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OutlineTransmissionMycobacteriaPathogenesisLTBILTBI vs TB DiseaseSymptoms of TB DiseaseFactors which increase the Risk of Developing TB DiseaseSites of TB DiseaseTreatment of TB DiseaseMedicationsDrug Resistant TB__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12A.Brief History of TBAfflicted mankind since ancient times.Evidence of TB found in Egyptian and Peruvian mummies. In the 19th century, the disease was often referred to as consumption. Other names wasting disease, White Plague.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________23Tuberculosis remains a Global ConcernAmong infectious diseases, TB remains the second leading killer of adults in the world, with more than two (2) million TB related deaths per year. It is estimated that 1 in 3 people on earth are infected with the TB bacillus.

Developing countries have the highest rates of TB. The incidence rate of tuberculosis in Canada is considered low (5.1 per 100,000), especially in the global context.

The highest incidence rates of TB in Canada are reported among Canadian-born Aboriginal peoples. There are wide fluctuations even among this group. In Ontario, rates are much lower among First Nations reserves than in Manitoba, Saskatchewan and the far north.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________34The history of TB in First Nations is a very painful and sad one. For many people a diagnosis of TB was a death sentence. Deaths resulting from TB in the early 20th century were at an estimated 42.6 per 1000 in the Indian population in western Canada.

Some First Nations people with TB were sent to sanatoria far from their communities. Many did not return for years and some felt like strangers in their community and family. Some patients died in the sanatorium and families never saw them again.

It is understandable that First Nations people who remember this have very negative feelings about TB.

Fort William SanatoriumHistory of TB in First Nations4________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Elders andTB Stories

5Elders tell their stories

6TB Transmission TB is spread from person to person through the air. The dots in the air represent droplet nuclei containing tubercle bacilli.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________78What is Tuberculosis? TB is a disease caused by an organism called Mycobacterium tuberculosis, a member of the bacteria family.

8________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Pathogenesis ( the mechanism that causes the disease) of Tuberculosis

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________910How does TB enter the body?Droplet nuclei containing tubercle bacilli are inhaled, enter the lungs, and travel to the alveoli.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1011Infection begins when droplet nuclei reach the alveoli.

11________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12A small number of tubercle bacilli enter the bloodstream and spread throughout the body. The tubercle bacilli may reach any part of the body, including areas where TB disease is more likely to develop (such as the lungs, kidney, brain, or bone).

12__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13Within 2 to 8 weeks the immune system produces immune cells called macrophanges that surround the tubercle bacilli. The cells form a barrier shell that keeps the bacilli contained and under control. This is known as Latent TB Infection (LTBI).

13__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Latent TB Infection ( LTBI)Latent TB infection (LTBI) means that tubercle bacilli are in the body, but the bodys immune system is keeping the bacilli under control and inactive. The immune system does this by producing special immune cells that surround the tubercle bacilli. The cells form a shell that acts as a fence and keep the bacilli contained and inactive.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1415If the immune system cannot keep the tubercle bacilli under control, the bacilli begin to multiply. This is TB disease. This process can occur in different places in the body such as the lungs, kidneys, brain, or bone.

15________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ LTBI TB DiseaseLatent TB Infection ( LTBI)Tuberculin skin test results usually positiveChest xray usually normalSputum smears and cultures negativeNo symptomsNot infectiousNot a case of TBTB disease in the lungsActive tubercle bacilli in the bodyTuberculin skin text results usually positiveChest x-ray usually abnormalSputum smears and cultures may be positiveSymptoms such as cough, fever, weight lossOften infectious before treatmentA case of TB__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________16Symptoms of TB diseaseCough for more than 3 weeks.Extreme tirednessFeverNo appetiteWeight lossSweating at night__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________17TB is not easy to catch!You generally have to spend a lot of time with a person coughing or sneezing germs at home, work, or school in order for you to catch TB germs.The disease spreads most easily in closed dwellings with little sunlight and poor air circulation.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________18

