Tuberculosis (TB)

Tuberculosis is a bacterial disease usually affecting the lungs (pulmonary TB). Other
parts of the body can also be affected, for example lymph nodes, kidneys, bones, joints, etc.
(extra pulmonary TB). Approximately 1,300 cases are reported each year in New York State.
Tuberculosis can affect anyone of any age. People with weakened immune systems are at
increased risk.Tuberculosis is spread through the air when a person with untreated pulmonary TB
coughs or sneezes. Prolonged exposure to a person with untreated TB usually is necessary for
infection to occur.
What is the difference between latent tuberculosis infection and tuberculosis disease?
Latent tuberculosis infection (LTBI) means the person has the TB germ in their body
(usually lungs), but has yet to develop obvious symptoms. In latent TB, the person has a
significant reaction to the Mantoux skin test with no symptoms of tuberculosis, and no TB
organisms found in the sputum. Tuberculosis disease indicates the person has symptoms, a
significant reaction to a Mantoux skin test and organisms found in the sputum. In order to spread
the TB germs, a person must have TB disease. Having latent TB infection is not enough to
spread the germ. Tuberculosis may last for a lifetime as an infection, never developing into
disease.
What is the treatment for tuberculosis?
People with latent TB infection should be evaluated for a course of preventive therapy,
which usually includes taking antituberculosis medication for several months. People with active
TB disease must complete a course of treatment for six months or more. Initial treatment
includes at least four anti-TB drugs, and medications may be altered based on laboratory test
results. The exact medication plan must be determined by a physician. Directly observed therapy
(DOT) programs are recommended for all TB patients to help them complete their therapy.
What can be done to prevent the spread of tuberculosis?
The most important way to stop the spread of tuberculosis is for TB patients to cover the
mouth and nose when coughing, and to take all the TB medicine exactly as prescribed by the
physician.
What is multidrug-resistant tuberculosis (MDR-TB)?
This refers to the ability of some strains of TB to grow and multiply even in the presence
of certain drugs which would normally kill them.
What is extensively drug-resistant tuberculosis (XDR-TB)?
Extensively drug-resistant TB (XDR-TB) is a subset of MDR-TB in which the strains of
TB bacteria are resistant to several of the best second-line drugs for TB. These strains are very
difficult to treat. XDR-TB cases make up approximately 10 percent of MDR-TB cases.
Who gets MDR-TB?
TB patients with drug sensitive disease may develop drug resistant tuberculosis if they
fail to take antituberculosis medications as prescribed, as well as TB patients who have been
prescribed an ineffective treatment plan. TB cases diseased with MDR-TB can transmit the drug
resistant infection to other individuals.
What is the treatment for multidrug-resistant tuberculosis?
For patients with disease due to drug resistant organisms, expert consultation from a
specialist in treating drug resistant TB should be obtained. Patients with drug resistant disease
should be treated with drugs to which their organisms are susceptible. The effectiveness of
treatment for latent infection with MDR-TB is uncertain.
What can be done to prevent the spread of MDR-TB?
Ensuring people with MDR-TB take all their medication and teaching patients to cover
their mouth and nose when coughing and sneezing can reduce the risk of spread of MDR-TB. In
addition, directly observed therapy should be used to ensure patients complete the recommended
course of therapy.

