PUBLIC HEALTH ASPECTS OF

TB
IMRAN HASSAM
AUBREY FILIMONI
ROSETTE KAMWAZA
TAWFEEQ QASSIM
CHANA KHULUZA
PAUL MLENGA
JUSTICE MAGASO
OBJECTIVES

1. Introduction
2. Epidemiology and global burden
3. TB transmission and risk factors
4. Clinical aspects, diagnosis and issues in treatment of TB
5. Global strategies against TB
6. Impact of Covid-19 on TB
1. INTRODUCTION

• Tuberculosis (TB) is contagious and airborne.

• In 2022, TB was the second leading infectious disease killer

worldwide.

• It was also the leading killer of people with HIV and a major cause of
deaths related to antimicrobial resistance.
 2. TB GLOBAL BURDEN
• In 2022, an estimated 10.6 million people fell ill with TB worldwide. People living
with HIV accounted for 6.3% of the total.

• The TB incidence rate (new cases per 100 000 population per year) rose by 3.9%
between 2020 and 2022, reversing declines of about 2% per year for most of the
past 2 decades.

• Globally in 2022, TB caused an estimated 1.30 million deaths, including 167 000
people with HIV.

• Eight countries accounted for more than two-thirds of the global total.
Global trends in the estimated number of TB incidence rate (2010–2022)
WHO’s END TB STRATEGY
Where are we now?...
TB BURDEN IN MALAWI

• The TB incidence was at 146/100 000 population in 2021 and TB

incidence has been declining at an average rate of 7.1% during the last
5 years.

• In 2019, tuberculosis death rate for Malawi was 14 cases per 100,000
people.

• 20.6 million are living with HIV in sub-Saharan Africa accounting to

71% of the global burden of HIV infection
3. TB TRANSMISSION AND RISK FACTORS
TUBERCULOSIS TRANSMISSION

• Airborne transmission
• Coughing
• Sneezing
• Singing
• Can remain suspended in the air for 30 minutes to several hours.
RISK FACTORS FOR TUBERCULOSIS

INDIVIDUAL RISK FACTORS ENVIRONMENTAL AND SOCIAL

RISK FACTORS
Age Occupation risk (health workers)
HIV infection Poor ventilation
Malnutrition Crowding
Diabetes mellitus Migration
Alcohol and smoking Homelessness
Closeness of contact
Duration of contact
4. CLINICAL ASPECTS, DIAGNOSIS AND ISSUES IN
TREATMENT OF TB

We will now look at:

• Available methods of diagnosing TB ( latent vs active TB)

• Standardized treatment regimens for TB
• Treatment of drug resistant TB
• Issues in treatment of TB
TB DIAGNOSIS
AVAILABLE DIAGNOSTICS

• Sputum Smear Microscopy

• Sputum culture
• X pert MTB/RIF
• Urine LAM
• Computer aided X-ray (DCXR)
• Chest X ray
• FASH (CAD)
1. SPUTUM SMEAR MICROSCOPY

• Two staining methods:

Ziel-Neelsen (ZN) staining
 Fluorescent auramine staining.
Advantages:
• Enables quick detection of infectious cases of TB
• A cheap and simple method
• Produces rapid and reliable results
• Essential for treatment monitoring

Limitations:
• Unable to differentiate drug-susceptible strains from drug-resistant strains
• Has low sensitivity
• Cannot distinguish mycobacterium tuberculous complex (MTB) from non-
tuberculous mycobacterium
2. SPUTUM CULTURE
• Gold standard

ADVANTAGES
• 30-50% more sensitive than microscopy
• Allows species identification and drug susceptibility testing
• Recommended for monitoring treatment response of drug resistance TB

LIMITATIONS
• High biosafety level requirement
• Requires well trained personnel
• Requires an efficient sample transportation system
3. SPUTUM XPERT MTB/RIF

Indicated for diagnosis of MTB and rifampicin resistance

Detection within 2 hours
Aids in prompt diagnosis and treatment
Gene xpert ultra is an improved version of xpert MTB/RIF
Highly sensitive second generation Xpert MTB

