1. Adult Medical-Surgical Nursing Respiratory Module: Tuberculosis

2. Tuberculosis (TB): Description Tuberculosis is a chronic infectious disease primarily of the lungs (but may spread elsewhere through blood/ lymph) Caused by Mycobacterium Tuberculosis, an acid-fast bacillus Spread by droplet infection: very infectious in close communities

3. Tuberculosis: Epidemiology/ Incidence TB is the leading cause of death from infectious disease world-wide Associated with poverty, malnutrition, overcrowding, poor health care, HIV A historical decline of TB occurred in C20 in some areas with ↑ housing, sanitation nutrition (↑ immunity) and later antibiotics Now increased incidence, associated with migration, HIV, multi-drug resistance

4. Tuberculosis: Pathophysiology TB bacilli are inhaled and start to multiply in the alveoli Inflammatory/ immune response occurs (2-10 weeks post-exposure): Exudate accumulates in the alveoli (bronchopneumonia) →

5. Tuberculosis: Pathophysiology Disease progression leads to formation of granulomas in the alveoli (live and dead bacilli surrounded by macrophages) → Granulomas fibrose surrounding a necrotic centre: “Ghon Tubercles” → Calcification = dormant state (no longer active disease)

6. Tuberculosis: Reinfection If while TB is dormant patient immunity becomes low: Reinfection/ re-activation occurs from the dormant state → Active disease The Ghon Tubercles ulcerate, releasing the cheesy material with live bacilli into the bronchi Bacilli are airborne and spread the disease

7. Tuberculosis: Progression of the disease TB is a chronic respiratory disease with: Slow progression in the lung Long remission periods Untreated disease spreads to other organs via the blood and lymph (kidneys, bone, brain) Prolonged intensive treatment required to eradicate the bacilli Health/ immune response affects progress

8. Tuberculosis: Clinical Manifestations Insidious onset Low grade fever Cough: Non-productive, mucopurulent or haemoptysis - “rusty” Night sweats Fatigue Weight loss

9. Tuberculosis: Diagnosis Chest Xray (AP/ lateral) Sputum for Acid-Fast Bacilli (AFB) Mantoux (PPD) tuberculin skin test: wheel/flare reaction read at 48-72 hours (if immunosuppressed may be no reaction) QuantiFERON-TB Gold Test: enzyme- linked immunosorbent assay (ELISA) blood test to detect interferon-gamma released from white blood cells in TB

10. Tuberculosis: Diagnosis To monitor spread of disease outside the lungs: Skeletal Xray Early morning urine samples for AFB

11. Tuberculosis: Management Notification to the Ministry of Health Immediate follow-up and screening of all contacts (given prophylactic treatment) If active TB, respiratory isolation until remission (usually non-infectious after 2-3 weeks of continuous therapy) Intensive antibiotic therapy over 6-12 months to prevent relapse

12. Tuberculosis: Antibiotic Therapy Anti-TB antibiotic drugs are: RifampicinPyrazinamide Isoniazid (INH) StreptomycinEthambutol

13. Tuberculosis: Antibiotic Treatment Regime At least 4 drugs used intensively for the first 8 weeks If sputum culture is sensitive to the drugs: Treatment with 3 drugs for further 8 weeks (stop Streptomycin or Ethambucil) Isoniazid (INH) and Rifampicin therapy for further 4-8 months (total 8-12 months) Vitamin B6 taken with INH to avoid neuropathy

14. Tuberculosis: Nursing Considerations Follow-up screening of all contacts Patient and family education: The importance of strict adherence to medication (* if not taken regularly resistance develops*) Avoidance of spread of disease (isolation): health education Importance of good nutrition, hygiene, adequate housing in improving immunity

15. Tuberculosis: Follow-up/ Monitoring Progress Monitor progress through: Vital signs (spiking temperature) Night sweats Weight (gain/ loss) Regular chest Xrays Sputum samples Monitor for drug side-effects