Download Morbility on tuberculosis in Ternopil region (on 100.000)

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Lecture 1
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Determination of tuberculosis
as a scientific and practical
problem.
 History of development of
phthisiology. Epidemiology of
tuberculosis. Description of
exciter. Pathogenic of
tuberculosis.
 Diagnoctics of tuberculosis
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Prof. L.A. Hryshchuk
The World Health Organization (WHO)
proclaimed tuberculosis to be the global danger.
According to its forecasts there will be 90 million new
tuberulosis cases in the world during the decade. Of
those who will fall ill approximately 30 million people
may die in the current decade unless the reaction to
this global problem radically improves.
Nowadays the world scientists distinguish threeunion
tuberculosis epidemic: the first is the epidemic of
typical tuberculosis that is treated well; the second is
the epidemic of chemioresistant tuberculosis and the
third one is the epidemic of tuberculosis and the AIDS.
Europe,1990-2010
Rate per 100.000 population/year
Rate per 100.000 population/year
Incidence
Rate per 100.000 population/year
TB/HIV incidence,
TB/HIV incidence
Prevalence
MDG target for prevalence
Mortality
MDG target for mortality
Source: Global TB control report, 2011
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The incidence of TB has slowly declined
during the past years, reaching 48
(confidence intervals 44-50) per 100 000
population in 2009.
 However there is a big discrepancy
between east and west.
 The TB prevalence decreased from 96
(confidence intervals 70-130) to 63
(confidence intervals 49-81) per 100 000
population between 1990 and 2009
against a target of below the prevalence
of 48 set out in the target for 2015.
 Mortality from TB must further decline,
from 6.9 (confidence intervals 5.7-8.3) per
100 000 persons in 2009 to 6 by 2015.
TB incidence
TB/HIV incidence, 2010
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We will start with the
patient since they are
typically the source of
infection. This slide
shows a violent sneeze
caught on film by high
speed photography
showing large liquid
droplets.
Most of these large,
visible droplets will fall
to the ground. However,
the small droplet nuclei
that can reach the deep
lung are not visible and
are 1:5 micro meters in
size.
According to the WHO criteria from 1995
tuberculosis epidemic has been registered in Ukraine in
so far as tuberculosis patients comprise over 1 % of the
total number of the population.
The statistics of sickness in all the forms of
tuberculosis in 2009 was 72,7 persons per 100 thousand
of the population.
Alarming is the fact that tuberculosis “has turned
younger”, its number among children, able-bodied and
reproductive ages increases.
HISTORICAL REVIEW
Tuberculosis, as an illness, is known since ancient
times.
Tuberculosis (TB) is believed to have been present in humans
for thousands of years. Skeletal remains show that prehistoric
humans (4000 BC) had tuberculosis, and tubercular decay has
been found in the spines of Egyptian mummies (3000-2400 BC).
The term “phthisis”, consumption,
appears first in Greek literature. Around
460 BCE, Hippocrates identified phthisis
as the most widespread disease of the
times, and noted that it was almost
always fatal.
 Due to common phthisis-related
fatalities, he wrote something no doctor
would dare write today: he warned his
colleagues against visiting TB patients in
late stages of the disease, because their
inevitable deaths might damage the
reputations of the attending physicians.
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The study of tuberculosis,
sometimes known as
phthisiatry, dates back to
''The Canon of Medicine''
written by Ibn Sina
(Avicenna) in the 1020s.
He was the first physician to
identify pulmonary
tuberculosis as a contagious
disease, the first to recognise
the association with diabetes,
and the first to suggest that it
could spread through contact
with soil and water.
The fact that tuberculosis is infectious was confirmed by
Fracastoro in the 16th century.
It was Morton who published the first monograph
“Phthisiology or a treatise on the phthisis”
( R. Morton, 1689) and named a science of
tuberculosis “phthisiology” (from the Greek word
“phthisis” ).
In the 17th century the French anatomist Sylviy,
describing the hurt lungs of patients who had died
of phthisis, used the word “hump” (tuberculum).
However, it was only in the 19th century in France that
pathologists and therapeutists G. Bayle, and then R. Laennec
proved the hump and caseous necrosis to be specific
morphological substratum of tuberculosis. In 1865 the French
physician B. Villemin experimentally proved the infectious
nature of tuberculosis, though he could not reveal the pathogene.
In 1882 the German bacteriologist Robert Koch (fig. 1)
discovered the pathogene of tuberculosis, which was named
bacillus of Koch (BK). He was also the first who obtained
tuberculin with the hope to successful treatment of tuberculosis
patients. These expectations of the scientist did not come true,
nevertheless for the purpose of diagnostics tuberculine has been
used for over 100 years Fig. 1. R.Koch (1843-1910)
M.I. Pyrohov studied clinico-morphological properties of
tuberculosis of various localization and for the first time
described typhoid form of miliar tuberculosis, histologic
structure of tuberculous granuloma.