Epidemiology
The study of the distribution of diseases in populations and of factors that influence the
occurrence of disease. Epidemiology examines epidemic (excess) and endemic (always present)
diseases; it is based on the observation that most diseases do not occur randomly, but are related
to environmental and personal characteristics that vary by place, time, and subgroup of the
population. The epidemiologist attempts to determine who is prone to a particular disease; where
risk of the disease is highest; when the disease is most likely to occur and its trends over time;
what exposure its victims have in common; how much the risk is increased through exposure;
and how many cases of the disease could be avoided by eliminating the exposure.
In the course of history, the epidemiologic approach has helped to explain the
transmission of communicable diseases, such as cholera and measles, by discovering what
exposures or host factors were shared by individuals who became sick. Modern epidemiologists
have contributed to an understanding of factors that influence the risk of chronic diseases,
particularly cardiovascular diseases and cancer, which account for most deaths in developed
countries today. Epidemiology has established the causal association of cigarette smoking with
heart disease; shown that acquired immune deficiency syndrome (AIDS) is associated with
certain sexual practices; linked menopausal estrogen use to increased risk of endometrial cancer
but to decreased risk of osteoporosis; and demonstrated the value of mammography in reducing
breast cancer mortality. By identifying personal characteristics and environmental exposures that
increase the risk of disease, epidemiologists provide crucial input to risk assessments and
contribute to the formulation of public health policy.
Epidemiologic studies, based mainly on human subjects, have the advantage of producing
results relevant to people, but the disadvantage of not always allowing perfect control of study
conditions. For ethical and practical reasons, many questions cannot be addressed by
experimental studies in humans and for which observational studies (or experimental studies
using laboratory animals or biomedical models) must suffice. Still, there are circumstances in
which experimental studies on human subjects are appropriate, for example, when a new drug or
surgical procedure appears promising and the potential benefits outweigh known or suspected
risks. See also Disease; Epidemic.
Descriptive epidemiologic studies provide information about the occurrence of disease in
a population or its subgroups and trends in the frequency of disease over time. Data sources
include death certificates, special disease registries, surveys, and population censuses; the most
common measures of disease occurrence are (1) mortality (number of deaths yearly per 1000 of
population at risk); (2) incidence (number of new cases yearly per 100,000 of population at risk);
and (3) prevalence (number of existing cases at a given time per 100 of population at risk).
Descriptive measures are useful for identifying populations and subgroups at high and low risk
of disease and for monitoring time trends for specific diseases. They provide the leads for
analytic studies designed to investigate factors responsible for such disease profiles.
Analytic epidemiologic studies seek to identify specific factors that increase or decrease
the risk of disease and to quantify the associated risk. In observational studies, the researcher
does not alter the behavior or exposure of the study subjects, but observes them to learn whether
those exposed to different factors differ in disease rates. Alternatively, the researcher attempts to
learn what factors distinguish people who have developed a particular disease from those who
have not. In experimental studies, the investigator alters the behavior, exposure, or treatment of
people to determine the impact of the intervention on the disease. Usually two groups are
studied, one that experiences the intervention (the experimental group) and one that does not (the
control group). Outcome measures include incidence, mortality, and survival rates in both the
intervention and control groups.
The transmission of tuberculosis (TB) in health care facilities is an important concern.
Several outbreaks of nosocomial TB in the United States accompanied the resurgence of the
disease in the general population in the late 1980s and early 1990s. Multiple factors contributed
to this problem, including deterioration of the public health infrastructure, the human
immunodeficiency virus (HIV) epidemic, and inadequate infection control measures in health
care facilities.Enhanced infection control measures, as promoted by the Centers for Disease
Control and Prevention (CDC) guidelines, have reduced healthcare-associated transmission of
TB, and improved public health TB control programs have reduced the incidence of TB in the
community as a whole [1]. The 2004 rate was the lowest recorded in the United States since
national reporting began in 1953 [1].The CDC has identified several key administrative control
measures for a successful TB control program
: Assigning responsibility for TB infection control.
Conducting TB risk assessment
Developing a written TB infection control plan
Early identification and management of patients with TB, including appropriate
institution of airborne precautions
Environmental control measures, such as the construction and maintenance of airborne
infection isolation rooms (AII; previously called negative pressure isolation rooms [NPIR])
Personal protection, including the use of appropriate respirators
Ensuring the timely availability of pertinent laboratory testing and reporting of results
An effective TB screening program for healthcare workers (HCWs)
HCW training and education regarding TB symptoms, transmission, and prevention
Using appropriate signage advising respiratory hygiene and cough etiquette
Ensuring proper cleaning and sterilization or disinfection of potentially contaminated
equipment (usually endoscopes)
Coordinating efforts with the local or state health department
TUBERCULOSIS OVERVIEW
Tuberculosis (TB) is a disease caused by the bacteria Mycobacterium tuberculosis. It
most commonly affects the lungs, although it can affect other parts of the body. Medications are
available to treat TB, although the medications must be taken every day for at least six months.
Worldwide, tuberculosis remains a leading cause of death. In the United States, TB is
now on the decline; the number of cases reported in 2007 is the lowest since the 1950s.
TB can be fatal if not recognized and treated. However, tuberculosis is preventable.
Identifying and treating those who are infected, but who have not yet developed active
tuberculosis, can prevent the spread of TB in the community.
HOW DOES TUBERCULOSIS OCCUR?
The tuberculosis bacteria are spread through the air from a person who is ill with active
tuberculosis. The bacteria are contained in small, airborne droplets created by coughing or
sneezing. Anyone who inhales these droplets is called a "contact". The contact person does not
usually develop active TB immediately. In some cases, the person's immune system is able to
remove the bacteria and he/she does not develop the infection. In other cases, the person
develops an immune response that controls the bacteria by "walling it off" inside the body. This
causes the bacteria to become dormant. The person does not develop active TB or become ill at
this time, but is said to have latent tuberculosis infection or LTBI. Up to one-third of the world's
population is infected with latent TB.
Latent TB — during this latent stage of tuberculosis, the person is well and cannot spread
the infection to others. If the person is treated at this stage, active TB can usually be prevented.
Treatment is recommended for individuals who are at increased risk for the development of
tuberculosis.
Active TB — Active tuberculosis may develop if latent infection is not fully treated. This
is called reactivation tuberculosis, and it occurs in 5 to 10 percent of people with latent infection.
Reactivation tuberculosis may occur if the individual's immune system becomes
weakened and is no longer able to contain the dormant bacteria. The bacteria then become active
and make the person sick with TB. The greatest risk for developing reactivation TB is within the
first two years following the initial infection. Reactivation can also occur in people with HIV,
diabetes mellitus, or those who take medications that weaken the immune system, such as
steroids or cancer chemotherapy. Reactivation may also occur for other, unknown reasons.
HOW IS LATENT TUBERCULOSIS DIAGNOSED?
Skin testing — The TB skin test (also called the purified protein derivative or PPD) is the
most commonly used test for diagnosing TB. In a person who is newly infected, the skin test
usually becomes positive within 4 to 10 weeks after exposure to a person with TB. (See
"Diagnosis of latent tuberculosis infection in adults".)TB skin tests are performed by injecting a
small amount of a solution just beneath the surface of the skin, usually on the forearm. The
solution contains an inactivated portion of the TB bacteria. Most individuals previously infected
with TB develop a skin reaction (a red or swollen bump) at this site.
Reasons for skin testing — Tuberculin skin tests are performed for a variety of reasons,
including:
If the person is a healthcare or laboratory worker who may have contact with patients
infected with tuberculosis.
If the person knows they were exposed to someone with active TB. If the first test is
negative, a second test will be performed 8 to 10 weeks later.
If the person requires a medication that may weaken the immune system, such as steroids
or some rheumatologic medications.
Interpreting the results — The skin test should be examined 48 to 72 hours after the
solution is injected under the skin. The skin is examined to determine if there is swelling (the