ADVANTAGES
High sensitivity and specificity
Detects both MTB and Rifampicin resistance
Requires minimal technical training
Quick results
4.URINE LAM 5. CHEST XRAY
 Point of care investigation in PLHIV.  Essential and fast tool for early
a) Alere-LAM detection of TB
b) Fuji-LAM  It has high sensitivity but limited
 Investigation takes one hour specificity for diagnosis of pulmonary
 Picks up antibodies TB
 Has higher sensitivity compared  It can assist diagnosis of TB among
with AlereLAM people living with HIV
 useful to rule out TB disease before
provision of treatment for latent TB
6. COMPUTER ASSISTED DIAGNOSIS

 Is a method of making a diagnosis using the output of a computerized

scheme for automated image analysis as a diagnostic aid
 This is just complementary to the opinion of the physician

ADVANTAGES
 Eliminates poor inter-reader reliability
 Eliminates potential delays in interpretation
7. FASH ULTRASOUND

 Aimed at improving TB diagnosis

for high risk group
 Essential for disseminated and
extrapulmonary TB
 Focus on findings as pericardial
effusion, pleural effusion, lymph
nodes, ascites, lesions and fluid
in specific areas
DIAGNOSING LATENT TB

Available testing methods for Mtb infection:

- Mantoux tuberculin skin test

- Interferon-gamma release assays (IGRAs)

o QuantiFERON-TB Gold test (QFT-G)
o Quantiferon-TB Gold In-Tube (QFT-GIT)
o T-SPOT
TREATMENT
 LATENT TB

DRUG REGIMEN
6 months isoniazid daily
3 months weekly Rifapentine plus Isoniazid (3HP)

TARGETS
PLWHIV
Under five years who are household contacts of PTB
The elderly
Drug-susceptible TB

Isoniazid (H)
Rifampicin (R)
Pyrazinamide (Z)
Ethambutol (E)
Streptomycin(S)
The standard treatment duration for drug-susceptible TB is 6 months
and 9 months for spinal TB and TB meningitis
DRUG RESISTANT TUBERCULOSIS

Multidrug-Resistant Tuberculosis (MDR-TB): resistant to both

Isoniazid and Rifampicin.

Extensively Drug-Resistant TB (XDR TB): resistant to isoniazid and

rifampicin, along with any one of the fluoroquinolones and at least
one of three injectable second-line drugs
 Treatment of MDR and XDR TB
A. Fluoroquinolones Levofloxacin (Lfx), Moxifloxacin(Mfx), Gatifloxacin (Gfx)

B. Second-line injectable agents Amikacin (Am), Capreomycin (Cm), Kanamycin(Km)

C. Other core second-line agents Ethionamide/Prothionamide (Eto/Pto)
Cycloserine/Terizidone (Cs/Trd)
Linezolid (Lzd)
Clofazimine (Cfz)

D. Add-on agents (not part of the D1 Pyrazinamide(Z), Ethambutol(E)

core DR-TB regimen) High-dose isoniazid (Hh)

D2 Bedaquilline (Bdq)
Delamanid (Dlm)

D3 p-amino salicylic acid (PAS)

Imipenem-cilastatin (Ipm)
Meropenem (Mpm)
Amoxicillin-clavulanate (Amx-Clv)
 STANDARDIZED REGIMEN FOR RR/MDR-TB MANAGEMENT

Intensive phase
8 Capreomycin-Levofloxacin-Cycloserine-Ethionamide-
Pyrazinamide

Continuation phase
12 Levofloxacin-Cycloserine-Ethionamide- Pyrazinamide
 ISSUES IN TREATMENT OF TUBERCULOSIS

