Download Clinical Presentation and Diagnosis of Tuberculosis (animated

ISTC Training Modules 2008
Slide 1
Clinical Presentation and Diagnosis of TB (animated version)
Instructor’s Guide
Module: Clinical Presentation and Diagnosis of
Tuberculosis
ISTC Standards covered: 1 – 5
Module Time: Approximately 60 minutes
Alternate slides: Introductory ISTC slides
Interactive options: Ideas for interactive discussions are
offered on many of the slides in this module. Participant
discussion can enhance active learning, but will add more time
to the lecture and must be planned for.
Slide-show Animation: A second version of this talk is
available with slide animations: Clinical Presentation and
Diagnosis of TB (Animated).
Additional Material: Slides containing related material may
be found in the following modules: Microbiological diagnosis
of Tuberculosis, TB and HIV Infection: Introduction and
Diagnosis.
Test Questions: May be attached or inserted within
presentation for discussion purposes, or alternatively,
combined with questions from other modules to produce
evaluation tool.
The full text of the ISTC and all supporting references are
available at www.istcweb.org
Other useful Resources/References:
• Management of tuberculosis training for health facility
staff. World Health Organization, 2003.
www.who.int/tb
• Radiographic Manifestations of Tuberculosis: A
Primer for Clinicians, Second Edition. Francis J.
Curry National Tuberculosis Center.
www.nationaltbcenter.edu
• Toman’s tuberculosis. Case detection, treatment and
monitoring, 2nd Edition. Freiden TR ed., World
Health Organization, 2004. www.who.int/tb
• A Tuberculosis Guide for Specialist Physicians. Jose
A. Caminero Luna, IUATLD, Sept. 2004.
www.tbrieder.org
[Image Credit: Lung Health Image Library/Jad Davenport]
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Slide 3
Slide 2
ISTC Training Modules 2008
•
It is intended that after completion of this module
the student will be able to describe the approach
to diagnosis of TB and the proper role of
diagnostic testing, particularly sputum
microscopy, in that process.
•
[Review objectives from slide]
•
Overview of Clinical Presentation and Diagnosis
of TB
[Review overview from slide]
•
Lecture/module includes International Standards 1
–5
•
[Image of sputum smear photomicrograph reveals
Mycobacterium tuberculosis bacteria using acidfast Ziehl-Neelsen stain]
Slide 4
[Image credits: Lung Health Image Library/Jad Davenport (top);
CDC Public Health Image Library/Dr. George P. Kubica (bottom)]
•
In introducing the Standards for Diagnosis of TB,
it is important to recognize: [Review content of
slide]
[Image credit: Lung Health Image Library/Virginia Arnold]
Clinical_diagnosis_animated_2008.ppt
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Slide 5
Animation Clicks: 3
ISTC Training Modules 2008
•
Therefore, two fundamental points that should be
stressed are: [Review content of slide]
•
[Click: Slide-show Animation].
•
To diagnose TB, we must Think TB.
Slide 6
[Image credit: Lung Health Image Library/Pierre Virot]
Begin with: Classic TB clinical presentation.
•
Slide 7
Animation Clicks: 1
•
Clinical_diagnosis_animated_2008.ppt
The most common symptom of pulmonary TB is
persistent productive cough, often accompanied
by nonspecific constitutional symptoms, such as
fever, night sweats, and weight loss.
Extra-pulmonary TB, such as lymphadenopathy,
may be noted, especially in patients with HIV
infection.
•
Nonspecific systemic, constitutional symptoms
may include:
[Review content of slide]
•
[Click: Slide-show Animation]. It is important
to also recognize that there are many cases of TB,
up to 10-20%, that may present without any
symptoms at all.
Page 3 of 22
Slide 8
ISTC Training Modules 2008
Slide 9
The diagnosis of TB with HIV co-infection can be more
difficult.
• Symptoms may be more nonspecific, but fever
and weight loss may be more prominent at
presentation.
• Cough and hemoptysis are less common because
there may be less cavitation, inflammation and
endobronchial irritation in HIV patients.
• CXR findings can be more variable, with both
“typical, post-primary or reactivation TB” and
“atypical, primary TB” CXR patterns commonly
seen. In people infected with HIV, obtaining a
timely CXR plays an important role in shortening
delays in diagnosis and should be performed early
in the investigation of a TB suspect.