size of the bump). The area may also be reddened, but redness should not be measured.
A trained healthcare provider (not the patient or a family member) interprets the test as
positive or negative based on the size of the bump. Anyone who has a bump larger than 15 mm is
considered to have a positive test, and some people with a bump that is 5 or 10 mm are
considered to have a positive test.
What does a positive TB skin test mean? —
The TB skin test indicates that tuberculosis bacteria are in the body. It cannot determine
if a person has active or latent TB. Further testing is needed to determine if the person has active
or latent TB. People who have active TB usually have symptoms, such as a cough (usually
persisting for several weeks), fevers, night sweats, and/or unexplained weight loss.
Skin testing after a positive test in the past — Anyone who has had a positive reaction to
the TB skin test in the past will usually have a positive reaction in the future. Even after taking
medication to treat tuberculosis, the reaction to the skin test will remain positive. Therefore,
anyone who has a positive skin test should not have skin testing again. Repeat testing can rarely
cause a large and painful skin reaction at the injection site.
 BCG vaccine — A TB vaccine (called Bacillus Calmette-Guerin, or BCG) is given in
many countries to prevent infection with TB. It usually is given to infants, although it may be
given again at other times. Unfortunately this vaccine offers very little protection, if any, against
tuberculosis beyond early childhood. BCG is not used to prevent TB in the United States.
This vaccine may or may not cause a positive skin test. In the United States, a positive
reaction to a TB skin test is interpreted as positive, regardless of prior BCG vaccination.
Previous BCG vaccination should NOT stop a person from obtaining a TB skin test unless the
person had a positive reaction in the past.
Two-step skin testing — In some people, the first TB skin test is falsely negative because
the immune system's response to TB has weakened over time. This may occur in people who
were exposed to TB many years before. If the first skin test is negative, a second skin test may be
done one to two weeks later. Performing the first test may "boost" the immune system, allowing
it to react if the person was previously exposed to TB.
If the person has two negative tests, this is considered a true negative. If the second test is
positive, further testing will be done to determine if the person has active or latent TB.
Two-step testing establishes a baseline in people who will need skin testing at regular
intervals in the future (eg, healthcare workers, employees and residents of institutions such as
prisons or nursing homes).
Blood tests for TB — Blood tests are available in some areas to test for tuberculosis
infection. The blood test may be offered instead of or in addition to the skin test. Blood tests may
simplify TB testing because they do not require the person to make a return trip to read the test
reaction. In addition, blood test results are easier to interpret for those who have received the
BCG vaccine.
Further testing — if the TB test is read as positive, a healthcare provider will ask some
specific questions, perform a physical examination, and obtain a chest x-ray to determine if
person has active TB, either currently or in the past. In some cases, the person will be referred to
a TB specialist for this evaluation.
If these tests indicate that the person has active, rather than latent TB, the treatment
regimen is different than that of someone with latent TB.
TREATMENT OF LATENT TUBERCULOSIS
Latent tuberculosis (LTBI) is treated with a medication to kill the dormant bacteria.
Treating latent TB greatly reduces the risk of the infection progressing to active TB later in life.
(See "Treatment of latent tuberculosis infection in HIV-seronegative adults".) While undergoing
treatment for TB, it is important to avoid drinking alcohol and taking acetaminophen (Tylenol®).
Both of these substances can make the liver work harder, potentially increasing the risk of liver
injury.
Isoniazid — one of the most commonly used treatments for latent TB is isoniazid (INH).
Isoniazid is a pill that is taken once per day for 9 months. It is important to take the medicine
every day and to finish the entire course of treatment since missing days or discontinuing the
medicine early may not prevent active TB.
Rifampin — another treatment option is a medication called rifampin. Rifampin is taken
as two capsules every day for four months. Rifampin interacts with many other medications,
such as hormonal birth control methods (skin patch, pills, and vaginal ring), blood thinners,
certain medications for high blood pressure, and others. Therefore, it is important to discuss
possible drug interactions with a healthcare provider.
Monitoring during treatment — People who are being treated for TB should be monitored
by a healthcare provider at least once per month to monitor for any signs of medication toxicity,
such as liver injury. Signs of liver injury may include: unexplained tiredness, loss of appetite,
nausea, vomiting, dark-colored urine, jaundice (yellowing of the skin or the white portion of the
eye), fatigue, abdominal pain, or rarely, unexplained bruises. Anyone who experiences one or
more of these problems should stop their medication immediately and notify their healthcare
provider.
Monthly monitoring may also include blood tests to monitor the function of the liver or
blood counts.
ACTIVE TUBERCULOSIS
Active tuberculosis occurs when the TB bacteria become active and cause a person to
become ill. This usually occurs in the lung, although TB can affect any part of the body,
including the lymph nodes, brain, kidneys, or bones. (See "Treatment of tuberculosis in HIV-
seronegative patients".)
If there is evidence on a chest x-ray or other signs that active tuberculosis is present,
sputum cultures will be performed to culture (grow) the bacteria in the laboratory. This usually
involves coughing up a "deep" specimen of phlegm from the chest. The phlegm is then sent to a
laboratory and cultured to determine if TB bacteria are present. Other tests, such as a
bronchoscopy or biopsy, may also be needed. (See "Patient information: Fiberoptic
bronchoscopy".)
While waiting for the results of the sputum culture (it may take as long as two months for
the bacteria to grow in the laboratory), treatment with several (usually four) TB drugs is usually
recommended. It is important to use more than one medicine and to take the medicines exactly as
prescribed to reduce the risk of the bacteria becoming resistant to one (or more) of the medicines.
Infection caused by a strain of tuberculosis that has become resistant to standard TB
drugs is more difficult to treat, and may require four to six medications. (See "Clinical
manifestations, diagnosis, and treatment of extensively drug-resistant tuberculosis" and
"Diagnosis, treatment, and prevention of drug-resistant tuberculosis".)
TUBERCULOSIS AND PUBLIC HEALTH. Tuberculosis is a disease that can easily be
spread by anyone with active disease. As a result, United States law requires that anyone with
active tuberculosis must be reported to the health department. Health department staff will work
with the person's healthcare provider and the patient to make sure that a safe and effective
treatment regimen is completed. Directly observed therapy (DOT) is a program used by public
health departments to ensure that a patient takes his or her medication exactly as prescribed.
With this program, a health worker watches a person swallow the TB medication every day.
DOT may help to improve cure rates. (See "Adherence to tuberculosis treatment".) The health
department can also help to identify people who have been in contact with a person with active
tuberculosis. Contacts are advised to have TB testing and treatment, if necessary.Public health
programs for tuberculosis are essential for two reasons: To reduce the number of new cases of
tuberculosis (by identifying and treating people with LTBI) To limit spread of the disease in the
community (by monitoring and assuring safe, complete treatment of people with active TB).
Tuberculosis is almost always curable if patients are given sufficient uninterrupted therapy. (See
"Treatment of tuberculosis in HIV-seronegative patients".) Despite the treatability of this
infection, however, tuberculosis has proved impossible to eliminate, and the number of drug-
resistant cases has increased. Most experts acknowledge the central role of patient adherence in
these problems, and its importance in efforts to control the disease [1]. Ensuring the regular
intake of drugs to achieve a cure is as important as making the diagnosis of tuberculosis [2].
The consequences of inadequate and incomplete TB treatment are serious:
Prolonged illness and disability for the patient
Infectiousness of the patient causing continued transmission to the community
Development of drug-resistant tuberculosis
Possibility of death
In one study, for example, nonadherent patients took longer than adherent patients to convert to
negative culture results (254 versus 64 days), were more likely to acquire drug resistance
(relative risk 5.6), and required longer treatment regimens (560 versus 324 days) [3].
THE PROBLEM OF NONADHERENCE
Patient nonadherence has been identified as the most serious remaining problem in tuberculosis
control [4], and a major obstacle to the elimination of the disease [5]. In the midst of renewed
efforts at TB control in 1993, 17.5 percent of patients failed to complete therapy within a 12
month period nationwide [6]. In some areas, the rate of nonadherence was nearly 50 percent. As
an example, a study of 184 patients in New York City diagnosed with tuberculosis in April 1991
(before strengthening of the control program) found that 88 patients (48 percent) were
nonadherent to therapy [3]. The goal is to get this failure rate below 10 percent.