Drug Resistance
 The emergence of drug-resistant strains of TB, such as multidrug-
resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-
TB), poses a significant challenge to TB control efforts.
 These strains are harder to treat, requiring more expensive and
lengthy treatment regimens, which strain healthcare systems and
may lead to poorer outcomes.
 This resistance develops due to inappropriate treatment
regimens, poor adherence to treatment, and inadequate
healthcare infrastructure.
Treatment Adherence
 TB treatment typically involves a prolonged course of
antibiotics, often lasting six months or more.
Ensuring patient adherence to treatment is crucial to prevent
the development of drug resistance and achieve successful
outcomes.
However, factors such as socioeconomic status, stigma, lack
of social support, and side effects of medication can all affect
adherence rates.
Co-infection and Comorbidities
TB often coexists with other health conditions, such as
HIV/AIDS, diabetes, and malnutrition, which can complicate
diagnosis and treatment.
Integrated approaches to healthcare delivery, addressing
both TB and its comorbidities, are necessary to improve
patient outcomes and reduce the burden of disease.
Access to Diagnosis and Treatment
Access to quality healthcare services, including diagnostic testing
and treatment, is essential for TB control.
However, Limited access to diagnostic tools, such as molecular
tests and chest X-rays, delays TB diagnosis and treatment
initiation.
- Additionally, barriers to accessing healthcare services, including
geographical remoteness and financial constraints, contribute to
delayed or inadequate treatment.
Stigma and Social Determinants of Health
Stigma associated with TB can lead to social isolation,
discrimination, and reluctance to seek care, particularly in
marginalized communities.
Addressing social determinants of health, such as poverty,
housing instability, and lack of education, is essential for
improving TB outcomes and reducing disparities in access to
care.
Healthcare Worker Safety
Healthcare workers are at increased risk of TB infection due
to occupational exposure.
Ensuring infection control measures, including proper
ventilation, use of personal protective equipment, and
screening of healthcare workers for TB, is critical to prevent
transmission in healthcare settings and protect both patients
and providers.
UPDATE ON TB TREATMENT

• 4- month rifapentine containing regimen

Rifapentine
Isoniazid
Pyrazinamide
Moxifloxacin
UPDATE ON MANAGEMENT OF MDR-TB

 6-month bedaquiline, pretomanid, linezolid (600 mg), and

moxifloxacin (BPaLM) is recommended rather than 9-month or longer
regimens in multi DR/rifampicin-resistant TB (MDR/RR-TB).

 9-month regimen is suggested instead of longer regimens in

fluoroquinolones-susceptible MDR/RR-TB.

 18-month regimens remain a valid option if shorter regimens cannot

be implemented
FOUR WAYS TO PREVENT DRUG RESISTANCE TB

Early detection and high-quality treatment of drug-susceptible and

drug resistant TB
Good TB infection control measures to minimize the risk of TB
transmission within populations
Health system strengthening and regulation and access to TB
diagnostics and drugs
Addressing underlying risk factors and social determinants of TB
4. GLOBAL STRATEGIES AGAINST TB
The End TB Strategy

PRINCIPLES

1. Government stewardship and accountability, with monitoring and

evaluation

2. Strong coalition with civil society organizations and communities.

3. Protection and promotion of human rights, ethics and equity.

4. Adaptation of the strategy and targets at country level, with global

collaboration
PILLARS AND COMPONENTS

1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION

a. Early diagnosis of TB including universal drug-susceptibility testing, and

systematic screening of contacts and high-risk groups.

b. Treatment of all people with TB including drug-resistant TB, and patient

support.

c. Collaborative TB/HIV activities, and management of comorbidities.

d. Preventive treatment of persons at high risk, and vaccination against TB.

2. BOLD POLICIES AND SUPPORTIVE SYSTEMS

a. Political commitment with adequate resources for TB care and prevention.

b. Engagement of communities, civil society organizations, and public and private

care providers.

c. Universal health coverage policy, and regulatory frameworks for case

notification, vital registration, quality and rational use of medicines, and
infection control.

d. Social protection, poverty alleviation and actions on other determinants of TB.

3. INTENSIFIED RESEARCH AND INNOVATION

a. Discovery, development and rapid uptake of new tools,

interventions and strategies.

b. Research to optimize implementation and impact, and promote

innovations.
5. COVID 19 IMPACT ON TB
OPPORTUNITIES

Mask wearing has become a regular practice

Avoidance of unnecessary physical contact
Most health facilities upgraded
The frequency of aerosol generation reduced
The health sector gained global attention
CHALLENGES

Fall in disease detection and notification

Similarity of symptoms
Stigma
Increased Spread and confinement
Limited laboratory services
Increase in annual TB incidence and mortality
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