• The diagnosis of TB may be further complicated
by the broader range of possible alternative
diagnoses. The physical signs of respiratory
infection in patients with pulmonary TB (PTB) do
not readily distinguish PTB from other chest
diseases and chest examination may even be
normal. Because of the broader differential
diagnosis, access to and utilization of culture and
more invasive diagnostic become more important
issues.
• An accurate TB diagnosis may be further
complicated due to the higher rate of
extrapulmonary and disseminated disease in HIVinfected individuals.
•
So what guidance do the International Standards
for TB Care offer for prioritizing who to evaluate
for the diagnosis of TB?
•
Standard 1: [Read Standard]
[Image credit: Lung Health Image Library]
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Slide 10
Animation Clicks: 1
ISTC Training Modules 2008
•
•
•
•
Although most patients with pulmonary TB have
cough, the symptom is not specific to TB; it can
occur in a wide range of respiratory conditions,
including acute respiratory tract infections,
asthma, and chronic obstructive pulmonary
disease.
While the presence of cough for 2-3 weeks is
nonspecific, traditionally, having cough of this
duration has served as the criterion for defining
suspected TB and is used in most national and
international guidelines, particularly in areas of
moderate- to high-prevalence of TB.
Data from India, Algeria, and Chile generally
show that the percentage of patients with positive
sputum smears increases with increasing duration
of cough, and a more recent assessment from
India demonstrated that by using a threshold of
>2weeks to prompt collection of sputum
specimens, the number of TB cases identified
increased by 46%.
Certainly, duration of cough is not the only
criterion that should raise suspicion for
tuberculosis, other features of the presentation
may raise your concern for TB in patients with a
shorter duration or even absence of cough,
therefore [Click: Slide-show Animation] clinical
intuition plays an important role in the evaluation
for TB. This is particularly true with HIV coinfection where TB presentation may be more
atypical and lack of cough more common.
[Reference: Santha T., et al. Comparison of cough 2 and 3 weeks to improve
detection of smear-positive tuberculosis cases among out-patients in India.
Int J Lung Dis 2005;9(1):61-8]
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Slide 11
ISTC Training Modules 2008
Slide 13
Animation Clicks: 1
Slide 12
In evaluating persons who have symptoms that my be
caused by TB it is important to identify risk factors for
either:
• Recent infection with M. TB due to transmission
risks and/or factors that may increase the
likelihood of progression to active TB once an
individual is infected.
Clinical_diagnosis_animated_2008.ppt
•
The presence of any of these factors should raise
the clinician’s suspicion for TB.
•
Significant risk factors for possible recent
infection include:
[Review content of slide].
•
Significant risk factors that may increase the
likelihood of progression to active TB once an
individual is infected include:
[Review content of slide]
•
[Interactive option – ask participants what risk
factors are most prevalent in their local areas and
practices? Are there any other special groups or
settings not listed here that are important to their
region?]
•
The physical examination is non-specific in TB
but useful to identify sites of TB: [Review
content of slide]
[Click: Slide-show Animation]
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Slide 14
ISTC Training Modules 2008
•
•
•
•
In persons who are suspected of having TB based
on symptoms and/or physical findings, every
effort must be made to identify the causative
agent.
The first important step is highlighted by the
International Standard 2: [Read Standard]
[Note: Guidelines have recently changed from
three sputum smears to at least two sputum
smears. The change is reflected above and differs
from the wording in the original published ISTC.]
[Image shows sputum smear with carbolfuchsinbased stain demonstrating typical acid-fast bacilli
morphology]
Slide 15
[Image credit: CDC Public Health Image Library / Dr. George P.
Kubica]
•
•
•
•
While a definitive microbiological diagnosis can
only be confirmed by culturing M. tuberculosis
complex (or, under appropriate circumstances,
identifying specific nucleic acid sequences) from
clinical specimens, in practice, there are many
settings where these tests are not currently
feasible (due to resource limitations).
Fortunately, microscopic examination of stained
sputum, i.e. an AFB smear, is feasible in nearly
all settings.
In almost all clinical circumstances in high
prevalence areas, finding acid-fast bacilli in
stained sputum is highly specific and, thus, is the
equivalent of a confirmed diagnosis.