Pathophysiology of Tuberculosis Disease

Tuberculosis (TB), formerly called consumption, infects one-third of the world's population,
killing three million people a year. It has been a global health problem since ancient times;
3,000-year-old Egyptian mummies show signs of damage from TB.

Cause
TB is caused by members of the genus Mycobacterium, especially Mycobacterium
tuberculosis. Mycobacteria have waxy cell walls that are difficult to Gram stain, and these
protect the bacteria and help them live outside the host. Mycobacteria are highly resistant to
drying and can remain viable for six to eight months in dried sputum.

Infection
When the patient inhales a droplet of tuberculosis or particle of dried sputum, the
organisms are phagocytized (or "eaten") by the white blood cells of the immune system, but this
does not kill them. Inside the white blood cells, the living microbes slowly multiple until the
white blood cells burst.

In the Lungs
After bursting from the white blood cells, if the tuberculosis is in the lungs, an acute
inflammatory response follows, causing pneumonia-like symptoms. The bacteria form lesions in
the lungs, which solidify into nodules called tubercles. If the tubercles are near blood vessels,
they can perforate the vessels and cause hemorrhage, resulting in blood-tinged spit.

Other Locations
Disseminated tuberculosis, frequently seen in AIDS patients, can be anywhere in the
body, and the infected cells become like casts. The tubercles multiply in a cell, destroying the
organelles inside, and a clump of microbes in the shape of the former cell remains. Tuberculosis
can also infect the bones or the intestine through drinking unpasteurized milk, though intestinal
tuberculosis can more likely be caused by swallowing infected sputum.

Treatment
TB is treated with isoniazid and rifapin for at least a year. There is a vaccine called BCG
that is used in the developing world, but it has not been approved for use in the United States.

Chain of Infection for Tuberculosis

Tuberculosis is a disease caused by Mycobacterium tuberculosis. Although TB is thought
of as a lung disease, it can attack other parts of the body such as the spine, kidney and brain. Left
untreated, TB can be fatal. It is spread through droplets in the air when an infected person
coughs, sneezes or talks. Once considered eradicated, TB is making a comeback, with stronger
and more antibiotic-resistant strains. The chain of infection for TB has six links;

Etiologic Agent
The etiologic agent is any microorganism that causes infection. For TB, it's
Mycobacterium tuberculosis. The better its ability to grow, invades tissue, and cause disease, the
greater the possibility of the bacterium causing an infection.

Reservoir
The reservoir of infection might be human, animal or objects such as countertops and
doorknobs. This gives the microorganism a place to thrive and reproduce. The only reservoir for
TB is the human.

Portal of Exit
This is where the microorganism leaves the reservoir. TB's portal of exit is via the mouth
and nose. When someone with TB sneezes or coughs, they release large numbers of the TB
microbacterium.

Mode of Transmission
The mode of transportation is how the bacterium moves from one place to another. Many
bacterium are transported by unwashed hands that transmit the bacterium to other surfaces. With
TB, however, the mode of transmission is the cough or sneeze that releases TB bacterium into
the air. It can then be inhaled by another person in the room.

Portal of Entry
Many portals of entry exist for microorganisms, including breaks in the skin, mucus
membranes (the nose and mouth) and orifices in the body. TB's portal of entry is also its portal of
exit--the human respiratory system. Just as the TB bacterium can be expelled by sneezing, it can
be inhaled by the nose and mouth.

Susceptible Host
Microorganisms look for a host who can easily be invaded, such as someone who is
already sick or has a low immune system. An older person with HIV or AIDS will have a much
harder time surviving TB than a young, healthy 25-year-old.

TB Facts
 According to the World health Organization, one-third of the world is infected with the
TB bacterium. Most cases of TB in the world occur in Africa and Southeast Asia. Untreated,
each person with TB can infect 10 to 15 people each year. Treating TB is no fast and easy fix.
Many months of antibiotics such as Rifampin and other drugs is being needed. In hospitals, the
patient is placed on droplet precautions and all who enter the room must wear an approved TB
mask. It is vital to take the full course of antibiotics to prevent new, stronger strains of drug-
resistant TB to emerge

A model used to understand the infection process is the chain of infection, a circle of links, each
representing a component in the cycle. Each link must be present and in sequential order for an
infection to occur. The links are: infectious agent, reservoir, portal of exit from the reservoir,
mode of transmission, and portal of entry into a susceptible host.Understanding the
characteristics of each link provides the nurse with methods to support vulnerable patients and to
prevent the spread of infection. An awareness of this cycle also provides the nurse with
knowledge of methods of self-protection.

Clinical manifestations

Clinical manifestations are the observable symptoms by which a disease may be

diagnosed by a physician. It is how a disorder 'manifests' itself to an observer.

Breathing patterns:
• Increased respiratory rate.
• Using a FULL connected breathing pattern Transformational Breath (TB) brings
awareness and life-force into the entire body, clears mental tapes, integrates suppressed
feelings (imprints) stored in the subconscious, and enhances the connection to and
experience of Presence.
Interventions for Ineffective Breathing Pattern
Patients with tuberculosis may need to work harder to breathe due to coughing, nervousness
or a high fever. Ineffective breathing pattern involves breathing at a faster or slower rate, use of
accessory muscles to breathe and fast heart rates amongst other things. Nursing interventions for
this problem are as follows:
• Administer oxygen if ordered and as ordered by a physician.
• Give the TB patients fluids to loosen up secretions for easier expulsion from the lungs.
• Position the patient in a high fowler’s position to reduce the work needed to breathe.
• Encourage and provide rest periods so the tuberculosis patient can have energy to
breathe.
Arterial Blood Gases (ABG):
An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon
dioxide in the blood from an artery. This test is used to check how well your lungs are able to
move oxygen into the blood and remove carbon dioxide from the blood.
Arterial Blood Gas
Arterial blood gas levels can tell your doctor many things about your lungs. More
commonly referred to as ABG's, arterial blood gasses are normally obtained to see the oxygen,
carbon dioxide, pH, and bicarbonate level in the blood.
How is blood gas samples obtained?
Blood Gases are normally obtained from an artery because arterial blood will give your
doctor the best idea of how well your lungs are working. The blood sample is obtained in much
the same way that a standard blood sample is taken. The only difference is that most blood
samples are taken from a vein and this sample will come from an artery. The amount of
discomfort should be about the same as any blood sample that you have given in the past. This
blood is usually drawn from your wrist or the inside of your arm just opposite of your elbow but,
it may be drawn from other areas as well.

Difference between an Artery and a Vein

Arterial blood has come from the lungs and is on its way to give oxygen to your muscles
(or other tissues). Venous blood (blood from a vein) is on its way from the muscles and back to
the lungs to pick up more oxygen and get rid of dangerous carbon dioxide (CO2). Since it is
difficult to know how much oxygen has been used after your blood reaches your muscles, arterial
blood will give the doctor a much better impression about your lungs.

Radiology Findings:
• Translucent (dark) lung fields
• Depressed diaphragm
Other signs and symptoms:
TB is a disease caused by bacteria that are spread from person to person through the air.
TB disease usually occurs in the lungs, but it can also occur in other parts of the body, such as
the brain, the kidneys, or the spine.

