1. Tuberculosis: What you need to know!
Gini Orthner RN, BScN
TB Nurse Clinician
TB Control Saskatchewan – Regina Office
History of TB Control
Provincial program run through the Saskatoon Health Region.
Staff include 6 RN’s
5 physicians
6 office staff
1 health records
3 stationary clinincs – Saskatoon, P.A., and Regina
Mobile clinics through out the northern part of the province
Partner with GP’s, specialists, FNIH, FN bands and staff, immigration, correctional institutions, general public

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
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. Directly observed therapy (DOT) was started in 1990.
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
Lymph node/scrofula – common in clavicular lymphnodes
Ocular – difficult to diagnose as obtaining specimens is difficult, often present with decreased visual acuity and often have signs of systemic TB (miliary)
Miliary/disseminated, wide spread dissemination of bacteria
Skin/bone marrow/great vessels – rare, treat empirically while waiting lab results

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
Infectious
Non-Infectious
Smear positive -isolation x 2 weeks
Smear negative
Culture positive
May have an Abnormal CXR
Start Treatment ASAP

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 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. Symptoms of TB Early Signs of TB Signs of Advanced 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

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)
If coughing, collect 3 consecutive early morning sputums. Send to Provincial Lab/ Saskatoon Lab for AFB testing. If child, arrange for gastric washings. If non pulmonary send fluid/tissue sample for testing.

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

21. Mantoux Tests
Indicates TB 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. Treatment - Now 1st Line Drugs 2nd Line Drugs Isoniazid (INH)
Rifampin (RMP)
Ethambutol (EMB)
Pyrazinamide (PZA)
2nd Line Drugs
Moxifloxacin
Levofloxacin
Amikacin
Occurs in places such as Russia, Phillipines,
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. TB kills more people than any other infectious disease
Interesting Facts…
After HIV/AIDS,
TB kills more people than any other infectious disease
WHO 2008

31. 1/3 of the world’s population is infected with TB
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 –
Saskatoon Office – /
Prince Albert Office –
Regina Office –