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TUBERCULOSIS (TB) -“I AM Stopping TB”- Slogan used for the 2008-2009 campaign. -

Perspective on TB and HIV by Nelson Mandela July 2004

 WHO 2006. All rights reserved Globally, 9.2 million new cases and 1.7 million deaths from TB occurred in 2006, of which 0.7 million cases and 0.2 million deaths were in HIV-positive people. TB: Estimated numbers of new cases, 2006 Estimated number of new TB cases (all forms) Swaziland is the #1 country with the highest rate of TB and corresponding HIV cases. South Africa falls into second place. No estimate 0–999 1000–9999 10 000–99 999 100 000–999 999 1 000 000 or more  WHO 2006. All rights reserved

TB in South Africa 180,507 cases (55%) reported in 1997                                                            TB in South Africa 180,507 cases (55%) reported in 1997 In 2006, 998 per 100, 000 people Of these, 44% (73, 679 cases) are infected with HIV -and- 218 per 100,000 cases resulted in death. **The impact of TB/HIV-coinfection in KwaZulu-Natal, Mpumalanga and Gauteng is leading to Increases in tbe rates in these areas

What is TB? -Causative Agent- Mycobacterium tuberculosis Bacteria - small rod-like bacillis These bacteria can attack any part of the body, but they most commonly attack the lungs. -Pulmonary tuberculosis is the infectious and common form of the disease, occurring in over 80% of cases. Extra-pulmonary tuberculosis is a result of the spread of tuberculosis to other organs, mos commonly pleura, lymph nodes, spine, joints, genito-urinary tract, nervous system or abdomen.

Transmission Person-to-person by droplet nuclei from someone with active infection. Expelled when person with active TB coughs, sneezes, speaks, or sings Transmission is influenced by: -Intimacy- How close you are to the infected person. -Duration of contact- How long a person is in the presence of the infected person. -Degree of infectivity -Shared contact environment.

Practical Implications… Open windows is a good nursing prevention measure

Common Sites of TB Disease: Lungs and pleural cavity Central nervous system Lymphatic system Genitourinary systems Bones and joints Disseminated or miliary TB Extra-pulmonary tuberculosis is a result of the spread of tuberculosis to other organs, most commonly pleura, lymph nodes, spine, joints, genito-urinary tract, nervous system or abdomen. Tuberculosis may affect any part of the body. -Extra-pulmonary cases are almost never infectious, unless they have pulmonary tuberculosis as well.

Pulmonary tuberculosis lungs and pleural cavity Picture 1- CHEST X-RAY: Abnormalities often seen in apical or posterior segments of upper lobe or superior segments of lower lobe. Cannot confirm diagnosis. Picture 2-This lung from a deceased patient shows the destruction of the lung tissue that tuberculosis causes. Picture 3-Tuberculous pneumonia of the right upper lobe but that his t also affects all fields of the left lung. 

Pulmonary TB in HIV (+) patients In HIV infected patients, the radiographic presentation of pulmonary tuberculosis is atypical and might be difficult to diagnose as this patient demonstrates

Lymphatic TB

This abscess was close to breaking through the skin, yet it felt cold to the touch and little pain is felt when the lesion was touched.  Such a finding should raise a high index of suspicion for tuberculosis.

Tuberculosis of the spine

Tuberculosis of the joint (ankle)

Disseminated or miliary TB The patient has tuberculosis of the ankle, tuberculous mastitis (exceedingly rare in men), pleural thickening from past pleural tuberculosis, multiple abscesses, and had been operated for a presumable tuberculous epididymitis.  While such multi-system disease in a young man should pose little difficulties in making the diagnosis of tuberculosis, it had not been taken into consideration for a prolonged period of time.

Tuberculosis meningitis Picture 1-Tuberculous meningitis is the most lethal form of tuberculosis. Many neurologic symptoms including cranial nerve involvement.  In this patient the sixth cranial nerve, Nervus abduces, was affected. In this patient, the resulting squinting gradually disappeared with chemotherapy. Picture 2: This child had more sever neuro. Symptoms including a hemi-syndrome.  He recovered on chemotherapy but remained with intellectual and motor nerve deficits.