Symptoms of TB disease depend on where in the body the TB bacteria are growing. TB
disease in the lungs may cause symptoms such as

• A bad cough that lasts 3 weeks or longer

• Pain in the chest
• Coughing up blood or sputum (phlegm from deep inside the lungs) Cough is the most
frequent symptom referable to the site of lung infection
• Fatigue- is a state of awareness describing a range of afflictions, usually associated with
physical and/or mental weakness
• Anorexia- an eating disorder of excessive weight loss and usually undue concern about body
shape
• low grade fever- haracterized by an elevation of temperature above the normal range
• Night sweats- A night sweat caused by a medical condition or infection can be described as
‘severe hot flashes occurring at night that can drench sleepwear and sheets, which are not
related to an overheated environment’.
• Weight loss
• No appetite
Clinical signs and symptoms of pulmonary TB in an infected adult are often nonspecific;
complete absence of symptoms occurs in approximately 5% of active adult case. Systemic
manifestations include low-grade fever, anorexia, fatigue, night sweats, and weight loss that may
persist for weeks to months. Erythema nodosum may occur with the acute onset of TB and
typically manifests at the time of development of specific immunity. The most common
hematologic manifestations associated with TB are raised peripheral blood leukocyte count and
anemia, each of which occurs in approximately 10% of patients. Hyponatremia, caused by
production of an antidiuretic hormonelike substance within affected lung tissue, may occur in up
to 11% of patients.

You should get tested for TB if:

• You have spent time with a person known to have TB disease or suspected to have TB
disease; or
• You have HIV infection or another condition that puts you at high risk for developing TB
disease; or
• You think you might have TB disease; or
 • You are from a country where TB disease is common (most countries in Latin America
and the Caribbean, Africa, Asia, Eastern Europe, and Russia); or
• You live in a place where TB disease is more common such as a homeless shelter, migrant
farm camp, prison or jail, and some nursing homes); or
• You inject illegal drugs

If you think you may have been exposed to a person with TB disease, contact your health care
provider or your state or local TB control office.

MEDICAL MANAGEMENT
Pyrazinamide is a drug used to treat tuberculosis. The drug is largely bacteriostatic, but can be
bacteriocidal on actively replicating tuberculosis bacteria.

DOSAGE :
20–25 mg/kg daily, or
50–70 mg/kg three times a week.
*The British Thoracic Society guidelines are for 1.5 g daily for patients weighing less than
50 kg, and 2 g daily for patients weighing 50 kg or more.

PHARMACOKINETICS :
- Pyrazinamide is well absorbed orally. It crosses inflamed meninges and is an essential part of
the treatment of tuberculous meningitis. It is metabolised by the liver and the metabolic products
are excreted by the kidneys.
MEDICAL USE :
-Pyrazinamide is used in the first two months of treatment to reduce the duration of treatment
required.
MECHANISM OF ACTION :
-Pyrazinamide is a prodrug that stops the growth of Mycobacterium tuberculosis
MOST COMMON:
joint pains
MOST DANGEROUS:
hepatotoxicity,

Isoniazid-is the first-line antituberculosis medication in prevention and treatment.

ADULTS
-5 mg/kg/day (max 300 mg daily).
CHILDREN
-8 to 12 mg/kg/day
SIDE EFFECTS :
rash,
abnormal liver function
hepatitis
*Headache, poor concentration, weight-gain, poor memory, and depression have all been
associated with isoniazid use. All patients and healthcare workers should be aware of these
serious adverse effects, especially if suicidal thinking or behavior are suspected
Streptomycin-is an antibiotic drug,and was the first antibiotic remedy for tuberculosis.
USES :
in combination with other anti-TB drugs. It is not the first line treatment, except in medically
under-served populations where the cost of more expensive treatments are prohibitive.

Ethambutol-prescribed to treat tuberculosis. It is usually given in combination with other

tuberculosis drugs.
*It is sold under the trade names Myambutol and Servambutol.
PHARMACOKINETICS :
- It is well absorbed from the gastrointestinal tract and well distributed in body tissues and fluids,
50% is excreted unchanged in urine.
SIDE EFFECTS :
Optic neuritis. Hence contraindicated in children below 6 yrs of age.
Red-green color blindness
Peripheral neuropathy
Arthralgia
Hyperuricaemia
vertical nystagmus
milk skin reaction

TIPS ON HOW TO PREVENT TB

Here are some effective ways of how to prevent tuberculosis and preventing the spread of the
disease.
 It is extremely important to isolate patients suffering from tuberculosis and treat them
effectively until the chances of them spreading the disease become negligible.
 At healthcare facilities, hospitals, and other treatment centers, certain standard ventilation
and air purification / filtration mechanisms are followed in an attempt to curb tuberculosis from
spreading further.
 Family and friends who were in close contact with patients diagnosed with tuberculosis are
recommended to exercise additional caution. Conventional medicine may advise the use of
antibiotics as a preventive measure toward how to prevent tuberculosis. We do not, but such
persons should work towards keeping their immune systems strong; they could also use herbal
antibiotics, such as garlic.
 In an attempt to minimize the risk of spreading tuberculosis and getting infected by the same,
one must meet and interact with tuberculosis patients only after at least two weeks of treatment.
 Nurses, physicians, other healthcare staff, family, and friends of patients might be advised to
wear a microfiltration mask while interacting with patients suffering from tuberculosis mainly to
protect themselves from catching the infection.
 People suffering from persistent cough should try and avoid close interaction with people
until they have been tested for TB, and others might want to maintain a safe distance from people
with persistent coughs because there is a possibility of catching the infection.
 Advise people who have a persistent cough to eat well and get exposure to morning sunlight.
If the cough continues beyond three weeks and shows no signs of decreasing; it is best to consult
a physician.
 When in contact with patients suffering from tuberculosis or people with persistent coughs, it
is advisable to wash your hands periodically with a disinfectant and warm water.
 While traveling to countries where tuberculosis is not completely eradicated, conventional
medicine might advise one to get vaccinated. We in natural health and healing do not support
vaccinations. Instead, we advocate keeping the body and its immune system well and strong. We
also use herbal antibiotics, such as garlic. Do not underestimate garlic and other herbs – they are
potent!
 Above all, as mentioned already a few times, it is best to concentrate on building immunity,
staying healthy, eating well, and exercising regularly to prevent getting infected by tuberculosis
or any other disease condition.

Program under doh and who

National TB Control Program
The rising incidence of tuberculosis has economic repercussions not only for the
patient’s family but also for the country. Eighty percent of people afflicted with tuberculosis are
in the most economically productive years of their lives, and the disease sends many self-
sustaining families into poverty. The rise in the incidence of tuberculosis has been due to the low
priority accorded to anti-tuberculosis activities by many countries. The unavailability of anti-TB
drugs, insufficient laboratory networking, poor health infrastructures, including a lack of
trained health personnel, have also contributed to the rise in the incidence of the diseases.
According to the World Health Organization, the Philippines rank fourth in the world for
the number of cases of tuberculosis and have the highest number of cases per head in Southeast
Asia. Almost two thirds of Filipinos have tuberculosis, and up to five million people are
infected yearly in our country. In 1996, WHO introduced the Directly Observed Treatment Short
Course (DOTS) to ensure completion of treatment? The DOTS strategy depends on five
elements for its success: Microscope, Medicines, Monitoring, Directly Observed Treatment, and
Political Commitment). If any of these elements are missing, our ability to consistently cure TB
patients slips through our fingers.

