Kenya Lung health Training Course

TUBERCULOSIS
INTRODUCTION
 National Tuberculosis, Leprosy and
Lung Disease (NTLD)-Program

Vision: Reduce the burden of lung disease and

render Kenya free of TB and leprosy

The NTLD Program is mandated to:

– develop policies, build capacity and provide technical
assistance to the counties
– implement its activities within the framework of the
National Strategic Plan for Tuberculosis, 2015-2018,
and in line with the End TB strategy.
 The End TB Strategy
• 3 pillars and in keeping with the UN Sustainable
Development Goals (SDG) 3 that proposes
ending the TB epidemic by 2030
SDG and End TB Targets
Key performance indicators for the
End TB strategy
 Module 1

EPIDEMIOLOGY OF TB
 Background
• Global TB monitoring system (annual WHO
Global TB report) established 2 decades ago
• Data from 205 countries
• Transitions in 2015:
– from the MDGs to a new era of Sustainable
Development Goals (SDGs), and
– from the Stop TB Strategy to the End TB Strategy
 Highlights of TB control
• TB mortality has fallen 47% since 1990, especially
since 2000, when the MDGs were set
– About 53 million lives saved between 2000 and 2016
• The MDG target to halt and reverse TB incidence has
been achieved worldwide
• Globally, TB incidence is falling at about 2% per year
• 4–5% annual decline is needed to reach the 2020
milestones of the "End TB Strategy".
• 16% of TB cases die from the disease
 2016 Global TB statistics
• An estimated incidence of 10.4 million TB cases
• Only 6.3 (61%) million new TB cases notified
 65% of the new TB cases notified were males
 6.9% of the new TB cases notified were children
• Of the 10.4 million cases,
 1.9 million were attributable to undernourishment
 1.0 million to HIV infection
 0.8 million to smoking
 0.8 million to diabetes.
• 600, 000 estimated DRTB cases, 490 000 being
multidrug-resistant TB (MDR-TB)
• Only 129 689 (22%) were enrolled on treatment
 Kenya TB Epidemiology, 2016
• Kenya is a high-burden country for TB, TB/HIV
and MDR-TB
• Total TB cases were 75,896
44,006(58%) Bacteriologically confirmed
6,620(8.7%) children
23, 528 (31%) were HIV+
• 445 DRTB Cases,
 351 (RR)
1 XDR
 Module 2

Introduction to TB
 Introduction
• Tuberculosis is caused by a bacteria called
Mycobacterium tuberculosis (M. tuberculosis)
• M. tuberculosis is transmitted through the air
• M. tuberculosis is from the family of bacteria called
Mycobacteriaceae
• Humans are the only known reservoir of M. tuberculosis
 Etiology
• Other Mycobacteria that may cause disease in
humans include:
– Mycobacterium Avium Complex (M. Avium and M. intracellulare)
– M. bovis
– M. africanum
– M. microti
– M. caprae
– M. pinnipedii
– M. canetti
– M. mungi

• The majority of TB cases are caused by M.

tuberculosis
 Risk factors for TB Transmission
• Susceptibility of the contact
• Environmental
• Infectiousness of the index case factors
– Presence of cough – Concentration of
– Presence of pulmonary or bacilli in the
laryngeal disease environment of the
– Poor cough etiquette child
– Cavitatory disease – Small enclosed
– Positive smear or culture spaces
• Exposure to the infectious case – Poor ventilation
– Duration of exposure – Poor air circulation
– Frequency of exposure – Poor specimen
handling
– Physical proximity
– Positive air
pressure into room
 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, sing,
talk or laugh
• These tiny particles can remain
suspended in the air for several hours
• Transmission occurs when a person
inhales droplet nuclei containing M.
tuberculosis
• TB is not transmitted by shaking hands,
sharing food, toothbrushes or touching
bed linen or toilet seats used by infected
persons
 Natural history
• Upon exposure to infected droplets from the environment,
one may inhale air that contains droplets with M.
tuberculosis bacilli
– These travel through the respiratory tract to reach the small
air sacs of the lung (the alveoli), where infection may begin
• 10-30% of persons exposed to TB bacilli will develop
infection

Exposure to TB

No Infection Infection
70-90 % 10-30%
 Natural history…cont’d
• Once infected, the bacilli pass through the respiratory
tract
– In the alveoli, some of the bacilli are killed, a few multiply in the alveoli
while others may enter the bloodstream and spread throughout the
body
• The immune cells in the alveoli may form an immune
capsule that keeps the bacilli contained
– This is the Ghon focus
• If the Ghon focus also involves infection of adjacent
lymphatics and hilar lymph nodes, it is known as
the Ghon's complex or primary complex
• 90% of persons who are exposed and infected with TB
bacilli do not develop signs and symptoms of TB disease
and are referred to as having Latent TB infection
 Natural history…cont’d
• In some people, the bacilli overcome the defenses of
the immune system and begin to multiply
– This results in the development of signs and symptoms and
this is known as Active TB disease
• 5% develop TB disease within 2 years of infection
– This is known as primary TB disease, and usually occurs in
young children or in severe immune-suppression
• 5% develop TB disease later on in life when their
immune system becomes weak
– This is known as secondary TB disease
• Secondary TB disease can be as a result of reactivation of LTBI or re-
infection
Summary of the natural history
of TB infection
Exposure to TB