In addition to being highly specific for M.tb,
identification of AFB by smear is particularly
important for three reasons:
•
It is the most rapid method for
determining if a person has TB
•
It identifies persons who are at greatest
risk of dying from the disease*
•
And it identifies the most likely
transmitters of infection
*[Note that in persons with HIV infection, mortality rates are greater
in patients with clinically-diagnosed TB who have negative sputum
smears than among HIV-infected patients who have positive sputum
smears.]
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Slide 16
ISTC Training Modules 2008
•
The limitation of sputum smear microscopy is its
sensitivity.
•
As illustrated in the table: compared with culture,
sputum smear microscopy is 68% sensitive in
detecting M. tuberculosis.
•
Of all specimens that are AFB positive nearly
86% are detected by examining one specimen and
an additional 12% are found on the 2nd specimen;
thus, the incremental yield of the 3rd specimen is
very low. A similar increment is found for the
sensitivity of the 2nd and 3rd specimens.
•
The yield is better with a single early morning
specimen than with a spot specimen obtained at
other times during the day.
[Reference: Mase SR, et al. Yield of serial sputum specimen
examinations in the diagnosis of pulmonary tuberculosis: a
systematic review. Int J tuberc Lung Dis 2007;11(5): 485-95]
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Slide 17
Animation Clicks: 1
ISTC Training Modules 2008
While we often focus on the pulmonary presentation and
evaluation for TB, it is important to remember that TB
may present in many ways.
Can this case be TB?
“A 54 year-old man with three months of focal low back
pain” presents with this radiographic finding.
[Click: Slide-show Animation]
• Yes, this is a patient presenting with spinal
tuberculosis, or “Pott’s disease”, with radiographic
evidence of vertebral destruction.
• Site specific symptoms are often the catalyst for
discovery of extrapulmonary sites of involvement.
• While the radiographic findings in this case may
easily bring TB into the differential diagnosis for
this patient, often with extrapulmonary disease,
pertinent TB risk factors must be recognized by
the astute clinician for TB to be considered and
proper diagnostic testing (which include both
culture and histopathologic sampling if available)
be initiated.
[Interactive option – Ask participants for their
experiences with cases of extrapulmonary TB where the
diagnosis was a surprise. What kind of sampling/testing
for extrapulmonary disease is available to them in their
practice? Any creative solutions to difficulties
encountered in obtaining diagnostic samples or
possibilities for shared resources?]
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
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Slide 18
ISTC Training Modules 2008
Standard 3 reinforces these points: [Read Standard 3]
•
•
•
•
Clearly, appropriate specimens may be difficult to
obtain from some extrapulmonary sites.
In spite of the difficulties, however, the basic
principle that bacteriological confirmation of the
diagnosis should be sought still holds.
Generally, there are fewer M.tb organisms present
in extrapulmonary sites, so identification of acidfast bacilli by microscopy in specimens from
these sites is less frequent and culture is more
important.
If tissue biopsy material is obtained, diagnosis of
TB may also be suggested by histopathologic
demonstration of appropriate granulomatous
lesions.
[Instructor Notes: If the Microscopic Diagnosis module
will not be covered in your curriculum, consider
reviewing the Microscopic Diagnosis module for
additional speaking points or slides that would be of
interest for this topic.]
Slide 19
Animation Clicks: 1
[Image credit: IUATLD www.tbreider.org]
•
•
Extrapulmonary TB (without lung involvement)
accounts for 15-20% of TB in populations with a
low prevalence of HIV infection.
In populations with a high prevalence of HIV
infection, the proportion of cases with
extrapulmonary TB is higher.
[Click: Slide-show Animation]
•
Clinical_diagnosis_animated_2008.ppt
Here, as a general example, is the breakdown of
extrapulmonary involvement by site as reported in
the United States.
[Review content of slide]
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Slide 20
ISTC Training Modules 2008
Other examples of extrapulmonary presentations:
•
Tuberculous pleural effusion
•
CNS tuberculomas (two enhancing lesions seen
on CT scan of head).
•
Tuberculous adenitis (sometimes referred to as
“scrofula”). Patient had both an enlarged anterior
cervical node as well as a draining cutaneous
fistula from supraclavicular nodes.
