Transcript TB or Not TB??? - lookmatters.net

Tuberculosis: What you
need to know!
Gini Orthner RN, BScN
TB Nurse Clinician
TB Control Saskatchewan – Regina Office
History of TB in Saskatchewan
Saskatchewan Anti-TB League was
founded in 1911 (TB was out of control
with nearly 1000 new cases every year
and 1-2 deaths each day).
 First TB Sanitorium was built in 1917
at Fort Qu Appelle (Fort San).
 Saskatoon Sanitorium was built in 1925.
Prince Albert Sanitorium was built in
1930.
 In 1929 Saskatchewan became the first
jurisdiction in North America to provide
TB treatment at no cost to the patient – it
remains this way!
 In 1948 Dr. John Orr introduced
prophylactic use of antibiotics in the
treatment of children under 5 with
positive Mantoux tests.
 1957 a centralized patient record
system was introduced. This database
attracted international attention. We
continue to use a form of this database –
now a computerized version.
 Prince Albert Sanitorium closed in
1961.
 Fort San closed in 1972.
 Saskatoon Sanitorium closed in 1978.
 In 1987 the responsibility for TB was
transferred from the Anti-TB League to
the provincial government.
 Directly observed therapy (DOT) was
started in 1990.
 In 2007 responsibility for TB was
transferred to the Saskatoon Health
Region.
The Encyclopedia of Saskatchewan
Current TB Control
 3 stationary clinics (Saskatoon, Regina,
Prince Albert)
 Mobile clinics in northern Sask.
 Staff consists of
4 physicians
6 nurses
6 administrative support staff
4 TB medication workers
Our Partners
 General Practitioners/Specialists
 First Nations and Inuit Health
 First Nations Bands and Staff
 Immigration Canada
 Correctional Institutions
 Communicable Disease Programs
 General Public
What is Tuberculosis (TB)
 an Acid Fast Bacilli (AFB) known as
Mycobacterium Tuberculosis Complex
(MTBC)
an airborne organism that most commonly
affects the lungs, but can affect any part of
the body
Active TB
Active Pulmonary – affects the lungs and
connective airways, can be infectious or
non-infectious
Active Non–Pulmonary – affects other
parts of the body (lymph nodes, CNS,
meninges, ocular, pericardial, abdominal,
bones/joints, genitourinary, miliary, great
vessels, bone marrow), non-infectious
How is TB Spread?
 mostly through inhalation of droplet
nuclei. (coughing, sneezing, singing, etc)
 very rarely through ingestion (mostly in
the past with unpasteurized milk)
Active Pulmonary TB Disease
Infectious or non-infectious
Infectious
Non-Infectious
Smear positive -isolation x Smear negative
2 weeks
Culture positive
Culture positive
May have an Abnormal
CXR
May have an Abnormal
CXR
Start Treatment ASAP
Start Treatment ASAP
Latent TB Infection (LTBI)
Inactive TB – Infection, NO Disease
Mantoux is positive (> 10mm)
CXR is usually normal
Prophylaxis treatment offered and encouraged
for <15 years old as most susceptible age group
Latent TB Infection (LTBI)
Treatment determined on case by case
basis for 15-35 years old
>35 years old encouraged to monitor for
top three signs & symptoms of early TB
disease as benefits of treatment do not
outweigh the risks (i.e. medication induced
hepatitis, thrombocytopenia)
Symptoms of TB
Early Signs of TB
 Cough for more than 1
month
 Unexplained fever for
more than 1 week
 Recurring pneumonia
that does not respond
to antibiotics
Signs of Advanced TB
 Night sweats
 Weight Loss
 Fatigue
 Rash
Diagnostic Tests
Sputum and/or other body fluids for AFB
Mantoux skin test – gold standard for
diagnosing LTBI
Chest X-ray
CT Scans
IGRA (Interferon-Gamma Release Assays)
Mantoux Tests
Also called:
Tuberculin Skin Tests (TST)
TB Skin Test
PPD Test
Mantoux Tests
 Indicates TB infection only – does not
mean person has TB disease
Elicits cellular immune response to PPD
antigen, causing a delayed hypersensitivity
reaction.
