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Overview of Tuberculosis
Michigan Department of Community Health American Lung Association of Michigan

History of M. tuberculosis
Phthisis (Greek) known since ancient times Often thought of as a hereditary condition 1854 first sanatorium 1882 Koch demonstrated relationship between germ and disease 1895 Roentgen discovery of diagnostic x-ray 1940s-1950s chemotherapy

Around the World

An estimated 1.58 million deaths occurred in 2005 from TB disease 8.8 million new TB cases estimated for 2005 1/3 of world population has TB infection

Estimated TB incidence rate, 2005

Estimated new TB cases (all forms) per 100 000 population

No estimate 0-24 25-49 50-99 100-299 300 or more

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved

High Burden Countries (WHO)

Afghanistan Bangladesh Brazil Cambodia China Democratic Republic of the Congo Ethiopia India Indonesia Kenya Mozambique Myanmar Nigeria Pakistan Philippines Russian Federation South Africa Thailand Uganda United Republic of Tanzania Viet Nam Zimbabwe

No. of Cases

Tuberculosis Cases Michigan, 1955 - 2005

7000 6000 TB Cases 5000 4000 3000 2000 1000 0 55 60 65 70 75 80 85 90 95 00 Year Reported 03 04 05

Reported TB Cases and Rates, Michigan, 2002 - 2006

2002 2003 2004 2005 2006
3.2/100,000 2.4/100,000 2.7/100,000 2.5/100,000 2.2/100,000 population population population population population

315

243

272

246

221

TB Cases by National Origin Michigan, 1997 2006

350 300 # of TB Cases 250 200 150
96 107 299 287 242 196 210 194 142 120 91 120 101 164 147 129 99 92

US Foreign

109

100 50 0

53

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year Reported

Percentage of Total TB Cases in Foreign-born Persons, Michigan, 1994-2006

45 40 35 30 25 20 15 10 5 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

% of TB Cases

Year Reported

TB by Race, Michigan, 2005-2006

120 100 80 60 40 20 0

108 78 81 86 55 52 1 White 2006 Cases 2005 Cases Black 1 1 Am Indian/AL Native Asian or Pacific Islander

Multiple Races

Countries of Birth for Foreign-born Persons Reported with TB Michigan, 2006

5% 4% 10% Mexico Vietnam India 20% 33 Other Yemen Phillipines 53% 8%

Transmission and Pathogenesis

Pathogenesis
Inhale droplet nuclei Bacteria multiplies Macrophages consume bacteria, then die Travel through the bloodstream, lymph system Containment-infection Multiplication-disease

Generation of TB Droplet Nuclei

One cough produces 500 droplets

The average TB patient generates 75,000 droplets per day before therapy This drops to 25 infectious droplets per day within 2 weeks of effective therapy

Factors Affecting TB Transmission

Characteristics of the source case Environment Factors increasing risk for contacts
source

contact environment

Classification System for TB

Class
0

Type
No TB exposure Not infected

Description
No history of exposure Negative reaction to tuberculin skin test

TB exposure History of exposure No evidence of infection Negative reaction to tuberculin skin test TB infection No disease Positive reaction to tuberculin skin test Negative bacteriologic studies (if done) No clinical, bacteriological, or radiographic evidence of active TB M. tuberculosis cultured (if done) Clinical, bacteriological, or radiographic evidence of current disease History of episode(s) of TB or Abnormal but stable radiographic findings Positive reaction to the tuberculin skin test Negative bacteriologic studies (if done) and No clinical or radiographic evidence of current disease Diagnosis pending

TB, clinically active

TB Not clinically active

TB suspected

Remember
TB disease is reportable to the State Health Department TB Control Program on the Report Verified Case of Tuberculosis (RVCT)

TB Infection
CXR: Normal No Symptoms Negative Sputum Culture Not a Case of TB NOT INFECTIOUS

TB Disease
CXR: Abnormal Symptoms Positive Sputum Culture Case of TB INFECTIOUS

Risk Factors for the Development of TB Disease

Risk factors Acquired immunodeficiency syndrome (AIDS) HIV infection Recent TB infection (within past 2 years) How many time higher is the risk of TB disease? 170 113 15

Certain medical conditions2 3 - 16 2Compared to the risk for people with no known risk factors For example, diabetes, certain types of cancer, or immunosuppressive therapy
Excerpt from CDCs Self-Study Modules on Tuberculosis, Module 1, March 1995

Signs/Symptoms
Productive cough 3 weeks or longer Shortness of breath Chest pain Hemoptysis Night sweats/fever/chills Unexplained weight loss Fatigue

TB can be found in all parts of your body

Brain Lymph node Lung Spine Eye Throat Bone Kidney

Suspect TB:
Chest x-ray Location of the infiltrate Presence of a cavity Hollow areas, dense areas, fluid on the lung or at margins Normal x-ray = usually no infectious TB disease

Chest Radiograph
Abnormalities often seen in apical or posterior segments of upper lobe or superior segments of lower lobe May have unusual appearance in HIV-positive persons Cannot confirm diagnosis of TB
Arrow points to cavity in patient's right upper lobe.