Slide 21
[Image credits: Francis J. Curry National TB Center (left and top
right); Austin Brewin, MD (bottom right)]
Slide 22
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
•
•
•
While CXR examination can be a useful tool in
the diagnosis of TB, remember that it is a
sensitive, but not specific test for detecting TB.
Key point: A diagnosis of TB cannot be
established by radiography alone. Reliance on
the chest radiograph as the only diagnostic test for
TB will result in both over-diagnosis of TB and
missed diagnosis of TB and other diseases.
Thus, the importance of Standard 4: [Read
Standard]
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
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Slide 23
Animation Clicks: 1
ISTC Training Modules 2008
Can this case be TB?
[Click: Slide-show Animation]
• Yes - This is an example of a classic CXR pattern
many would describe as a “typical pattern” or a
reactivation/post-primary TB pattern.
• The distribution of disease is often cited as:
[Review content of slide]
•
Note that the presentation of an isolated upper
lobe anterior segment infiltrate on CXR is unusual
for M.tb, and may hint at another etiologic
organism, perhaps a non-tuberculous
mycobacterium (e.g. M. avium complex). The
anterior segment of the upper lobe in this CXR is
clear.
[Interactive option – ask participants to respond to the
question (this will likely illicit a quick “yes” response
and will confirm what they know)]
Slide 24
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
•
Specific radiographic patterns seen on CXR that
may be associated with reactivation/post-primary
TB include: [Review content of slide]
•
This radiograph shows a small area of opacity
with cavitation in the left upper lobe.
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
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Slide 25
Animation Clicks: 1
ISTC Training Modules 2008
Can this case be TB?
• [Top CXR: Focal right mid-lung infiltrate with
hilar adenopathy]
• [Bottom CXR: Focal left lower lobe infiltrate]
[Click: Slide-show Animation]
• Yes, both of these patients had TB and represent
examples of “atypical” patterns” of CXR
presentation [Review content of slide].
• An “atypical pattern” may often be associated with
Primary TB and also be commonly seen in
patients with TB and HIV/AIDS co-infection.
[Interactive option – ask participants to respond to
question. There may be less certainty in participant
response because these CXR findings are common for
other infectious pneumonias.]
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
Slide 26
Can this case be TB?
[Automatic Slide-show Animation]
Yes, these are all examples of the fine, stippled pattern of
small nodules seen in miliary TB by chest radiograph
(which correspond to the gross pathology demonstrating
scattered granulomatous lesions seen on the right).
•
•
This pattern of nodules, which reflects the
hematogenous spread of disease, can also be
appreciated well by chest CT imaging.
Note that a miliary pattern may be seen in either
primary or reactivation/post-primary disease.
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco (left and center); University
of California, San Francisco/Walter Finkbeiner, MD (right)]
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Slide 27
Animation Clicks: 1
ISTC Training Modules 2008
Can this case be TB?
[Click: Slide-show Animation]
•
Yes, these are examples of residual radiographic
findings that can be found as the sequelae of prior
active TB
[Review content of slide]
•
[Top: Ca+ granuloma and hilar node calcification
- Ranke complex]
[Left: Apical pleural thickening]
[Right: Apical fibrosis with volume loss]
•
•
[Interactive option – ask participants to respond to
question.]
Slide 28
[Image credit: Francis J. Curry National Tuberculosis Center,
University of California, San Francisco]
•
•
•
Over-reliance on CXR without the use of sputum
microscopy is a common practice in some areas.
Data from a study done in a high-incidence
country demonstrates just how misleading
reliance on the CXR alone can be.
[Review content of slide]
Overall, radiographic examination for the
evaluation of TB is most useful when applied as
part of a systematic approach -- particularly, as we
will discuss next, in the evaluation of persons
whose symptoms and/or findings suggest TB, but
who have negative sputum smears.
[Reference: Nagpaul DR, Proceedings of the 9th Eastern Region
Tuberculosis Conference and 29th National Conference on
Tuberculosis and Chest Diseases. 1974 Delhi, as cited in Toman’s
tuberculosis. Case detection, treatment and monitoring, 2 nd Edition.
Freiden TR ed. Geneva: World Health Organization, 2004]
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Slide 29
ISTC Training Modules 2008
•
•
•
•
The designation of “sputum smear-negative
tuberculosis” presents a difficult diagnostic
dilemma.