No infection(70-90%) Infection (10-30%)

Active TB(10%) ill

Latent TB(90%) well -5% develop TB within 2 years
-Never develop TB -5% develop TB many years later
-Non-infectious

Untreated Treated

50% die within 5 years Cured

25% recover
25% remain sick
 Risk Factors for Tb infection and disease
Risk factors for TB infection Risk factors for active TB disease
(exposure)(LTBI)
High prevalence of TB disease in Immunosuppression e.g HIV, diabetes,
population Malnutrition, alcoholism, smoking,
immunosuppressant therapy,silicosis

Smear positivity of cases in population Recent prior infection

(infectivity of cases)
Type of TB disease (e.gcavitary, Poorly treated previous TB
pulmonary more infectious)
Proximity and duration to infectious Extremes of age
cases (contact)
Environmental factors e.g poor
ventilation, overcrowding
 Module 3

Management of Mycobacterium
tuberculosis
Diagnosis of Tuberculosis
 Case Definition of TB
Presumptive TB: Case is one who presents with symptoms or signs
suggestive of TB (previously known as a TB suspect)
Case of TB: A patient who has been diagnosed with TB
2 types
• A bacteriologically confirmed TB case;
 biological specimen is positive by smear microscopy, culture
or WRD (WHO-approved Rapid Diagnostics such as Xpert
MTB/RIF)
• A clinically diagnosed TB case;
 does not fulfil the criteria for bacteriological confirmation
 has been diagnosed with active TB by a clinician or other
medical practitioner who has decided to give the patient a full
course of TB treatment
 Case definition of TB…cont’d
• Clinically diagnosed cases subsequently found to
be bacteriologically positive (before or after
starting treatment) should be reclassified as
bacteriologically confirmed
• All such cases should be notified regardless of
whether TB treatment was started or not
 Diagnosis of Drug Sensitive TB
Diagnosis of TB depends on numerous factors including;
1. High index of TB suspicion among community members
2. High index of suspicion among health care workers
3. Turnaround time of laboratory results
4. Capacity to conduct active tracing and screening of contacts,
5. Capacity to follow up all patients with positive lab
investigations (bacteriologically confirmed) for timely
treatment initiation.
6. Integration of TB services within other areas such as maternal
and neonatal child health, nutrition, diabetes and HIV clinics
 Diagnosis of pulmonary TB (PTB)

History
TB should be suspected if these are present:
• Cough
• Fevers
• Night sweats
• Loss of weight
• Chest pain
• Shortness of breath
• History of contact with an adolescent or adult with proven or
suspected TB should be taken for all children suspected to have
TB. Module 1 - Tuberculosis
31
 Physical examination
Physical signs may include: Atypical presentations in children:
• Bronchial breath sounds • Acute severe pneumonia
• Tachypnoea – Fast breathing and chest in-
• Wasting drawing
• Haemoptysis – Occurs especially in infants
• Anaemia and HIV-infected children
• Asymmetrical/persistent • Suspect PTB if response to
wheeze not responding to antibiotic therapy is poor
broncho-dilators (airway • If HIV infected suspect other
compression due to enlarged HIV-related lung diseases e.g.
tuberculous hilar lymph nodes) PCP
Module 1 - Tuberculosis
32
 Investigations
• All attempts must be made to make a
bacteriological diagnosis of PTB in both adults
and children
• Sputum for AFB or Gene Xpert is therefore
mandatory for all presumptive cases of PTB
Investigations should be preceded by proper history
taking and a thorough physical exam
Investigations should be conducted to confirm a
diagnosis based on the symptoms a patient presents
with
Test Target Group Purpose
1. Gene Xpert The first line test for all For diagnosis of TB
presumptive TB
2. Smear All presumptive Pulmonary • Detect TB disease
microscopy TB • Monitoring smear positive and
(FM & light gene xpert positive TB patients on
microscopy) treatment at months 2, 5 and 6
3.Chest X-ray All presumptive pulmonary Support TB diagnosis especially where
TB sputum for AFB/gene xpert is negative.
4.Histology All presumptive EPTB Tissue diagnosis in suspected EPTB e.g
TB adenitis
Other supportive tests
5. Tuberculin Children with • An adjunct test to detect TB exposure
skin test presumptive TB in children
• Conducted in tertiary institutions
6. ESR In presumptive TB • ESR is usually elevated in active TB.
(Erythrosite • Howevere it is neither sensitive nor
Sedimentation specific enough to be of value in the
Rate )
 Sputum smear examination
TB diagnosis using sputum for ZN and FM microscopy
involves collection of 2 sputum samples: Spot and Morning
Sample When is it collected? Where is it collected?