Sputum Collection
Sputum specimens are essential to confirm TB Sputum: mucus from within the lung, not saliva 3 specimens on 3 different days Spontaneous morning sputum more desirable than induced specimens

AFB Smear Results

Positive
Need at least 10,000 bacilli per ml Positive in about half those with TB disease Signal a very infectious person Other mycobacteria may make the smear a false

Negative
Too few bacilli to be seen directly under the microscope Provides some reassurance that patient is less infectious to others

positive

AFB Smear: AFB (shown in red) are tubercle bacilli

Cultures
Use to confirm dx of TB Culture all specimens, even if smear Result in 4-14 days when liquid medium systems used Susceptibility testingessential
Colonies of M. tuberculosis growing on media

Drug susceptibility testing on solid media. Upper left contains no drugs.

Alternative Techniques
BACTEC can confirm TB growth within one week, by indirectly measuring TB bacilli growth in special bottles and medium Other tests can confirm TB by amplifying DNA and other methods that look for the TB bacilli genes

Potential Chains of Tuberculosis Transmission Before and After DNA Fingerprinting of Isolates

DIVERSITY OF RFLP PATTERNS

# # # # #

Individual TB CDC Cluster totals for Outstate Michigan and the City of Detroit 1996 to 2000.
Outstate 64 cluster totals: Size Freq. % 2 person 42 65 % 3 person 7 10.9 % 4 person 7 10.9 % 5 person 1 1.6 % 6 person 2 3.1 % 7 person 1 1.6 % 8 person 1 1.6 % 9 person 1 1.6 % 10 person 1 1.6 % 31 person 1 1.6 % Detroit 53 cluster totals: Size Freq. % 2 person 25 47.2 % 3 person 6 11.3 % 4 person 4 7.5 % 5 person 5 9.4 % 6 person 3 5.7 % 7 person 2 3.8 % 8 person 1 1.9 % 10 person 1 1.9 % 13 person 1 1.9 % 18 person 1 1.9 % 58 person 1 1.9 % 70 person 1 1.9 %

Detroit CDC 00027

70 cases 68% Male, 90% Black 99% US citizens 76% Pulmonary 29% Cavitary 4 cases prior TB 17% HIV+ 10% Homeless 7% Long term care 13% Injecting drugs 11% Non-injecting drugs 20% Alcohol abuse 51% Unemployed 89% -Ages 30 to 54

Treatment

How much INH is needed for the prevention of TB?

Longer duration of therapy corresponded to lower TB rates among those who took 0 - 9 months No extra increase in protection among those who took > 9 months
Comstock GW, Int J Tuberc Lung Dis 1999;3:847-50

Treatment of Latent TB Infection (LTBI)

Consists of 9 months of daily isoniazid (INH) Substantially reduces the infected persons risk of developing clinical TB Monitor patient at least monthly for symptoms of toxicity and adherence

Treating TB Disease: General Principles

Always treat with multiple drugs Never add a single drug to a failing regimen Treatment course depends on drugs selected. Usually 6 months, sometimes 9 months: Four drugs for two months
INH-RIF-EMB-PZA

Two drugs for four or seven months

INH-RIF

How will we know if the treatment is effective?

The symptoms improve Sputum smears become negative Sputum cultures change to negative, usually within 2 3 months The chest x-ray improves (important for kids)

Non-adherence
A very serious problem Failure to take all the prescribed TB treatment is the single most important reason for tuberculosis treatment failure

Non-adherence (2)
The non-adherent patient risks Continuing transmission of TB infection Development of drug resistant TB bacilli Increasing disability and death

Infectiousness
Patients should be considered infectious if they Are coughing Are undergoing cough-inducing or aerosolgenerating procedures, or Have sputum smears positive for acid-fast bacilli and they Are not receiving therapy Have just started therapy, or Have poor clinical response to therapy

Infection Control
Administrative-reduce risk of exposure
Alert to S/S of MTB Prompt therapy with suspect Alert for undiagnosed pulmonary illness with HIV Engineering-prevent spread, reduce conc. of droplet nuclei
Neg. pressure isolation room Filtration system

Personal protection-use in areas of increased exposure

Client (surgical mask) to mask outside HCW (N-95) to mask inside