*How infectious or contagious is the TB patient? *In what kind of environment did the exposure occur? *How long did the exposure last?*How virulent ( strong) are the tubercle bacilli?These four factors influence the probability that TB will be transmitted.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________19Conditions that increase the risk of developing TB disease.Infection with HIVChest x-ray findings suggestive of previous TBSubstance abuse ( especially illegal injection drug use)Recent TB infection ( within the past 2 years)Prolonged therapy with corticosteroids and other immunosuppressive therapy such as prednisoneOrgan transplantSilicosisDiabetes MellitusSevere kidney diseaseCertain types of cancerCertain intestinal conditionsLow body weight ( 10% or more below ideal)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________20Risk of Developing TB Disease

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________21Sites of TB DiseasePulmonary TB TB that occurs in the lungs. Most cases of TB are pulmonary. Patients usually have a cough and an abnormal chest x-rayExtrapulmonary TB- occurs in places other than the lungs such as the larynx, the lymph nodes, the pleura ( the membrance surrounding each lung), the brain, the kidneys, or the bones and joints.Miliary TB- occurs when tubercle bacilli enter the bloodstream and are carried to all parts of the body where they grow and cause disease in multiple sites. Chest xray has the appearance of millet seeds scattered throughout the lung________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________22Remember:Only pulmonary/laryngeal TB is contagious and can be spread to others.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________23QUIZ1) A person with TB infection can spread TB germs to others. T F 2) People with TB disease lose weight. T F3) TB Infection is when the TB germs are sleeping in your body and not making you sick. T F4) Once a person catches TB germs, they will have them all their lives. T F5)You will feel weak and tired all the time if you have TB Disease. T F6) TB is only found in the lungs. T F7)TB can be cured. T F8)TB disease is when the TB germs start growing and making the person sick. T F9) TB germs can be spread through the air from one person to another. T F __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2425The good news now is there is a cure for TB!!

25Treatment of TB DiseaseTB disease must be treated for at least 6 monthsMost of the tubercle bacilli are killed during the first 8 weeks of treatment ( the initial phase)Treatment with at least two drugs must be continued for several more months to kill the remaining bacilli (the continuation phase)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________26 MedicationsThe initial regimen for treating active TB disease should include the following four drugs:IsoniazidRifampinPyrazinamideEthambutolTB disease must be treated with at least two drugs to which the bacilli are susceptible__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________27Drug- resistant TB

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________28Drug-resistant TBCan be caused in two different ways:Primary caused by person-to-person transmission of drug-resistant organismsSecondary develops during TB treatment, either because the patient was not treated with the appropriate treatment regimen or because the patient did not follow the treatment regimen as prescribed__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________29How does drug resistant TB develop?Patient does not take their medicine regularly.Patient does not take all of their medicine, as told by their health care providerPatient develops active TB disease again, after having taken TB medicine in the pastPatient comes from area of the world where drug-resistant TB is common________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30

DOT- Directly Observed TherapyDirectly observed therapy means that a health care provider administers the medication to the clientAssists the client to consistently take their medication until completion.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3132E.Treatment of TB DiseaseUntreated TB carries a high mortality rateMore than one drug is required for cureUsual regimen for uncomplicated TB:4 drugs x 2 months2 drugs x 4 monthsIn consultation with a TB specialist, drug therapy may continue for 9, 12, or more months.

Poor compliance leads to relapse and drug resistance. Directly Observed Therapy (DOT) is the gold standard world-wide.Even with perfect compliance a small % will relapse.32________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Review QuestionsWhat organism causes TB?How is TB spread?The probability that TB will be transmitted depends on what four factors?What is drug-resistant TB?What is the difference between primary and secondary drug-resistant TB?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________33REMEMBER:If you need more information about TB, contact the Tuberculosis (TB) Control Program(807) 737-4797 Toll Free: 1-855-885-8824 34