Spot-1st sample On the spot when patient In the health facility

presents to facility

Morning -2nd Patient collects upon At home and brings to

sample waking up the following health facility

morning (Or in hospital if

patient is hospitalized)
 Quality sputum specimen collection

Instructions to patient Instructions to health care worker

The patient should 1.
1. Take a deep breath
2. Cough severally
3. Attempt sputum 2.
production. Number 1
to 3 can be repeated
several times
3.
4. Spit sputum (and not
saliva) into the
provided container
5. Close the lid tightly
6. Submit to laboratory as 4.
soon as possible
Label the sputum containers on the
side (not on the lid) prior to sputum
collection
Fill in the sputum examination forms
ensuring that the patient’s contacts
are included
Instruct the patient to collect sputum
samples in a well ventilated area
preferably outdoors (not in the
facility lavatories)
Give patients clear instructions on
when to return for their results
 In patients who cannot expectorate,
sputum may be obtained through:
1. Gastric aspiration; Through insertion of a nasogastric tube (NGT)
to aspirate gastric contents

2. Sputum induction done through nebulization with hypertonic

saline (greater 0.9%) solution, followed by aspiration through
suction.

3. Bronchial wash or broncho-alveolar lavage sample obtained

through fiberoptic bronchoscopy

NB. Sputum induction and bronchoscopy may lead to a substantial

generation of infectious aerosols, and should only be carried out in
clinical environments with appropriate infection prevention
measures in place.
 Sputum culture examination

Indications for sputum TB culture and DST include:

1. All previously treated patients including:
• Relapse
• Treatment after failure
• Treatment after loss to follow up
• Other previously treated patients
2. Patients who remain smear positive at end of month 2 while
on first line treatment
3. Patients with treatment failure:
• Smears still remains positive at month 5 or later during
treatment
4. Symptomatic contacts of drug resistant TB cases
5. Health care workers
 Gene Xpert
• Molecular test to detect M. Tuberculosis & Rifampicin resistance
• More sensitive and specific than sputum micsroscopy in detecting TB
• The preferred test of choice for TB diagnosis among children, PLHIV,
HCWs, prisoners, smear negative persons and previously treated persons
• Test takes 2 hours
 Chest X-ray

• The chest x-ray may aid the diagnosis of PTB but should not
be used as the sole means of establishing a TB diagnosis
• Radiographic features suggestive of PTB include:
– Patchy opacification in the upper zone of lung
– Cavitations and scarring (fibrosis)
– Mid-zone shadows and the presence of hilar or mediastinal lymph
node enlargement
– Miliary mottling
– Pleural and/or pericardial effusion
– In HIV infected persons the radiological picture is more often atypical
with the lower or generalized opacifications

All patients with chest x-ray features suggestive of TB

should have sputum specimens submitted for bacteriologic
examination
 Differential diagnosis for
Pulmonary TB
1. Chronic bronchitis/ COPD
2. Bronchiectasis
3. Lung abscess
4. Lung cancer
5. Heart failure
6. Sarcoidosis
7. Pneumocystis jirovecii
8. Atypical pneumonias e.g. (caused by unusual
pathogens such as fungi)
Type of EPTB (3) Typical Symptoms Confirmatory tests

Headaches Brain CT scans ; useful in

TB encephalitis including Vomiting demonstrating lesions
Tuberculoma Convulsions Difficult to confirm the diagnosis
Limb weakness of brain TB and most patients are
Cranial nerve palsies treated empirically
TB of the skin Lupus vulgaris: Persistent and Skin biopsy; The diagnosis is
progressive form of cutaneous TB usually made or confirmed by
Small sharply defined reddish-brown a skin biopsy
lesions with a gelatinous consistency
Typical tubercles are caseating
(apple-jelly nodules)
epithelioid granulomas that contain
Untreated, lesions persist for years,
acid-fast bacilli. These are detected
leading to disfigurement
by tissue staining, culture and
Scrofuloderma: Skin lesions from polymerase chain reaction (PCR)
direct extension of underlying TB
infection of lymph nodes, bone or
joints
Firm, painless lesions that eventually
ulcerate with a granular base. May
heal even without treatment but this
takes years and leaves unsightly scars
 To Note

• Once TB is diagnosed, a patient should be classified

based on the following:
1. HIV status
2. Anatomical location
3. History of previous treatment
4. Drug sensitivity pattern
END
END