Tuberculosis of the skin

Latent vs. Active TB Latent TB or Tuberculosis Infection **The immune system contains the infection** (+) skin or blood test Normal chest x-ray and (-) sputum test TB bacteria are alive but inactive Does not feel sick Cannot spread TB to others. Needs treatment to prevent disease. If exposed and infected by a person with MDR-TB or XDR-TB, preventive treatment may not be an option. Active TB or Tuberculosis Tb bacteria has overcome the defenses of the immune system. (+) skin or blood test Abnormal chest x-ray, or (+) sputum culture or smear. Active TB in his/her body. Feels sick and has symptoms (coughing, fever, weight loss) May spread TB to others Needs treatment to treat active TB disease. If another person inhales air that contains the “droplet nuclei”, he or she may become infected. Not everyone infected with TB bacteria becomes sick.

Risk Factors for TB The following are risk factors for TB: Known or suspected HIV infection - Exposure to a pulmonary TB case, especially a sputum smear-positive case Industrial silica dust exposure (eg. in underground miners). Poor nutrition

Nursing Assessment A careful history should be taken (OLDCARTS) of a patient who presents with symptoms of TB

Nursing Assessment Symptoms of TB Early Infection… Fever Chills Night sweats Appetite loss Slow weight loss Fatigue Irregular menses Late Infection… Productive, prolonged cough (> 3 weeks)- yellow sputum Chest pain Hemoptysis ***Other symptoms depend on body part affected*** A patient presenting with these symptoms who is, or was in contact with a person with infectious tuberculosis is more likely to be suffering from tuberculosis. Symptoms of extra-pulmonary tuberculosis depend on the organ involved. Chest pain from tuberculosis pleurisy, enlarged lymph nodes and sharp angular deformity of the spine are the most frequent signs of extra-pulmonary tuberculosis.

Nursing Assessment Physical Findings Auscultation: rhonchi, crackles, wheezing Dullness on percussion Unequal lung expansion Trachea not midline—has shifted to one side Large liver and/or spleen Swollen/enlarged lymph nodes Abnormal behavior, headaches, seizures Examine for extrapulmonary TB (lymph, bones, joints, eye, abdominal organs, neurologic system, genitourinary, larynx). Add sound bytes

Diagnosis of Pulmonary TB Chest X-ray: Not diagnostic Smear Examination: - Obtain 3 sputum specimens for smear examination and culture (If unable to cough up sputum, induce sputum, bronchoscopy or gastric aspiration) Follow infection control precautions during specimen collection Wear Masks Open windows Strongly consider TB in patients with smears containing acid-fast bacilli (AFB) Smear is only presumptive diagnosis of TB The TB Control programmes moving away from chest x-rays as a primary method of diagnosis. A crucial element of DOTS is to use microscopes to ensure that infectious TB is reliably and cost -effectively diagnosed. The first priority and the key issue in the new programme is to cure infectious patients at the very first attempt to slow down the epidemic.

AFB Smear

Sputum Culture *Use culture to confirm diagnosis of TB* Culture all specimens, even if smear negative Colonies of M. tuberculosis growing on media

If the necessary lab facilities are not available… If the necessary lab facilities are not available…. DIAGNOSIS IS BASED ON SYMPTOMS

TREATMENT of TB

***Ensure that you give the correct doses** Common TB Drugs: rifampin (RIF) ethambutol (EMB) pyrazinamide (PZA) isoniazid (INH) streptomycin A combination of these drugs is given for (+) effect. intensive phase ( 2 months) continuation phase (4 months). ***Ensure that you give the correct doses**

Common side effects of TB drugs

Special Considerations… Do not give streptomycin in pregnancy or to patients >65 y.o. Do not give ethambutol to patients <8 y.o. Ask about other drugs or traditional medicine patient is taking.

DOTS: Directly Observed Treatment Short-course -International strategy to fight spread of TB. **STRATEGY 1. Sputum smear microscopy to detect the infectious cases among those people with symptoms of TB (Most importantly cough of three week’s duration or more). 2. Standardized short-course anti- TB treatment for at least all confirmed sputum smear positive pulmonary TB cases, with direct observation of treatment for at least the initial two months. 3. A regular, uninterrupted supply of all essential anti-TB drugs. 4. A standardized recording and reporting system.

