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Tuberculosis: What you need to know!

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).

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Tuberculosis: What you need to know!

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  1. Tuberculosis: What you need to know! Gini Orthner RN, BScN TB Nurse Clinician TB Control Saskatchewan – Regina Office

  2. 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).

  3. First TB Sanitorium was built in 1917 at Fort Qu Appelle (Fort San).

  4. Saskatoon Sanitorium was built in 1925.

  5. Prince Albert Sanitorium was built in 1930.

  6. 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.

  7. 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.

  8. Prince Albert Sanitorium closed in 1961. • Fort San closed in 1972. • Saskatoon Sanitorium closed in 1978.

  9. 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

  10. 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

  11. Our Partners • General Practitioners/Specialists • First Nations and Inuit Health • First Nations Bands and Staff • Immigration Canada • Correctional Institutions • Communicable Disease Programs • General Public

  12. 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

  13. 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

  14. 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)

  15. Active Pulmonary TB Disease • Infectious or non-infectious

  16. 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

  17. 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)

  18. 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 Symptoms of TB

  19. 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)

  20. Mantoux Tests • Also called: • Tuberculin Skin Tests (TST) • TB Skin Test • PPD Test

  21. Mantoux Tests • IndicatesTB infection only– does not mean person has TB disease • Elicits cellular immune response to PPD antigen, causing a delayed hypersensitivity reaction.

  22. Mantoux Tests 5 units(0.1ml) of Tuberculin (PPD) injected intradermally, 3-4 fingers down from the anticubital space

  23. Mantoux Tests Measure transverse diameter of induration only (not erythema) Record in mm No induration is recorded as 0mm

  24. 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

  25. Treatment – In the Early Days Sunshine & fresh air!

  26. 1st Line Drugs Isoniazid (INH) Rifampin (RMP) Ethambutol (EMB) Pyrazinamide (PZA) 2nd Line Drugs Moxifloxacin Levofloxacin Amikacin Treatment - Now Other medication used for treatment include: streptomycin, fluoroquinolone, injectable agents (amikacin, kanamycin, capreomycin, ethionamide, clofazamine, para-aminosalicylic acid, cycloserine, PZA, EMB)

  27. 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)

  28. Treatment – LTBI • INH and RMP (standard) • 6 months of twice weekly medication • Ideal total of 52 doses within the 6 month time frame

  29. 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

  30. Interesting Facts… After HIV/AIDS, TB kills more people than any other infectious disease WHO 2008

  31. Did you know??? 1/3 of the world’s population is infected with TB Canadian Tuberculosis Standards 2007

  32. 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

  33. TB in Canada • BC, Ontario and Quebec made up 69% of total cases • Nunavut had the highest rates • PEI reported no cases!

  34. TB in Canada • Foreign born – 62% of cases • Canadian Aboriginal – 21% of cases • Canadian Non Aboriginal – 13% of cases

  35. 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)

  36. TB in Saskatchewan • Canadian Aboriginal – 72 cases • Foreign Born – 11 cases • Canadian Non-Aboriginal – 9 cases

  37. Multi-drug resistant (MDR-TB) • TB bacteria resistant to INH and RMP with or without resistance to other first or second line drugs WHO

  38. 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

  39. 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

  40. XDR-TB • By 2008, 55 countries reported at least 1 case of XDR-TB WHO

  41. 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

  42. 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.

  43. THINK TB! • Obtain CXR • Obtain sputum (body fluid) for AFB testing. Send to Provincial Lab. • Contact TB Control with questions and for further instructions

  44. “The most common physical finding in pulmonary TB is a… totally normal examination.” Canadian TB Standards, 2007

  45. Questions???

  46. Contact Information Toll Free Number – 1-866-780-6482 Saskatoon Office – 655-1740/655-1741 Prince Albert Office – 765-4260 Regina Office – 766-4311

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