In 1887 R. Philip in Edinburgh (Scotland)
founded the world first antituberculosis
dispansery. This new institution offered the
patients not only medical but also social help,
which later on laid the foundation of the
organization of antituberculosis service also in
this country.
In 1882 in Rome C. Forlanini offered
artificial pneumothorax for treating lung
tuberculosis patients.
In 1895 Wilhelm Kondrat Roentgen discovered X-rays, which
have been widely used in medicine up to today. Actually, it’s
known well enough that X-rays were discovered by Ukrainian
scientist Ivan Pulyuy (1845-1918) from Halichina 17 years
earlier. However, he made his announcement about the discovery
7 days after Mr. Roentgen had made his one, thus the preference
was given to Mr. Roentgen who received Nobel Prize.
An important achievement of the start of the 20th century was
the creation by the French scientists Calmette and Guerin (1919)
of the antituberculosis vaccine BCG (Bacilles Calmette, Guerin).
Since 1935 mass vaccination began. At the same time in 1924
Abre in Brazile introduced the method of fluorographic
observation of the population for active revealing lung
tuberculosis patients.
THE WORLD TUBERCULOSIS
EPIDEMIOLOGICAL SITUATION
More than 2 billion people (about one-third of the world
population) are estimated to be infected with tuberculosis . The
global incidence of TB peaked around 2003 and now appears to
be declining slowly . In 2006 the World Health Organization
(WHO) issued the following estimates :
The prevalence of active infection was 14.4 million,
corresponding to a prevalence rate of 219/100,000 persons.
The incidence of new cases was estimated to be 9.2 million,
corresponding to an incidence rate of 139/100,000.
Twelve of the 15 countries with the highest estimated TB
incidence are in Africa, where the TB incidence rate was 363/100,000
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In 2006 there were 1.7 million deaths from TB worldwide, a death
rate of 25/100,000.
Every year 7-10 million people fall ill with
tuberculosis all over the world, including 4-4,5 mln.
– with bacterial secretion and about 3 mln. adults
die of it (of these 97 % – in the developing
countries) and approximately 300 thousand
children. The total number of tuberculosis patients
reaches 50-60 mln.
Nowadays tuberculosis is the most menacing illness
for the whole mankind. It kills more patients
worldwide than all the infectious and parasitic
illnesses taken together. Present tuberculosis
epidemic has acquired the global scales. In many
parts of the world tuberculosis epidemic is beyond
the control.
The highest tuberculosis statistics of sickness is
noted in African and Asian regions, in the countries
of the Pacific Ocean coast. Tuberculosis epidemic
situation got worse in the countries of Europe too,
especially in the countries of the former Socialist
community.
In 2009 the lowest tuberculosis index was
registered in the highly developed countries, such
as Malta (4,2), Sweden (5), Norway (5,5), Iceland
(6,2), Italy (8,4 per 100000 of the population), the
highest – in Romania (114,6), in the former Soviet
Union, as in Kirgistan (127,8), Kazakhstan (126,4),
Georgia (124,4), Turkmenistan (86,1 per 100.000 of
the population) (fig.3).
Morbility on tuberculosis and HIV in Ukraine
The statistics of morbidity in all forms of tuberculosis in
Ukraine from 1990 to 2011 increased from 32 to 68,4 per
100 thousand population/
100
80
60
40
20
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2011
ВІЛ
Туберкульоз
The pathogenesis of
tuberculosisInfection with
Mycobacterium tuberculosis,
the causative agent, follows a
relatively well-defined
sequence of events. The
infectious bacilli are inhaled as
droplets from the atmosphere.
In the lung, the bacteria are
phagocytosed by alveolar
macrophages and induce a
localized proinflammatory
response that leads to
recruitment of mononuclear
cells from neighbouring blood
vessels. These cells are the
building blocks for the
granuloma, or tubercle, that
defines the disease.
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The granuloma consists of a kernel of infected
macrophages, surrounded by FOAMY GIANT CELLS
and macrophages with a mantle of LYMPHOCYTES
delineating the periphery of the structure.
This tissue response typifies the 'containment' phase of
the infection, during which there are no overt signs of
disease and the host does not transmit the infection to
others. Containment fails after a change in the immune
status of the host, which is usually a consequence of old
age, malnutrition, or HIV-co-infection.
Under such circumstances, the centre of the granuloma
undergoes caseation and spills viable, infectious bacilli
into the airways. This leads to development of a
productive cough that facilitates aerosol spread of
infectious bacilli.