TB/HIV HIV, by attacking the immune system, makes a person who is infected with TB more likely to get sick with active TB. TB often occurs early in the course of HIV disease. TB probably accelerates the progression of HIV disease. In the absence of HIV infection, only about 10% of people infected with TB will get active TB during their lifetime. In people who are infected with HIV, about 50% get active TB.

About 50% of TB patients in South Africa are infected with HIV. TB/HIV in South Africa About 50% of TB patients in South Africa are infected with HIV. Active TB can be prevented and cured in people living with HlV/AlDS. -Prevented: Using: same drugs for same amount of time.

***Treatment for TB/HIV*** People with TB/HIV are more likely to have recurrent TB after completing TB treatment. All re-treatment patients should have sputum sent for culture and susceptibility testing. The re-treatment regimen should only be given to patients with a positive smear or culture.

The adult patient NOT on ARV’s with newly diagnosed TB CD4 count >200 Treat TB fully before initiating ARV’s <50, or very ill Complete initiation phase (2 months) and then start ARV’s 50-200 Initiate TB treatment & wait until patient is stable (2-4 weeks), then start ARV’s.

The adult patient on ARV’s with newly diagnosed TB ARV regimen 1a Continue regimen unchanged Efavirenz 600mg *d4T 30 mg bd 3TC 150mg bd 1b Consider substituting Nevirapine with Efavirenz; If not, monitor LFT’s weekly. d4T 30 mg bd 3TC 150 mg bd Nevirapine 200mg bd 2 Add 3 Ritonavir bd (TB treatment decreases Kaletra, increasing the Ritonavir compensates) ddl 250/400mg daily on an empty stomach *Lopinavir/Ritonavir 400mg/400mg bd. AZT 300mg bd*

Side effect ARV TB treatment Management Nausea + vomiting DDI AZT Ritonavir Pyreazinamide (PZA) Exclude lactic acidosis if on ARV >4months, consider pancreatitis; else symptomatic treatment and consider substitution if severe. Hepatitis Nevirapine Efavirenz Rifampicin Isoniazid PZA If ALT/AST >5x normal, refer doctor. If no other cause dc meds and reinsititute liver sparing TB regimen, then add rifampicin followed by INH if stable. Starte ARV’s once fully stable on TB regiment. Peripheral neuropathy D4T Vit B6 25-50mg daily Amitryptaline 25mg up to 100mg. Loosen shoes. Rash Isioniazid If involving mucous membranes or associated with systemic symptoms dc all meds and refer. Else manage with cream and antihistamines.

MDR-TB Multidrug-Resistant Tuberculosis TB that is resistant to at least two of the best anti-TB drugs: isioniazid and rifampin. It is difficult and expensive to treat: A combination of second-line drugs are used. *More side effects. *Much longer treatment. *The cost may be up to 100 times more than first-line therapy. *MDR TB strains can also grow resistant to second-line drugs, further complicating treatment. -These drugs are first-line drugs and are used to treat all person with TB…

MDR-TB Multidrug-Resistant Tuberculosis Cure rate of MDR: <50%. Prevention is Key: -MDR TB is only diagnosed by TB culture and susceptibility testing. -MDR TB can be prevented by treating TB patients with appropriate TB regimens. -Ensuring patient adherence to treatment by providing DOT and obtaining drug susceptibility tests when indicated. Refer MDR TB patients to a MDR TB unit where experienced clinicians can treat the patient according to the ‘Guidelines for the Management of Drug-resistant Tuberculosis Patients in South Africa’

XDR-TB Extensively Drug Resistant Tuberculosis XDR TB occurs when a Mycobacterium tuberculosis strain is resistant to: isoniazid AND rifampin. -as well as- -Key drugs of the second line regimen: -fluoroquinolones -at least one of the three injectable drugs. *XDR TB strains may also be resistant to additional drugs, greatly complicating therapy.

BOTH MDR-TB and XDR-TB are difficult to treat and may take up to 2 years. PREVENTION IS KEY!!

***?’s*** Ngiyabonga ka khulu!