On average, sputum smear microscopy is only
about 50-70% sensitive when compared with
culture.
When clinical judgment suggests a high suspicion
for TB, it is important that a rigorous approach be
taken to evaluate fully for this diagnosis, despite
the finding of three negative sputum smears.
Standard 5 addresses the diagnosis of smearnegative TB. To diagnose smear negative TB, the
following criteria should be met:
[Read Standard]
Slide 30
[Note: Guidelines (WHO – pending publication) have recently
changed from three sputum smears to at least two sputum smears.
The change is reflected above and differs from the wording in the
original published ISTC.]
Continued:
Clinical_diagnosis_animated_2008.ppt
[Read Standard]
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Slide 31
Animation Clicks: 3
ISTC Training Modules 2008
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A number of algorithms have been developed as a means
to systematize the diagnosis of smear-negative TB,
although none has been adequately validated under field
conditions.
Here, as an example of a systematic approach, is a
modified algorithm developed by WHO for use in HIVnegative patients or low HIV prevalence settings. The
difference in approach to the evaluation based on HIV
status illustrates the desirability to have HIV testing on
all TB suspects.
• Begin with the clinical suspicion for TB (TB
Suspect).
• [Click: Slide-show Animation]. The most
important first step toward making a diagnosis
would be to obtain sputum for AFB microscopy.
• [Click: Slide-show Animation]. If at least two
smears are negative, the WHO offers one practical
step-wise approach that incorporates the criteria in
Standard 5. [Review as above: down right side of
flowchart]
• [Click: Slide-show Animation]. And if the
smear results are positive initially, treat as TB.
[Review as above: down left side of flowchart]
• Note: This is one example of an algorithm that
incorporates the fundamental principles
recommended for diagnosing TB, and in practice,
some local or national programs may follow a
different sequence.
• Caution: it should be emphasized that the
completion of all of the steps requires a
substantial amount of time; thus, the algorithm
should not be used for patients with an illness
that is worsening rapidly. This is especially true
in patients with HIV infection in whom TB may
be rapidly progressive (as will be outlined on next
slide).
• As noted in Standard 5, the use of
fluoroquinolones as empiric treatment for
respiratory track infections may confuse the
picture by causing a transient improvement of TB,
thus delaying both the diagnosis of TB and the
institution of proper treatment.
• And finally, following the above approach may be
quite costly to the patient and deter her/him from
continuing with the diagnostic evaluation.
• Given these concerns, application of such an
algorithm in patients with at least two negative
sputum smears must be done in a flexible.
•
Page 16 of 22
• manner.
[Note: Guidelines (WHO – pending publication) have
recently changed from three sputum smears to at least
Slide 32
ISTC Training Modules 2008
Because of the increased frequency of AFB smear
negative TB among persons with HIV infection a
separate set of algorithms has been developed for use in
high HIV prevalence settings. [Automatic animation
will highlight “Seriously ill TB suspects”].
•
•
•
Clinical assessment of the severity of illness
determines the recommended course of action,
and two diagnostic algorithms based on
severity of illness are offered.
In seriously ill patients the tempo of the
evaluation and initiation of treatment must be
accelerated. Empiric broad spectrum antibiotic
treatment is recommended in seriously ill patients
and empiric treatment for P. jiroveci pneumonia
(PCP) should be considered. One or more of the
following danger signs would suggest that a
patient is seriously ill: inability to walk unaided,
respiratory rate over 30 breaths per minute, fever
of more than 39 C, or pulse rate of over 120 beats
per minute.
It should be noted that even when the diagnosis is
TB, patients may respond to a course of antibiotic
treatment.
Slide 33
[Reference: World Health Organization. Improving the diagnosis
and treatment of smear-negative pulmonary and extrapulmonary
tuberculosis among adults and adolescents. Recommendations for
HIV-prevalent and resource-constrained settings. Geneva: WHO
2007]
•
•
•
In patients who do not present with signs/symptoms of
a serious level of illness, i.e. those considered
ambulatory, but still with known HIV or at high
risk due to high HIV prevalence, the evaluation may
be managed along a somewhat different path.
Obtaining cultures, if available, remains of key
importance in these smear-negative suspects.
If the smears are negative and the initial clinical
evaluation deems a diagnosis of TB unlikely, it is
reasonable to give treatment for alternative diagnoses
more time and fully assess the response before
considering a re-evaluation for TB.