TB Network
What is TB Network?
1. It is the official communication handle of the National Tuberculosis Control Program or NTP
That will stand for DOH’s re-energized fight against TB.
2. It is a product of DOH’s collaboration with the LGUs, Phil CAT, and Phil health.
3. It is a “special group” dedicated to help/ take care of TB symptomatic and TB patients.
a. Initially, it comprises regular health workers in the RHUs, MHOs and PHOs. b. Eventually, it
Will include everyone in the community who wish to help in the administration and financing of
D.O.T.S.; family and relatives of TB symptomatic / patients, church, church organizations,
Civic organizations, NGOs, schools, companies/corporations.
1. TB Network comes with several information materials, such as print ads, radio and TV
Commercials. Poster of this TB Network as endorsed by Secretary Dayrit himself and with its
Battle cry “Kakampi Laban sa TB” will also be distributed as soon as ready.
2. It is participated in by the different stakeholders like donor agencies, private sector,
nongovernment organizations, academe, professional societies, pharmaceutical companies and
Other TB DOTS partners and individual advocates united as one for a common cause.
3. Members of TB Network have also expanded to a huge number of other government agencies
as also members of the Comprehensive & Unified Policy for TB Control in the Philippines or
C.U.P.
4. DOH in cooperation with all the involved agencies as members of TB Network continuously
Works hand-in-hand in increasing case detection and cure rates in accordance with the NTP
Targets every year.
5. In the end, it can blossom into a systematic, well-oiled, nationwide movement for the
Eventual complete eradication and/or control of TB-spearheaded by DOH.
Despite the limitation of resources, the tuberculosis research program has progressed to the
attainment of its objectives by the initiation of projects that could help understand, control and
prevent multi-drug resistant tuberculosis. The program also aims to improve the diagnosis of
pulmonary and extra pulmonary tuberculosis. Dr. Jaime Montoya originally led the program.
The following were the research activities that have been initiated: 1) a community-based study
on the prevalence and transmission patterns of multi-drug resistant tuberculosis in an urban and
rural setting in the province of Laguna; 2) a study of Mycobacterium vaccaeas an
immunotherapeutic agent in the management of pulmonary tuberculosis; 3) a study on the
clinical, microbiologic, radiologic and pathologic features of drug-susceptible and resistant M.
tuberculosis and mycobacteria other than tuberculosis in patients with HIV infection; 4) the
detection of a novel family of tuberculosis isolates in the Philippines; and, 5) a study on the
diagnosis of Mycobacterium tuberculosis in cerebro-spinal fluid of smear-negative
tuberculous meningitis using polymerase chain reaction with nested amplification
With the reorganization of the Department of Health, the TB control program was further
strengthened with the initial formal agreements between the Governments of the Philippines and
Japan to setup the National TB Reference Laboratory at RITM. A number of staff members
from the national control program and other offices of the central Department of Health were
deployed to RITM and became part of RITM staff. Underway is the final agreement and
subsequent preparation of RITM grounds for the construction of the National TB Reference
Laboratory.
What is the National TB Program of the Government?
The National TB Program (NTP) is the Government's commitment to address the TB problem in
the country. The NTP is being implemented nationwide in all government health centers and
government hospitals. Its objectives are to detect active TB cases (at least 70%) and cure them
(at least 85%). Achieving and sustaining targets will eventually result to the decline of the TB
problem in the Philippines.
NATIONAL TUBERCULOSIS CONTROL PROGRAM
Agency Department of Health-Center for Health Development Western Visayas
Project Title: National Tuberculosis Control Program
Description of DOTS stands for Directly Observed Treatment Short-Course or in Tagalog
Approach: “Tutok Gamutan“. It is a comprehensive strategy endorsed by the World Health
Organization (WHO) and International Union Against Tuberculosis and Lung
Diseases to detect and cure TB patients. DOTS is aimed to ensure treatment
compliance by assigning a responsible person to observe or watch the patient
take correct medications daily during the whole course of treatment. DOTS cures
TB, with up to 95 percent cure rate, even in the poorest countries
The National Tuberculosis Control Program (NTP) adopted the Public-Private
Mix DOTS (PPMD) strategy, designed to increase case detection and to
synchronize management of TB among TB care providers. The NTP endorses the
PPMD strategy to foster harmony and complementation of TB services among
public and private sectors in the country, thereby improving the quality of DOTS
implementation.
TB Diagnostic Committees (TBDC) were established in order to evaluate cases
of TB symptomatics who are smear negative, but whose x-rays show lesions
suggestive of TB. This will reduce the level of over-diagnosis and over-treatment
among smear negative cases and ensure that active cases of smear negative are
detected and provided with the appropriate anti-TB treatment. Drug wastage is
likewise prevented.
Certification and accreditation of DOTS Centers, public and private facilities
alike, ensured high quality DOTS implementation and for the availment of Out-
Patient TB-DOTS package of the Philippine Health Insurance Corporation
(PHIC). PHIC-certified DOTS centers are greatly helped financial access
to quality health care services and to eradicate the health and economic burden of
tuberculosis among Filipinos.
Situation Prior Prior to DOTS in 1996, Western Visayas was second highest in
to TB cases nationwide. As such, it qualified the region to be a
Intervention: DOTS pilot area. The NTP has been implemented since 1978 but
there was no reduction in number of cases. In 1987, the Short
CourseChemotherapy was implemented but still there was no
marked improvement in the TB control program. The condition
worsened for Multi Drug Resistance TB cases developed due to
incomplete treatment. Private physicians aggravated the situation
as they did not have good follow-up of their patients and they just
give prescriptions resulting in poor compliance. TB case
managementwas then ineffective and inefficient, resulting in
waste of government’s very limited resources.

