Tuberculosis

 INTRODUCTION

 

          Tuberculosis is a communicable disease suffered by all ages.  Tuberculosis is known to man since ages.  Hippocrates called this disease as ‘phithesis’ which means ‘To dry of disease accelerated greately’.  The disease primarily affects lungs and causes pulmonary tuberculosis.


DEFINITION:

          Pulmonary tuberculosis is an infectious disease of the parenchyma of the lung caused by ‘Mycobacterium tuberculosis’ characterized by the formation of tubercle.

 

EPIDEMOLOGICAL FEATURES

Geographical Distribution

          World wide, particularly in developing and under developed countries.

Agent

Mycobacterium tuberculosis

          Human and bovine strains of the bacillus are of importance to man and fairly resistant to the action of chemicals and heat.

 

Source of Infection

          Human and bovine.  Bovine is no problem in India because people take boiled milk.  Infective material s the sputum of the patient suffering from TB bacilli are also found in pus, pleural and periotoneal fluid.

 


Host Factors

Age: It can occur at any age.  Majority of cases 20 to 40 years.  In India prevalence is higher in the elder age group.

Sex:

          More in males than in females, more prevalent among males over 40 years.  It effects all races and is not a hereditary disease.

Nutrition:

          Studies shows that nutrition and diet had no influence on recovery of patients.

Immunity:

          Man has no inhereited immunity against the disease.  It is acquired as a result of natural infection or BCG vaccine.

Environmental factors:

          Standard of living is related factors with occurrence of disease and social factors

Ø     Over crowding

Ø     Poverty

Ø     Education

Ø     Occupation

Ø     Large families

Ø     Industrialisation

Ø     Malnutrition

 

Social Customs

Ø     Habits of indiscriminate spitting

Ø     Use of common hooka

 

Economic aspects:

          Mass treatment by the government is not possible  due to high costs

 

Mode of Transmission

1.    Droplet infection

2.    Inhalation of fine dust containing tubercle bacilli from infected sputum.

3.    Ingestion of contaminated food and milk.

 

Clinical Features

        The outset of tuberculosis is insidious and early symptoms vary from one individual to the

Ø     Dry cough, later moist with varying amount of sputum.

Ø     Loss of weight associated with general malaise and fatigue.

Ø     A persistent pyrexia is presented.

Ø     In some cases cough associated with blood stained sputum.

Ø     Chest pain

Ø     Dysponea

Ø     Marked weakness and wasting.

Ø     Heamoptysis

 

Prevention and Control of Tuberculosis

Early detection of cases:

          The case is one whose sputum is positive for tubercle bacilli.  All others are termed suspects.

 

a) Sputum Examination:

          Sputum examination of two consecutive specimens [Eg: On the spot and overnight sputum]

1.     Cough more than two weeks duration

2.     Chest pain

3.     Hemoptysis – spitting  of blood

4.     MMR [Mass Miniature radiography]

5.     Tuberculin Testing

 


Manlaux testing:

          PPD injection ill to fore arms results in red papule after 72 hours, palpable oedema or induration more than 10 mm in the longitudinal diameter is considered acceptable infection with bacilli.

Examination of the chest:

          It is expensive but more sensitive and specific like sputum examination.

 

Chemotheraphy

Antitubercular Drugs

          Thaicetazone 150mg + 1NH 300 mg in a single tablet with streptomycin daily for first two months yield 100% success.

          In order to avoid drug resistance, treatment must be complete and regular atleast with 2 to 3 drugs in combination.  Regimens of treatment are as follows.

 

1) Daily regimens

1. 1NH + Thiacetazone

2. 1NH+Ethambatol

          For seriously ill sputum positive TB patient daily streptomycin 0.75 gm may be added in one of the above mentioned regimes for initial 2 months period.

 

2) Bi-weekly or intermittent regimens

Preferable for sputum positive cases

Streptomycin       -        0.75 gm

1NH                     -        600 or 700 mg

Pyridoxine           -        10mg

 

Short Course of Chemotheraphy

          There are two recommended regimens under the programme NTCP (National Tuberculosis Control Programme).  These regimes have two phases, intensive phase of first two months and continuations phase of 4 to 6 months.

