Lecture 5
TUBERCULOSIS (TB)
MAJOR GLOBAL HEALTH THREAT
Course Instructor : Nadira Sultana Kakoly (NSK)
Assistant Professor
Department of Public Health
School of health and life sciences, North south
university
Global TB situation
► Leading cause of death from a single infectious agent
► Approximately 2 billion are currently infected with TB
► A total of 8 countries share the 2/3 of global TB burden, India, Indonesia, China, the
Philippines, Pakistan, Nigeria, Bangladesh and South Africa
► 10 million new cases developed in 2019 (7.1 million detected), 12% of them were
under-5 children and 32% were adult female
► In 2019, 1.2 million HIV- TB patient died and 208,000 more who were HIV+
► By 2022, a total of 13 billion USD will be required for TB prevention, diagnosis and care
SDG target for TB
TB etiology
► TB is caused by a bacteria Mycobacterium tuberculosis (MTB). Also
known as Acid fast bacilli (AFB)
► Robert Koch isolated MTB in 1882 which won him the Nobel Prize in
1905. MTB is also called Koch’s bacillus
TB Transmission
What happens after MTB enters…
Droplet
Infected nuclei Healthy
person MTB person
Cough/sneeze stay in air, 1-
inhales
exhales 5 micron
Macrophage Engulfed by MTB goes to
tries to kill Macrophage Lung
MTB (a special type tries to
MTB tries to of immune cell) multiply
survive
Macrophage and Formation of MTB becomes
other immune cells Granuloma dormant or
makes a (protective layer latent
protective shell consisting of immune
cells around MTB) (LTBI)
around MTB
Fate of TB infection
Later the granuloma can breakdown (due to reduced
immunity or other causes) and cause “Reactivation”
of MTB that results in active TB disease.
Click the icon to see a
video on LTBI and LTBI Active Miliary
Active disease TB TB
TB classification (site)
Tuberculosis
Pulmonary Extra-pulmonary
Tuberculosis Tuberculosis
(affects organs other than
(affects the lung)
lung)
Primary or Secondary Lymph node TB
TB Gastrointestinal TB
TB Meningitis
Skeletal TB (Bone
TB/Spine TB)
Pericardial TB
LTBI vs. TB Disease/Active TB
Criteria LTBI TB Disease
Symptoms Absent Present
Feeling sick Does not feel Feels
sick sick
Spreading TB Can not spread Can spread
CXR – negative, Sputum – CXR, Sputum, skin test –
Test results
negative, skin test – positive positive
Treatment requirement Depends on context Required
Pulmonary TB (PTB) vs. Extra pulmonary TB
(EPTB)
Criteria Pulmonary TB Extrapulmonary TB
Lung Other than lung (Brain, spine,
Site
bone, lymph node)
Cough, blood in cough, chest General symptoms plus
Symptoms
pain Specific to location
Can spread TB Cannot spread TB
Spreading TB
Sputum + Sputum –
Test results skin test + Skin test +
Chest X ray + Chest X ray -
Shorter Longer
Treatment duration
Risk Factors for Progression (LTBI 🡪 Active TB)
► Persons infected with HIV; 2.2
► Children younger than 5 years of age;
Global number of TB
cases (in millions)
► Persons infected with M. tuberculosis in the past 2 years attributable to the risk
factors
► Persons who are receiving immunosuppressive therapy
0.8
0.7 0.7
► Persons with diabetes, kidney disease, pre-existing lung disease
0.4
► People with undernutrition; medically underserved, low-
income population n n se g s
itio tio u k in e te
tr fe
c ol o
ia
b
nu in o m
► Cigarette smokers, drug abusers, alcoholics er IV oh S D
nd H lc
U A
Symptoms of Active TB
► Evening rise of temperature ► Weakness or fatigue
► Cough lasting 3 weeks or longer ► Weight loss/no appetite
► Chest pain ► Chills and sweating at night
► Coughing up blood or sputum
Diagnosis – conventional
for LTBI…
Skin test/Tuberculin skin test (TST)/Mantoux test (MT)
► The TB skin test is performed by injecting a small amount of fluid
(called tuberculin) into the skin on the lower part of the arm
► A person given the tuberculin skin test must return within 48 to 72
hours to have a trained health care worker look for a reaction on
the arm
► A swelling of 10 mm or more indicates positive for TB infection. For
HIV+ patients or history of exposure, 5 mm is also considered
positive
Diagnosis – conventional
for LTBI…
Interferon Gamma Response Assay (IGRA)
► Whole blood are collected and mixed with a TB derived antigen
► White blood cells produce interferon gamma
► Measuring the response can determine prior exposure to TB
Diagnosis – conventional
For TB disease/Active TB
Sputum for bacteria
► Smear – examined under microscope after staining
► culture media – a specially made material to
support the growth of MTB.