Mantoux Tests
5 units(0.1ml) of Tuberculin (PPD) injected
intradermally, 3-4 fingers down from the
anticubital space
Mantoux Tests
Measure transverse diameter of induration only (not erythema)
Record in mm
No induration is recorded as 0mm
Interpreting Mantoux Tests
History of BCG is not considered
Significant Reaction if:
10mm or greater
5mm or greater in contacts to infectious TB,
HIV positive, pre school children
Treatment – In the Early Days
Sunshine & fresh air!
Treatment - Now
1st Line Drugs
Isoniazid (INH)
Rifampin (RMP)
Ethambutol (EMB)
Pyrazinamide (PZA)
2nd Line Drugs
• Moxifloxacin
• Levofloxacin
• Amikacin
Other medication used for treatment include: streptomycin,
fluoroquinolone, injectable agents (amikacin, kanamycin, capreomycin,
ethionamide, clofazamine, para-aminosalicylic acid, cycloserine, PZA,
EMB)
Treatment – Active TB (or
suspected)
 INH and RMP (standard)
28 daily doses followed by twice weekly doses
for 8 months
Ideal total of 98 doses within 9 month time
frame
4 drug therapy if drug resistance suspected
until drug sensitivity results are obtained (2-6
weeks)
Treatment – LTBI
 INH and RMP (standard)
6 months of twice weekly medication
Ideal total of 52 doses within the 6 month time
frame
Treatment in Saskatchewan
All treatment is provided by directly
observed therapy (DOT).
WHY?
 to prevent drug resistance
 to prevent relapse of TB
 to ensure treatment completion
Interesting Facts…
After HIV/AIDS,
TB kills more people than any other
infectious disease
WHO 2008
Did you know???
1/3 of the world’s population is
infected with TB
Canadian Tuberculosis Standards 2007
Prevalence
WORLD
9.4 million new cases of active TB in 2008
 1.3 million people die each year from TB
CANADA
 1600 new cases in 2008
SASKATCHEWAN
 93 new active cases in 2008
WHO
Public Health Agency of Canada
TB in Canada
BC, Ontario and Quebec made up 69% of
total cases
Nunavut had the highest rates
PEI reported no cases!
TB in Canada
Foreign born – 62% of cases
Canadian Aboriginal – 21% of cases
Canadian Non Aboriginal – 13% of cases
TB in Saskatchewan - 2009
 2 Cases of TB Meningitis
 1 death caused by TB – found on autopsy
 2 case of multi-drug resistance (INH and
RMP)
TB in Saskatchewan
Canadian Aboriginal – 72 cases
Foreign Born – 11 cases
Canadian Non-Aboriginal – 9 cases
Multi-drug resistant (MDR-TB)
TB bacteria resistant to INH and RMP with
or without resistance to other first or second
line drugs
WHO
MDR-TB World Wide
0.5 million cases of MDR-TB in 2007
27 countries account for 85% of cases (15
countries are in European Regions)
Top 5 countries affected: India, China,
Russia, South Africa, Bangladesh
WHO
Extensively Drug Resistant
(XDR-TB)
TB bacteria resistant to at least INH and
RMP from the first line drugs plus
resistance to any fluoroquinolone and at
least one of three injectable second line
drugs (capreomycin, kanamycin and
amikacin)
WHO
XDR-TB
By 2008, 55 countries reported at least 1
case of XDR-TB
WHO
Total Drug Resistance
 new term used in an article based on a
case in Iran
 a case of TB that is essentially resistant
to all antibiotics known to effectively
treat TB
THINK TB!
Assess for symptoms
• Cough with sputum for more than 1 month.
• Unexplained fever for more than 1 week.
• Pneumonia not improving with antibiotic treatment.
THINK TB!
Obtain CXR
Obtain sputum (body fluid) for AFB
testing. Send to Provincial Lab.
Contact TB Control with questions and for
further instructions
“The most common physical finding in
pulmonary TB is a…
totally normal examination.”
Canadian TB Standards, 2007
Questions???
Contact Information
Toll Free Number – 1-866-780-6482
Saskatoon Office – 655-1740/655-1741
Prince Albert Office – 765-4260
Regina Office – 766-4311