in countries of the
former Soviet Union.
 Among cases of MDR-TB in 2017, 8.5% (95% confidence interval, 6.2–11%) were
estimated to have extensively drug-resistant TB (XDR-TB).
 About 1.7 billion people, 23% of the world’s population, are estimated to have a latent
TB infection, and are thus at risk of developing active TB disease during their lifetime.

Pattern of Tuberculosis disease according to:

b. Person

 Globally, the best estimate is that 10.0 million people (range, 9.0–11.1 million)
developed TB disease in 2017: 5.8 million men, 3.2 million women and 1.0 million
children.
 There were cases in all age groups but, overall, 90% were adults and 10% were children
(aged <15 years). Globally, 64% of cases were among men and boys, and 36% were
among women and girls. The higher shares of TB cases among men are consistent with
evidence from prevalence surveys, which show that TB disease affects men more than
women, and that gaps in case detection and reporting are higher among men.
 The M: F ratio of incident TB cases for all ages ranged from 1.3 in the WHO Eastern
Mediterranean Region to 2.1 in the WHO Western Pacific Region. In children, the M: F
ratio was close to 1.
-
c. Place

 Globally in 2017, there were an estimated 10.0 million incident cases of TB (range, 9.0–
11.1 million), equivalent to 133 cases (range, 120–148) per 100 000 population.
 Most of the estimated number of cases in 2017 occurred in the WHO South-East Asia
Region (44%), the WHO African Region (25%) and the WHO Western Pacific Region
(18%); smaller proportions of cases occurred in the WHO Eastern Mediterranean Region
(7.7%), the WHO Region of the Americas (2.8%) and the WHO European Region (2.7%).
 The 30 high TB burden countries accounted for 87% of all estimated incident cases
worldwide, and eight of these countries accounted for two thirds of the global total:
India (27%), China (9%), Indonesia (8%), the Philippines (6%), Pakistan (5%), Nigeria
(4%), Bangladesh (4%) and South Africa (3%).
 These and 22 other countries in WHO’s list of 30 high TB burden countries accounted for
87% of the world’s cases.
 The proportion of TB cases co-infected with HIV was highest in countries in the WHO
African Region, exceeding 50% in parts of southern Africa.
d. Time

 The fastest declines in the 5-year period 2013–2017 were in the WHO European Region
(on average, 5% per year).
 In the same period, particularly impressive reductions (4–8% per year) occurred in
southern Africa (e.g. Eswatini [formerly Swaziland], Lesotho, Namibia, South Africa,
Zambia and Zimbabwe) following a peak in the HIV epidemic and the expansion of TB
and HIV prevention and care, and in the Russian Federation (5% per year) following
intensified efforts to reduce the burden of TB and scrutiny of progress from the highest
political levels.
Determinants of
Tuberculosis disease

 The influence of
various
social and
economic
determinants on the TB epidemic has long been recognized
 The links between TB and poverty, social protection, the prevalence of undernutrition,
diabetes, HIV, alcohol use, smoking, indoor air pollution and income per capita have
been analyzed, reviewed and summarized in recent publications

e. Risk factors
 Prevalence of undernourishment
- Under-nutrition weakens the body’s defense against infections and is a strong risk
factor for TB at the national and individual level.
 HIV prevalence
- HIV is a strong risk factor for development of TB disease and is associated with poorer
treatment outcomes. HIV prevalence (rather than incidence) will be monitored because
it is directly measured and those newly infected with HIV are at lower risk of developing
TB compared with those who have been infected for more than 1 year.
 Prevalence of smoking among those aged ≥ 15 years
- Smoking is a strong risk factor for TB disease at the individual level, although a link
with TB incidence at the national (as opposed to individual) level has been difficult to
establish due to confounding.
 Prevalence of diabetes
- Diabetes is a strong risk factor for development of TB disease, although a link with TB
incidence at the national (as opposed to individual) level has been difficult to establish
due to confounding. Diabetes prevalence is more relevant than mortality for TB since it
directly influences the risk of developing TB.
 Prevalence of alcohol use disorder
- Alcohol use is a strong risk factor for TB disease and poorer treatment outcomes at the
individual level, although a link with TB incidence at the national (as opposed to
individual) level has been hard to establish due to confounding. The prevalence of
alcohol use disorder is the most relevant indicator in the context of TB.
 Proportion of urban population living in slums, informal settlements or inadequate
housing
- Living in a slum is a risk factor for TB transmission due to its link with overcrowding. It
is also a risk factor for developing TB disease, due to links with air pollution and under-
nutrition

e. Modes of transmission

 M. tuberculosis is carried in airborne particles, called droplet nuclei, of 1– 5 microns in


diameter.
 Infectious droplet nuclei are generated when persons who have pulmonary or laryngeal
TB disease cough, sneeze, shout, or sing.
 Depending on the environment, these tiny particles can remain suspended in the air for
several hours.
 M. tuberculosis is transmitted through the air, not by surface contact. Transmission
occurs when a person inhales droplet nuclei containing M. tuberculosis, and the droplet
nuclei traverse the mouth or nasal passages, upper respiratory tract, and bronchi to
reach the alveoli of the lungs
Prevention of Tuberculosis