 

Regimens(A)

It is a biweekly intermittent supervised regimen total duration of treatment is only 6 months.  In the first two months patient is given streptomycin (.75mg) 1NH (600mg), rifampicin (600mg) twice a week for 4 months.

 

 

Regimen (B)

        Initial intensive phase of four drugs comprises treptomycin (0.25mg) 1NH (300mg) rifampicin (450mg) Pyrazinamide (1.5mg) given daily for two months followed by daily administration of 1NH (300mg) and thiazetazone (150mg) for a period of 6 months.  Total duration of treatment is 8 months.

 

BCG Vaccination

          The aim of BCG vaccination is to induce a benign, artificial primary infection, which will stimulate an acquired resistance to possibly subsequent infection with virulent tubercle bacilli.

Vaccine:

          BCG is the only widely used live bacterian vaccine.  It consists of living bacteria derived from an attenuated bovine strain of tubercle baccille.

Administration:

          The standard procedure recommended by WHO is to inject the vaccine intradermally using a ‘Tuberculin’ syringe.  The site of injection should be just above the insertion of the dettoid muscle.

 

DIRECTLY OBSERVED TREATMENT, SHORT COURSE PDDTS] CHEMOTHERAPY

 

          DOTS is a strategy to ensure cure by providing the most effective medicine and confirming that it is taken.  It is the only strategy which has been documented to effective world wide on a programme basis.  In DOTS, during the intensive phase of treatment a health worker or other trained phase of treatment a health worker or other trained persons watches as the patient swallows the drug in his presence.

 

          During the continuation phase, the patient is issued medicine for one week in a multiblister combipack, of wich the first dose is swallowed by the patient.  The consumption of medicine in the continuation phase is also checked by return of empty multiblister combipack, when the patient comes to collect medicine for the next week.


Rehabilitation

a)     Divisional reading, music and indoor games

b)     Occupational: learning music, knitting, drawing and painting, photography, toy making.

c)      Vocational clinical job, laboratory job, typing, weaving carpet making tailoring, poultry, farming.

d)     Chemoprophylaxis: The 1934 expert committee on TB emphasized that preventive treatment is irrational ever for special group.  In this regimen BCG has priority over chemoprophylaxis.

 

Role of hospitals

Ø     Emergencies such as massive haemoptysis and spontaneous pneumothorax.

Ø     Surgical treatment

Ø     Management of serious types

Ø     Social indications no one to look after the patient.

 

Drug resistance – resistant strains

a)       All drugs used in the treatment of TB tend to produce resistant strains

b)      Primary or pre-treatment resistance

c)       Secondary or post – treatment resistance

b) Prevention of drug resistance

Ø     Treatment with two or more drugs in combination

Ø     Using drugs to which the bacteria are sensitive

Ø     Ensuring that the treatment is complete, adequate and regular

 

HEALTH EDUCATION

          It is also an important aspect of programme more stress to be given on health education of the community to educate them about various aspects of tuberculosis for taking timely action in prevention and treatment of TB disease.  This will also help in getting early care and to get co-operation of the people.

 

NATIONAL TUBERCULOSIS PROGRAMME [NTP]

          The national Tuberculosis programme has been in operation since 1962.  it is essentially a permanent country wide programme, integrated with the general health services at both the rural and urban levels.  The long term goal of the NTP is “To reduce the problem of tuberculosis in the community sufficiently quickly to the level where it ceasts to a public health problem”.

 

Main activities strategies of NTCP

Ø     BCG Vaccination of suspectible population under universal immunization programme

Ø     Isolation and treatment of cases

Ø     Setting up of training cum demonstration centres

Ø     Rehabilitations

Ø     Research activities

 


 

CONCLUSION

 

          Despite effective case finding and effective therapeutic tools and declines in mortality and morbidity rates in some countries, tuberculosis appears to continue as an important communicable disease problem, world wide.


 

BIBLIOGRAPHY

 

Community Health Nursing

B.T. Basavanthappa

2nd Edition

Page No.713-715.

 

Parks Text Book of Preventive and Social Medicine

17th Edition

Page No.146-150

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