survillance
Comparison of tuberculosis surveillance systems in low-incidence industrialised
countries
Abstract
The comparative analysis of National Tuberculosis Control Programmes (NTPs) in
industrialised, low-tuberculosis-incidence countries is limited. Analysis of applied methods,
function and accumulated experience contributes to improving global tuberculosis control.
 A questionnaire addressing NTP surveillance infrastructure and characteristics was
completed in 19 industrialised countries, with populations of >3 million and annual notified
tuberculosis incidence rates of <16 cases per 100,000 population (2003 data).
All European countries surveyed adopted World Health Organization Collaborating
Centre for the Surveillance of Tuberculosis in Europe (EuroTB) definitions. Surveillance
information, which usually includes names, was transferred electronically to the national level in
17 out of the 19 countries. Surveillance systems capture process and social determinants. Case
notification to the central level occurred within a median period of 7 days, independent of
mandatory notification requirements. The mean completeness of tuberculosis case-reporting was
estimated to be 93.5% (range 65–100%). Integration between HIV and tuberculosis registries
was performed in two countries, and, in seven others, both databases were cross-matched
periodically.
National Tuberculosis Control Programme function in industrialised low-incidence
countries utilises well-established infrastructure and relies upon centralised operations.
Approaches are consistent with current World Health Organization surveillance
recommendations. The present study lays collaborative groundwork for additional multinational
analyses for the enhancement of global tuberculosis surveillance, which may assist policy-
makers in countries moving from medium to low rates of incidence.
Tuberculosis (TB) control in industrialised countries varies substantially in its
organisation, function and history. Consequently, it may be challenging to point to a set of
discrete institutional components and label them the National Tuberculosis Control Programmes
(NTPs). Each country has established NTP function, composed of an amalgamated network of
organised public and private efforts, which has evolved in association with societal and
economic trends in industrialised countries with what is now a low incidence of TB.
Surveillance performance, which provides notice of epidemiologically significant
changes, is one of the fundamental public health activities necessary for the control and
elimination of TB 1. Since the 1950s, many countries have increasingly introduced organised
surveillance activities at a national level. More recently, the World Health Organization (WHO)
began comprehensive worldwide annual reporting of traditional TB surveillance data, as well as
elements of programme management, which also include treatment outcomes and drug
supply 2, 3.
Although surveillance performance in industrialised countries has developed independent
of supranational guidance, most are consistent with the current WHO recommendations 3. The
definitions used for surveillance have also been endorsed by the International Union Against
Tuberculosis and Lung Disease 4. Since the 1990s, substantial efforts have been invested at the
international level in developing recommendations and guidance for specialised areas in
countries with high TB rates and technical matters related to policy development, including
transition issues in countries shifting from low to middle income or from high to medium rates of
incidence 5–11.
TB incidence in most industrialised countries is low (defined by the WHO as <20 cases
per 100,000 population 12, 13). In addition to their developed economies and smaller
populations, industrialised countries tend to have a highly functioning NTP in the setting of
lower endemicity of TB. This occurs, in part, due to a combination of robust societal support of
the NTP-associated agencies, consistent application of technologies and long-lasting control
efforts. The essential elements of TB control in developed and low-incidence countries were
addressed in Wolfheze Workshops 12 and published in the frameworks for TB control in
Europe 13, 14.
The WHO annual global reports are a useful source for comparing countries’ burden of
disease and the accomplishments of the various NTPs 3. However, this information does not
fully address the existing variation between the different programmes, nor does it readily permit
robust comparison between important components of NTPs. Thus a more detailed description
and analysis of surveillance systems from industrialised countries should provide better
understanding of operational standards and methods, based on decades of experience gained.
Lessons learned could be used to contribute to the development of guidelines for both developing
countries and countries undergoing transitions in TB incidence and economic status.
The present first descriptive study compares surveillance system function across
industrialised countries with low TB incidence and lays the collaborative groundwork for
advanced and additional analyses.