 The World Health Organization has just issued updated WHO guidelines on TB infection
prevention and control. This will contribute to cutting transmission and reducing the burden of
TB illness and death to reach the global targets. TB prevention and control consists of a
combination of measures designed to minimize the risk of M. tuberculosis transmission within
populations. A three-level hierarchy of controls comprising administrative controls,
environmental controls and respiratory protection has been shown to reduce and prevent the
risk of transmission and exposure to M. tuberculosis.

1. Administrative controls are the first and most important level of the hierarchy. These are
management measures that are intended to reduce the risk of exposure to persons with
infectious TB.
● Recommendation 1: Triage of people with TB signs and symptoms, or with TB disease, is
recommended to reduce M. tuberculosis transmission to health workers (including
community health workers), persons attending health care facilities or other persons in
settings with a high risk of transmission.
● Recommendation 2: Respiratory separation / isolation of people with presumed or
demonstrated infectious TB is recommended to reduce M. tuberculosis transmission to
health workers or other persons attending health care facilities.
● Recommendation 3: Prompt initiation of effective TB treatment of people with TB
disease is recommended to reduce M. tuberculosis transmission to health workers,
persons attending health care facilities or other persons in settings with a high risk of
transmission.
● Recommendation 4: Respiratory hygiene (including cough etiquette) in people with
presumed or confirmed TB is recommended to reduce M. tuberculosis transmission to
health workers, persons attending health care facilities or other persons in settings with
a high risk of transmission.
2. Environmental control is the second level of the hierarchy to prevent the spread of infectious
droplet nuclei and reduce their concentration.
● Recommendation 5: Upper-room germicidal ultraviolet (GUV) systems are
recommended to reduce M. tuberculosis transmission to health workers, persons
attending health care facilities or other persons in settings with a high risk of
transmission.
● Recommendation 6: Ventilation systems (including natural, mixed-mode, mechanical
ventilation and recirculated air through high-efficiency particulate air [HEPA] filters) are
recommended to reduce M. tuberculosis transmission to health workers, persons
attending health care facilities or other persons in settings with a high risk of
transmission.
3. Respiratory protection control is the third level of the hierarchy. It consists of the use of personal
protective equipment in situations that pose a high risk of exposure to M. tuberculosis.
● Recommendation 7: Particulate respirators, within the framework of a respiratory
protection program, are recommended to reduce M. tuberculosis transmission to health
workers, persons attending health care facilities or other persons in settings with a high
risk of transmission.

Treatment of Tuberculosis
 Patient-centered care is the main component of WHO’s end Tuberculosis strategy. All patients
should receive educational, emotional, economic support to enable them to complete the
diagnostic process as well as the treatment.
 Community based treatment may lead to more favorable outcomes
 People infected with TB have life time risk of falling ill 10%, however, people with compromised
immune system have higher risk.

 Active, drug-sensitive TB
Treatment:
- standard 6 month course of 4 antimicrobial drugs with proper information, supervision,
support

TB TREATMENT COVERAGE 3 WHO Regions achieved 75%

o 2017- 64% o America


o 2010- 53% o Europe
o 2000- 35% o Western Pacific Region

 Multi-drug resistant TB
- NO response to at least Isoniazid and Rifampicin which are the 2 most powerful anti-
tuberculosis drugs.
- Can be detected using special laboratory tests like Xpert MTB or culture based.
- can be treated with 2nd line MDR-TB treatment regimen
- Groups of drugs to treat MDR-TB:
 Group 1- first line oral agents
 Group 2-injectible agents
 Group 3-fluoroquinolones
 Group 4-oral bacteriostatic 2nd line agent
 Group 5- agents with unclear role in tx of drug-resistant TB
- TB patients that are also HIV positive
Treatment regimen:
o initiate TB treatment first
o co-trimoxazole preventive therapy
o anti retroviral therapy (ART)
REFERENCES:

National Tuberculosis Prevalence Survey 2016 Philippines. Department of Health. Retrieved from
http://www.doh.gov.ph

National Tuberculosis Control Program Manual of Procedures, 5th ed. Department of Health. Retrieved
from http://www.doh.gov.ph

Snow, K. (2018, November 9). Tuberculosis among Children, Adolescents, and Young Adults in the
Philippines: A Surveillance Report. World Health Organization. Retrieved from http://ncbi.nlm.nih.gov
Global tuberculosis report 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0
IGO

WHO guidelines on tuberculosis infection prevention and control, 2019 update, Geneva: World Health
Organization; 2019. License: CC BY-NC-SA 3.0 IGO.

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