Pathogenesis of
Tuberculosis
Etiology
M. tuberculosis
M. bovis
M. africanum
Thin section transmission electron micrograph of Mycobacterium
tuberculosis
The granuloma consists of a kernel of infected macrophages,
surrounded by FOAMY GIANT CELLS and macrophages with a
mantle of LYMPHOCYTES delineating the periphery of the
structure
Automated screening molecular genetic test to identify
Mycobacterium tuberculosis and resistance R - Xpert
MBT / Rif
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Cultures were on a liquid environment: automated
microbiological analyzer BACTEC MGIT 960
Performed in all patients
with pulmonary tuberculosis
(with positive and negative
sputum smear)
Test drug sensitivity to drugs
and second row
Growth of Mycobacterium
tuberculosis in 7-14 days.
Increases confirm TB in
patients with negative
sputum smear at 20%
At a molecular genetic test:
GenoType MTBDRplus
Perform all
patients with
Positive sputum smear
Carried out in parallel
with the classical
culture method
Detects DNK MBT , resistance to isoniazid and rifampin and
isoniazid combination
Planting on solid medium
Performed in all TB patients
lungs (with positive and negative smear
sputum):
Bank of cultures
Test drug sensitivity
drugs II series
CLINICAL CLASSIFICATION
OF TUBERCULOSIS
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I. TYPE OF TUBERCULOUS
PROCESS
1. First diagnosed tuberculosis – FDTB
(date of its ascertainment)
 2. Tuberculosis relapse – TBR (date of its
ascertainment)
 3. Chronic tuberculosis – CTB (date of its
ascertainment)
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II. CLINICAL FORMS OF
TUBERCULOSIS
A 15.-A 16. – Lung tuberculosis (LTB) (from a facultative
designation of the form of injury)
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A 15.-16.Primary tuberculous complex
A 19.- part
Disseminated lung tuberculosis
A 15-16.Nidus lung tuberculosis
A 15-16.Infiltrative lung tuberculosis
A 15-16.Caseous pneumonia
A 15-16.Lung tuberculoma
A 15-16.Lung fibrous-cavernous tuberculosis
A 15-16.Lung cirrhotic tuberculosis
A 15-16./J65
Tuberculosis of respiratory organs
combined with dust professional lung diseases
(coniotuberculosis)
III. CHARACTERISTIC OF
TUBERCULOUS
PROCESS
 1. Localization of defect
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Localization of defect in lungs according to the
numbers (names) of segments, names of lung sections,
and in other organs and systems – according to
anatomical names of localization of a failure.
2. Presence of destruction
(Destr +) destruction is present
(Destr -) destruction is not present
facultatively it is necessary to specify a phase of
tubercular process:
infiltration, decay (Destr +), sowing;
suction, condensation, scarring, calcination.
3. Etiologic confirmation of tuberculosis
diagnosis
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(MBT +) it is confirmed by the results of bacteriological analysis (code A 15), in this case
to specify:
(M +) positive result of sputum analysis on acid-resisting bacteria (ARB);
(C 0)
cultural analysis was not done;
(C -)
negative result of cultural analyses;
(C +)
positive result of cultural analyses, in that case to specify:
(Resist 0) MBT resistance to preparations of I line was not analysed;
(Resist -) resistance to preparations of I line has not been established;
(Resist +) ( abbreviation of antitubercular preparations of I line) resistance МBТ to
preparations of I line has been established (in brackets to list all the preparations of I line
to which resistance has been determined).
(Resist II0) MBT resistance to preparations of II line was not analysed;
(Resist II-) resistance to preparations of II line has not been established;
(Resist II+) ( abbreviation of antitubercular preparations of II line) resistance МBТ to
preparations of I line has been established (in brackets to list all the preparations of I line
to which resistance has been determined).
( МBТ-) is not confirmed by the results of bacteriological analysis (the code A16), in this
case to specify:
(S 0) sputum was not investigated;
(S -) negative result of sputum analysis on acid-resisting bacteria (ARB);
(C 0) cultural analysis was not done;
(C- ) negative result of cultural analysis;
(Hist 0) histologic analysis was not carried out;
(Hist -) is not confirmed by the results of histologic analysis (the code A 16);
(Hist +) it is confirmed by the results of histologic analysis (the code A 15).
IV. COMPLICATIONS OF
TUBERCULOSIS
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Complications of lung tuberculosis (LTB):
haemoptysis, lung haemorrhage, spontaneous
pneumothorax, lung insufficiency, chronic lung
heart, atelectasis, amyloid disease etc.
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Complications of extrapulmonary tuberculosis
(EpTB): bronchus stenosis, pleura empiema,
fistulae (bronchial, thoracic), renal (adrenal)
insufficiency, sterility, commissure, ankylosis,
amyloid disease etc.
