TUBERCULOSIS

BY
DR. AREEJ M. NOAMAN
4TH CLASS
► TB is a major cause of morbidity and mortality all over the world but the
greatest burden is borne by developing countries. TB is caused mainly by
the bacterium Mycobacterium tuberculosis (M. tuberculosis).

► TB is a chronic infection. The great majority of infections are caused by

M. tuberculosis. TB can also be caused by M. bovis, which is acquired by
drinking unpasteurised milk from infected cows.

► TB is an ancient disease which remains a worldwide problem.

► A total of 1.3 million people died from TB in 2022 (including 167 000
people with HIV). Worldwide, TB is the second leading infectious killer
after COVID-19 (above HIV and AIDS).

► In 2022, an estimated 10.6 million people fell ill with tuberculosis (TB)
worldwide, including 5.8 million men, 3.5 million women and 1.3 million
children. TB is present in all countries and age groups. TB is curable and
preventable. WHO
► About 95% of the world’s cases of TB occur in the developing countries
of South East Asia, Sub-Saharan Africa and the Western Pacific. The
largest number of cases occur in South East Asia and this region accounts
for 33% of incident cases globally. The highest mortality from TB also
occurs in this region. It is estimated that 1-2% of the Indian population are
infected with tubercle bacilli.
► Multidrug-resistant TB (MDR-TB) remains a public health crisis and a
health security threat. Only about 2 in 5 people with drug resistant TB
accessed treatment in 2022.

► Global efforts to combat TB have saved an estimated 75 million lives

since the year 2000.
► Transmission
When people with active pulmonary TB cough, sneeze, speak, sing, or spit,
they expel infectious aerosol droplets 0.5 to 5.0 µm in diameter. A single
sneeze can release up to 40,000 droplets. Each one of these droplets may
transmit the disease, since the infectious dose of tuberculosis is very small
TB bacteria spread through the air from one person to another.
 Symptoms

► Primary TB infection. The first stage is called the primary infection. Immune system
cells find the germs. The immune system may completely destroy the germs. But
some germs may still survive and multiply.
► Most people don't have symptoms during a primary infection. Some people may get
flu-like symptoms, such as:

► Low fever.
► Tiredness.
► Cough.
They will also have a positive Mantoux test
► Latent TB infection. Primary infection is usually followed by the stage called latent
TB infection. Immune system cells build a wall around lung tissue with TB germs. The
germs can't do any more harm if the immune system keeps them under control. But the
germs survive. There are no symptoms during latent TB infection.

► Active TB disease. Active TB disease happens when the immune system can't control
an infection. Germs cause disease throughout the lungs or other parts of the body.
Active TB disease may happen right after primary infection. But it usually happens
after months or years of latent TB infection.
► Symptoms of TB can be divided into general symptoms and those specific to the organ
infected
► The lung is the predominant organ affected, being involved in over 75% of
cases.
► Commonly affected organs following haematogenous spread from the
lung are the abdomen, lymph nodes, spine, meninges, kidneys, bone and
reproductive organs.

► Pulmonary TB (PTB): The apical region is the most commonly affected in

adults. Pulmonary lesions may involve any part of the lung in infancy and
childhood.
► TB infection can spread from the lungs to other parts of the body. This is called
extrapulmonary tuberculosis. Symptoms vary depending on what part of the body is
infected.

► Fever.
► Chills.
► Night sweats.
► Weight loss.
► Anorexia
► Tiredness.
 Diagnosis

It is important to note that specific symptoms and signs may be absent…

► history of chronic cough with the general symptoms of fever, malaise and
weight loss
► clinical signs
► CXR
► Sputum examination
Useful in adults with productive cough
- Sputum microscopy: Smear stained with the Ziehl-Nielsen stain to demonstrate the
presence of the acid and alcohol fast bacilli (AFB).
-Sputum culture: Takes about 6-8 weeks and so is of limited use in clinical diagnosis.
► Gastric washings examined for AFB: Carried out in children as they swallow rather
than cough-up sputum.
► Other investigations
Are indicated depending on the organs/ systems affected by the disease
 Treatment

► Administration of a single antibiotic in the treatment of TB has been

shown to lead to the development of mycobacteria resistant to that drug
Combination chemotherapy is the treatment of choice.
► DOTS means Directly Observed Therapy Short Course.
► It involves the administration of a combination of antituberculous drugs to
a TB patient under the supervision of a healthcare personnel. DOTS helps
to ensure compliance, reduce transmission by shortening the period of
infectivity, improve the cure rate and reduce the risk of drug resistance.
There are many regimens for treating TB, but commonly used drugs include:
► Intramuscular streptomycin
► Oral rifampicin
► Oral isoniazid (INH)
► Oral pyrazinamide
► Oral ethambutol may be substituted for IM streptomycin in patients that are above the
age of 6 years
► Treatment lasts for 6 months (but IM streptomycin / oral ethambutol and oral
pyrazinamide are usually given during the first 60 days of treatment only.
 Prevention and Control

► WHO also promotes preventive action through early screening and treatment for
active TB.
► TB Control Strategies include
► Case finding: aims to identify TB cases promptly and treat them with effective drugs.
► Contact tracing: Close contacts of TB cases are screened for evidence of infection.
Mantoux positive cases are treated with oral isoniazid for 6-9 months to prevent them
from developing the disease.
► BCG vaccination: Although the efficacy of BCG vaccination in protecting against
TB is controversial, it is generally accepted that BCG is more effective in preventing
disseminated disease and death
 BCG Vaccine

► Children. BCG vaccination should only be considered for children who have a
negative tuberculin skin test and who are continually exposed, and cannot be separated
from, adults who:
1. Are untreated or ineffectively treated for TB disease (if the child cannot be given
long-term treatment for infection); or
2. Have TB caused by strains resistant to isoniazid and rifampcin.
► Health Care Workers. BCG vaccination of health care workers should be considered
on an individual basis in settings in which a high percentage of TB patients are infected
with M. tuberculosis strains resistant to both isoniazid and rifampcin;
 Contraindications

► Immunosuppression.
BCG vaccination should not be given to persons who are immunosuppressed (e.g.,
persons who are HIV infected) or who are likely to become immunocompromised (e.g.,
persons who are candidates for organ transplant).

Pregnancy.
BCG vaccination should not be given during pregnancy. Even though no harmful effects
of BCG vaccination on the fetus have been observed, further studies are needed to prove
its safety.
► Iraq is one of the countries in WHO Eastern Mediterranean Region (WHO-EMRO)
with the highest tuberculosis (TB) burden. The estimated incidence of TB is about 130
new cases / 100.000 population / year [WHO / MOH 2003], with about 30.000 new
cases per year among which 12600 new smear positive pulmonary Tuberculosis (PTB).

► Control of TB is a top priority for Iraqi Ministry of Health (MOH) and a most
challenging task. the Directed Observed Therapy – Short Course (DOTS) has been
adopted in