[World Health Organization. Improving the diagnosis and treatment
of smear-negative pulmonary and extrapulmonary tuberculosis
among adults and adolescents. Recommendations for HIV-prevalent
and resource-constrained settings. Geneva: WHO 2007]
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Slide 34
Animation Clicks: 1
ISTC Training Modules 2008
•
Slide 35
Animation Clicks: 4
•
•
•
While this lecture has reviewed many of the
classic features of the clinical presentation of TB,
it is worth repeating that it is a disease that may
attempt to fool even the most astute clinician. A
great range in presentation exists, especially if
HIV is present (where atypical presentations
are more common).
One should remember: [Review content of slide]
[Click: Slide-show Animation]. Therefore it is
important to realize that TB can present in many
ways beyond the classic description. The ISTC
offer guidelines to help prioritize our
investigations in the initial recognition and
diagnostic workup for TB.
To summarize, the key points of this presentation
were:
[Review content of slide]
Slide 36
Animation Clicks: 2
[Click: Slide-show Animation].
•
And in summary, the International Standards
reviewed: (abbreviated)
[Review content of slide]
[Click: Slide-show Animation].
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Slide 37
Animation Clicks: 1
ISTC Training Modules 2008
•
[Continued - Review content of slide]
[Click: Slide-show Animation].
And above all, Think TB.
Slide 39
Slide 38
[End]
•
Alternate Slides: Offer additional options that
may be added or substituted into module.
•
See Facilitator’s Guide for further information.
The International Standards for Tuberculosis Care
(ISTC):
• Are intended to unite public and private sectors in
providing a uniformly accepted level of care for
all patients with, or suspected of having, TB.
• Describes the essential elements of TB care that
should be available everywhere.
• Provides a vehicle for mobilizing professional
societies globally in support of TB programs.
• Serves as a powerful advocacy tool to ensure that
the essential elements are available.
[Image Credit: Lung Health Image Library/Gary Hampton]
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Slide 40
ISTC Training Modules 2008
•
•
•
•
•
•
•
The ISTC consist of 17 evidence-based standards.
Standards differ from existing guidelines in that
standards present what should be done, whereas,
guidelines describe how the action is to be
accomplished.
To meet the requirements of the Standards,
approaches and strategies, determined by local
circumstances and practices and developed in
collaboration with local and national public health
authorities, will be necessary. There are many
situations in which the level of care can, and
should, go beyond what is specified in the
Standards.
The Standards should be viewed as a living
document that will be revised as technology,
resources, and circumstances change. Revisions
to the original document released December 2005
are currently underway.
Funded (Oct 1, 2004) by USAID via TBCTA,
development was supervised by an international
steering committee (28 members / 14 countries)
chosen to represent perspectives relevant to
tuberculosis care and control.
The Standards are also intended to serve as a
companion to and support for the Patients’
Charter for Tuberculosis Care developed in
tandem with the Standards.
A Handbook for using the International
Standards for Tuberculosis Care is also available
(2007). The Handbook presents suggestions and
guidance, based mainly on country-level
experiences, for using the ISTC as a tool to foster
and guide the delivery of high-quality care by all
practitioners providing TB care.
[Resource: www.istcweb.org]
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Slide 41
ISTC Training Modules 2008
•
•
The Standards are addressed to all healthcare
providers, private and public, who care for
persons with proven tuberculosis or with
symptoms and signs suggestive of TB.
Three categories of activities are addressed by the
Standards: diagnosis, treatment, and public health
responsibilities of all providers. The ISTC are
Slide 43
Slide 42
intended to be complementary to local and
national TB control policies that are consistent
with the World Health Organization (WHO)
recommendations.
•
In many parts of the world there is great
variability in the quality of tuberculosis care, and
poor quality care continues to plague global
tuberculosis control efforts. Effective
engagement of all providers in providing high
quality care in collaboration with TB control
programs is key to the promotion of sound
tuberculosis control.
•
Questions: May be used for interactive
discussion, course evaluation, or continuing
medical education purposes.
•
See Facilitator Guide for further information.
Correct Answer: C
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Slide 44
ISTC Training Modules 2008
Slide 45
Correct Answer: D
Correct Answer: C
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