V. CLINICAL AND DISPENSARY
CATEGORY OF THE REGISTRATION
PATIENT
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Category 1 (Cat 1) First diagnosed tuberculosis
with bacterial excretion (FDTB МBТ +), and also
other grave and wide-spread forms of the disease
without bacterial excretion (FDTB МBТ-)
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Category 2 (Cat 2) Relapses of tuberculosis
(RТB МBТ +) and (RТB МBТ-) and first
diagnosed tuberculosis inefficiently treated (
FDTB IT МBТ +) and (FDTB IT МBТ-)
 Category 3 (Cat 3) First diagnosed tuberculosis
with the limited process, without bacterial
excretion (FDTB МBТ-) and tuberculosis of
unstated localization in children (tubintoxication)
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Category 4 (Cat 4) Chronic tuberculosis (CТ) of
various localizations МBТ + and МBТCategory 5 (Cat 5) Risk groups to tuberculosis or its
reactivation
Group 5.1 residual changes of cured tuberculosis,
Group 5.2 contact persons,
Group 5.3 adults, tuberculosis patients of doubtful
localization,
Group 5.4 children and teenagers with latent
tubinfection, persons from risk group, and also
children who were not vaccinated in the neonative
period and with postvaccinal complications.
Group 5.5 children and teenagers whose etiology of
sensitivity to tuberculin it is necessary to specify, or
character of changes in the lungs with the purpose of
difdiagnosis.
VII. TUBERCULOSIS
CONSEQUENCES
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Residual changes after healed lung tuberculosis:
fibrous, fibrous-nidus, bullous-dystrophic, calcinates
in lungs and lymphatic nodes,
pleuropneumosclerosis, cirrhosis, consequences of
surgical intervention (with the indication of the type
and the date of an operation), etc.
 Residual changes after healed tuberculosis of
extrapulmonary localisation: cicatricial changes in
various organs and their consequences, calcinosis,
consequences of surgical intervention (with the
indication of the type and the date of an operation).
ORGANIZATION OF ANTITUBERCULOUS
ACTIVITY IN THE PERIOD OF
TUBERCULOSIS EPIDEMY
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Tuberculosis is a social disease and is a mirror of social-economic
prosperity of the state and the well-being of its people, therefore
antituberculous measures under present conditions must be taken
on the national level by the government of the country.
At present time, the principal task in fighting tuberculosis in
Ukraine is to take the epidemy of the illness under control (I
stage), to stabilize the epidemiological indices (infestation,
morbidity, sickliness and death rate) of tuberculosis (2 stage), and
then their gradual decrease (3 stage).
For the successful organization of antituberculous measures close
cooperation of the medical system, sanitary-epidemiological
service and the organs of the state power is necessary. The general
organization and methodological guidance of antituberculosis
activity in this country is realized by the Ministry of Health
Protection of Ukraine and Acad. F.G.Yanovsky Ukrainian
phthisiology and pulmonology research institute (scheme 1).
STRUCTURE OF ANTITUBERCULOSIS SERVICE
IN UKRAINIAN
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The Ministry of Health Protection
Acad. F.G.Yanovsky Ukrainian phthisiology and pulmonology
research institute
Regional of antituberculous dispensary
Distric(town) of antituberculous dispensaries
Tubcabinet
At child’s policlinic
At policlinic
At medical parts
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Antituberculous dispensary (Engl. dispensation –
distribution) is a specialized medicative-prophylactic
institution, which work is aimed at lowering morbidity,
sikliness, infestation with tuberculosis and death rate
caused by it as well as at conducting a complex of
organizational and methodical, prophylactic
antituberculous measures among the district population.
The main tasks of an antituberculous dispensary are:
1) prophylaxis;
2) early revealing;
3) treatment of tuberculosis patients;
4) registration of groups of tuberculosis patients and
contingents of persons
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Other very important tasks of an antituberculous
dispensary are revealing, registration and treating
tuberculosis patients. The results of treating tuberculosis
patients to a considerable degree depend on the disease
being timely revealed. In this connection, firsty diagnozed
tuberculosis patients are divided into three groups: timely,
untimely and lately revealed. For children and teenagers
the fourth group is separated – early revealing.
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The main criteria of dividing patients into groups are the
character of a specific process, the presence or absence of
destruction (cavern) and bacterial excretion, peculiarities
of the prognosis at treatment, the degree of a patient’s
danger for healthy persons.
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Children and teenagers, in whom the
following factors are diagnosed, compose a
group of early revealed:
 1) tuberculin test range;
 2) primary tubinfestation;
 3) hyperergic Mantoux test;
 4) tuberculous intoxication.
DISPENSARY CATEGORY
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Contingents of antitubercular dispensaries are
divided into categories, which enables to examine
them differentially, define the treatment tactics,
perform prophylactic and rehabilitation actions.
 Contingents of adult persons, children and
teenagers due to being observed at an
antitubercular dispensary, are divided into 5
dispensary categories: 1, 2, 3, 4 and 5.
 To 5 categories (Cat 5) are referred dispensary
contingents of risk to disease to a tuberculosis and
its relapse.