► GeneXpert – It amplifies the genetic material of
MTB and identifies
Chest X ray
► to identify the lung physiology altered by MTB
infection
Diagnosis – new line of diagnosis
For LTBI or Active TB
Blood based biomarker for diagnosis
► When MTB enters our body, our immune system puts up a concerted effort to fight
infection leading to change in genetic levels of the blood cells
► Detection of these changes can allow us to diagnose TB from blood sample
Treatment – drugs
► Majority of the active TB cases can be effectively treated with current drugs available
► Treatment required for 6-9 months A new line of treatment, known as the Host directed
► Two lines of drugs: therapy (HDT) has been developed for TB. These
drugs does not kill the TB bacteria but modulates the
► First line:
immune response against the TB, thus facilitates the
► Isoniazid clearance of MTB from host body
► Rifampicin
Conventional Anti-TB drugs + HDT can reduce the
► Ethambutol duration of the treatment, thus reducing the toxic
► Pyrazinamide effect of conventional anti-TB drugs
► Second line (levofloxacin, moxifloxacin, bedaquiline, delamanid, linezolid, streptomycin)
MDR-TB and XDR-TB
Multidrug resistant TB (MDR-TB)
Organisms resistant to the most effective anti-TB drugs, isoniazid and rifampicin
Extensively Drug Resistant TB (XDR-TB)
Organisms resistant to both first line anti-TB drugs, isoniazid and rifampicin plus two or more
second line drugs
ALL TB
BACTERIA
MDR
TB
XDR
TB
Facts about MDR-TB & XDR-TB
► MDR and XDR TB are the same M. tuberculosis organism with the same way of transmission and
infectivity. They are just “more difficult to cure”
► Drug resistance occurs when drug-susceptible TB patients do not receive the correct treatment
regimens or do not complete the of treatment.
► MDR and XDR-TB forces us to go for more toxic and longer duration treatment.
► Globally, 465,000 patients are infected with MDR-TB (3.3% of all TB cases). Around 0.5 million
cases were detected in 2019
► In 2019, 12,300 cases of XDR-TB were detected.
► Worldwide, only 57% of MDR-TB patients are currently successfully treated
Prevention
Vaccine
► BCG (bacille Calmette-Guérin) is mostly used vaccine
► Being used for 8o years, in many countries including Bangladesh
► Prevents severe TB in children, also TB meningitis
► Does not prevent primary infection or reactivation of LTBI
► Research on new experimental vaccines going on (14 vaccine candidates are being
worked on)
Bangladesh situation
► Bangladesh one of 8 countries sharing 2/3 of global TB burden
► In 2019, a total of 361,000 new cases were detected and 38,000 deaths (11% case fatality rate) were
attributed to TB. MDR cases reported 3,300. Around 7 XDR-TB cases were detected.
► Treatment coverage is 81%
► Have been implementing Directly Observed Chemotherapy, Short Course (or DOTS) since 1993
► A treatment success rate of 94% has been achieved among TB cases. MDR-TB treatment success rate is
also high at 73% (greater than 55% globally)
► Challenges: ensuring universal access to TB care, Lack of engagement of private health practitioners and
lack of awareness
https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/
TB Treatment
facilities/DOTS
THANK