METHODS
Countries were chosen for the present study on the basis of: 1) high income, 2) low TB
incidence, and 3) population of >3 million (to exclude city states and micronations). A high-
income country was defined as having a gross national income of >US$10,726 per capita, as
defined by the World Bank 15. Low incidence was defined, for the purpose of the present study,
as a mean of <16 new cases per 100,000 population annually during the period 2000–2003 16.
This is a slightly lower threshold than the WHO standard of 20 new cases per 100,000
population, and includes those countries with a similar pattern of epidemiology,e.g. high
incidence among foreign-born population. United Nations 2005 data were used for the total
population size in each country 17.
NTP managers (n=    21) from the 19 eligible countries were contacted by electronic mail
and asked to participate by completing a survey containing 48 questions in March 2006. The
questionnaire focused on the notification process and the capacity of the surveillance system,
such as reporting regulations, features of the data collection systems, time required for
notification, periodic data analysis, process determinants (e.g. follow-up sputum culture results
and records of adverse events due to treatment) and whether the system captured social
determinants (e.g. country of origin, immigration date and status, homelessness, incarceration,
marital status and occupation) 18. Participants were asked whether incentives were provided to
the reporting professionals (e.g. monetary value or access to the data) or whether penalties were
instituted (e.g. civil litigation or reprimands by the medical regulatory authority). Parametric
values were compared using the two-tailed Pearson’s correlation test and continuous values were
compared using a two-tailed unpaired t-test.
Previous SectionNext Section
RESULTS
Completed questionnaires were received from all 19 countries between June and August
2006. All of the countries, except for Australia, Canada, New Zealand and the USA, form part of
the European region of the WHO.
All 15 of the 15 European countries surveyed had adopted the WHO collaborating Centre
for the Surveillance of Tuberculosis in Europe (EuroTB) case-reporting definitions and outcome
categories (table 1⇓) 19, which include a minimum set of variables required for notification,
links between physician and laboratory notification systems, and unified outcome measures,
promulgated in 2002 13. Data were submitted electronically in most of the 19 countries (n=    17;
89%) and sent to the national level in 16 (84%) countries. Patients’ data (name, address and
identification number, when available) were reported in 10 (53%) countries. France and Norway
were the only two countries with mandatory national reporting of latent TB infection, although
reporting was mandatory in Norway only if preventive treatment was started. TB suspects were
also reported in 14 (74%) countries; five countries reported suspects only as high as the local
level, and nine countries reported to the national level. At the national level, 10 (50%) countries
captured process determinants and 12 (63%) included social determinants.
DISCUSSION
NTP surveillance function in the low-incidence industrialized countries surveyed is well
established at both the national and subnational level, and is similar in aspects of reporting
indicators. The flow of data moves in a prompt manner, even in those countries in which no time
requirements are specified, no penalties are imposed and no incentives are provided. The data
and information structure of the national registries in each country are consistent with WHO
recommendations.
Data are transmitted electronically in most industrialized countries examined, and, in the
others, systems are being upgraded to include electronic transmission, away from letters and
faxes. As industrialized low-incidence countries continually increase and refine their use of
information technology, data and information transfer among countries could be enhanced. This,
for example, might help improve international coordination of immigrant health screening.
Moreover, this surveillance enhancement could serve as a model for global surveillance system
integration, monitoring additional communicable and emerging infections.
As the trend of global migration of people from countries with a high to those with a low
incidence of TB increases 23, interest in international comparison of social characteristics may
increase and benefit from a more standardized approach 24. These particular data are used in
case management and programmed planning, including identification of high-risk groups, which
underscore the continued association between morbidity and the social determinants of TB in
industrialized countries 25. A significant proportion of TB cases in industrialized countries are
foreign-born individuals 24, 26.
NTP programmed structure differs. For example, some countries use codes assigned to
TB cases rather than personal identifiers for reporting, as required by law to protect
confidentiality. Personal identifiers may facilitate internal reliability, whereas coding may
promote notification since patients are ensured of their privacy protection. The ability to protect
patients’ rights and ensure data integrity is a delicate balance that countries are careful to
maintain.
Minor differences exist in outcome definitions of TB and in reporting time among
countries outside of the European region of the WHO, which may limit comparison of these
determinants among different NTPs 27. In order to perform more accurate global comparisons,
industrialized countries should consider further refinements and harmonization of these
definitions 28.
Nurses facilitate the reporting of TB cases in many of the countries, although only
physicians and laboratories are obliged by law to notify to the national level. As nurses are
increasingly becoming the backbone of human resources in public health systems, along with the
increasing accreditation in their profession, further evaluation should be performed to assess
whether formal transfer of some surveillance tasks from physicians to nurses could enhance
reporting efficiency, completeness and quality.
Most TB control measures are performed at the provincial or regional level. Based on
unsolicited comments from some countries, such as Australia, Belgium, Canada, Switzerland and
the UK, significant intra-national differences were found among internal regions (e.g. states,
cantons and provinces). These differences reflect greater autonomy or political constraints below
the national level, which may limit standardization of TB control. In order to increase the quality
of data collection, collaborative efforts made by local professionals in internally diverse
countries could increase internal reporting.
HIV infection status is an integral component of TB surveillance systems in only a few
countries, an unexpected finding given the inextricable link between the two infections and, in
many European countries, their association with immigration24, 29. Instead, HIV is captured in a
separate registry, to which TB data are cross-matched in some countries. The reasons for separate
registries may be to better protect confidentiality, minimize technical obstacles in integration,
and ameliorate political and financial challenges. Additional studies should be preformed to
assess whether HIV testing for each TB patient, strengthening TB/HIV monitoring 5 and
merging the two databases for routine analysis improve the effectiveness of surveillance and
patient care in industrialized countries. Surveys and special studies might be used in countries in
which the merging of TB and HIV databases cannot be carried out for confidentiality reasons, or
in which culture and drug susceptibility testing data are not collected for all individuals, to
monitor the incidence and trends of multidrug- or extensively drug-resistant strains.
 Finally, although incorporation of latent TB infection cases into the central registry and
preventive treatment outcome indicators may further support the national TB registry, especially
in countries which are close to TB elimination in their native-born population 13, no consensus
was evident among the countries surveyed regarding the applicability and sustainability of their
inclusion; further studies are needed in this area.
The specific NTP infrastructure of each country has a direct impact upon TB detection
rates, treatment outcome and control 14. Several factors may be operative. First, each currently
industrialized country established it’s programmed according to its own distinctive
epidemiology, health infrastructure, political commitment, social norms, geographic structure
and resources available. In most industrialized countries examined, NTP function was
established independently, and when TB rates and economic status were different. Secondly,
since TB epidemiology in industrialized countries is sensitive to immigration, different
adjunctive components (including surveillance) were added to control programmers in some
countries to address evolving local immigration patterns and to meet domestic naturalization
regulations. Finally, the unique organization and funding of health systems in each country
reflect individual development. Collectively, these factors underlying different NTP
infrastructure make the development of cohesive international guidelines that are applicable to
emerging industrialized countries challenging 30.
Effective linkage between laboratories and public health authorities, especially electronic,
is helpful for ensuring completeness of reporting and increasing the validity of the national
registry 22. Laboratories that confirm TB cases have been considered the most complete source
of data 20, 31. It was therefore expected that greater completeness of reporting would be found
among countries in which reporting by the laboratory was required; however, this could not be
demonstrated as it applied to only two countries in the present study. Moreover, there may be
under-reporting among non-laboratory-confirmed cases, where the diagnosis is based on clinical
findings alone.
Global TB figures are reported annually by the WHO and compare incidence across
countries. It would be worthwhile to evaluate whether harmonized approaches to programmed
evaluation might further encourage periodic inter-country evaluation of the completeness and
validity of TB surveillance. Validation of surveillance data is often costly and labor intensive 22,
yet is the basis for estimating case detection rates 25, 32. Although intuitively true, there is no
evidence that decentralization of TB surveillance system operations and function strengthens
overall information quality.
The present survey results may further assist countries with a higher TB incidence in
improving their surveillance systems. For example, the present authors believe that the use of a
reliable nationwide electronically connected system that includes the national level should also
be established between TB laboratories and the national HIV/AIDS registry. Moreover, reporting
should include clinical, diagnostic and social determinants of the patients and be registered at the
national level. Greater autonomy of mid-level health departments may improve the verification
of cases and the completion of missing information prior to transmission to the national level.
Importantly, nurses should participate in data reporting, since they have the clinical experience
and administrative skill to perform these tasks. Finally, evaluation of the completeness of the TB
database and time required for cases to be reported should be performed periodically. In the
present study, no significant association was found between incentives or penalties for the
reporter and estimated completeness, and the present authors believe that it is the NTP manager’s
responsibility to persuade local professionals of the importance of notification, in part to
decrease reporting bias.
The present study is subject to several limitations. First, it is cross-sectional and does not
dissect the development of the various systems over time. Secondly, it excludes industrialised
countries not meeting the present case definition, potentially missing extensive experience
gained in TB control among other less-populated industrialised countries. Thirdly, the present
survey was not designed to incorporate any measure of effectiveness, and thus it is not possible
to prioritise or suggest how a difference in one system might affect another if applied. Finally,
the present study, in its focus on surveillance systems, may miss other effects of NTP function
and organisation that affect surveillance, such as changes in the quality of human resources and
adherence to treatment over time. In order to obtain a deeper perspective of the effects of the
structure of different NTPs, additional detailed comparisons should be performed, evaluating
financial incentives, treatment funding, relationships between public and private providers, and
additional structure indicators, such as qualification and training of personnel, and number and
location of treatment sites.
CONCLUSION
National Tuberculosis Control Programme surveillance function in low-incidence high-
income countries is well established, centrally operated and consistent with World Health
Organization (including World Health Organization Collaborating Centre for the Surveillance of
Tuberculosis in Europe) and International Union Against Tuberculosis and Lung Disease
recommendations for reporting and data dissemination. Improved global harmonisation in
outcome determinants and Internet-based electronic contact among various industrialised
countries may enhance global tuberculosis control. Analysis of surveillance data and function
may assist medium-incidence countries moving from medium to low rates of incidence and from
vertically to horizontally organised healthcare systems. Nevertheless, detailed studies should be
performed to compare the structure, process and effectiveness of different National Tuberculosis
Control Programme systems in order to identify the fundamental attributes of an optimal system.