Some epidemiology… TB rates in persons by age group, England and Wales, UK born Born abroad
Tuberculosis case reports by ethnic group (%), England and Wales,
World-wide epidemiology 3 million deaths from TB in % cases of TB in developing countries. 98% of deaths from TB in developing countries. 75% of TB in developing countries in age group. (WHO guidelines for National Programmes 2nd edition 1997)
When should I suspect active tuberculosis ?
Anyone at high risk for TB and has symptoms of Weight loss Fever, Night sweats Anorexia Malaise Cough (more than 3 weeks) Enlarged lymph nodes commonly cervical and mediastinal
Which people are considered high risk ?
People born in high prevalence area 40/100,000 population Close contacts of a person with active PTB Previous or incomplete treatment for TB Immunocompromised (HIV, diabetes, chronic renal failure, chemotherapy, malignancy, corticosteroid use, young children) Homeless, institutionalised e.g. prison Alcohol or intravenous drug users
How should I manage suspected active tuberculosis ?
Examination Check contact/travel history Exclude other conditions Arrange CXR Send 3 early morning sputum samples for culture and microscopy – acid fast bacilli Ring for advice or refer to TB Specialist Services at NUH City Campus tel even before results are known Clinic appointment offered in same or following week
TB : Diagnostic tests…pitfalls Sputum smear 50-70% +ve in pulmonary TB Sputum culture85-90% +ve in pulmonary TB CXRRarely, normal even in smear +ve (eg. endobronchial TB) Heaf/Mantoux68 – 83% +ve in pulmonary TB 17 – 32% false -ve
Difficulties of treatment and role of the TB Specialist Nurse COMPLIANCE TREATMENT COMPLETION SIDE EFFECTS
How would you diagnose latent TB ?
Screening for latent TB in two instances: Contact tracing – Specialist TB Service mantoux/IGRA testing Immigrant screening at port of entry and then local referral to TB Specialist service OR at first registration in primary care – refer to TB Specialist service Recent CXR (last six months) from high risk countries with incidence < 40/100,000 CXR plus mantoux from high risk countries < 500/100,000 e.g sub-Saharan Africa Mantoux only in children under 12 and pregnant women IGRA testing if Mantoux positive * Treatment only offered to the under 35’s
Latent TB / TB infection Tuberculin reaction may be positive for following TB disease Previous BCG Atypical Mycobacteria TB infection (Latent TB)
Mantoux test 1
Mantoux test 2
Mantoux test 3
End notes TB remains a fascinating challenge Awareness and early referral to reduce transmission Direct referral to Specialist TB Services for advice and appointments tel/fax Choose and book not appropriate BCG has only been offered to high risk groups since 2005