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Learning Objectives
At the end of this module, the participant will be able to:
1. Explain the TB epidemic and the annual global TB burden 2. Describe the forms of TB and how TB is transmitted 3. Discuss the ISTC Standards for Diagnosis 4. Define and compare various methods of TB diagnosis,
Learning Objectives
5. Describe NTP and its purposes 6. Describe the role of the laboratory in NTP 7. Describe the DOTS component of STOP TB strategy 8. Explain the importance of AFB microscopy in the DOTS program 9. Describe levels of TB laboratory services.
What is tuberculosis? The TB epidemic and the annual global TB burden Transmission and forms of TB Risk of Disease ISTC Standards for Diagnosis TB Diagnosis
Content Overview
Content Overview
National TB Program and its purposes The role of the laboratory in NTP The DOTS component of STOP TB strategy The importance of AFB-microscopy in DOTS
programs Levels of laboratory services
Global Emergency
Tuberculosis kills 5,000 people a day !
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
Disturbing Statistics
1/3 of worlds population is infected with TB 8 Million people develop active TB every year TB kills more young women than any other
disease
PHILIPPINE STATUS
What is TB?
TB is an infectious disease that affects mainly the lungs (pulmonary TB or PTB) but can also attack any part of the body (extra-pulmonary TB or EPTB)
The Causes of TB
Mycobacterium tuberculosis complex
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Staining Characteristics
Mycobacteria are called Acid-Fast Bacilli (AFB) due to their microscopic appearance after decolorization. Organisms appear red on a blue background
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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TB Transmission (infection)
Person to person via Airborne transmission in Confined environment
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
Untreated AFB smear positive PTB cases are the most infectious
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
What is MDR-TB?
Multidrug-resistant TB (MDR TB) is TB that is
resistant to at least two of the best anti-TB drugs, isoniazid and rifampicin. These drugs are considered first-line drugs and are used to treat all persons with TB disease.
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What is XDR-TB?
Extensively
drug resistant TB (XDR TB) is a relatively rare type of MDR TB. XDR TB is defined as TB which is resistant to isoniazid and rifampin, plus resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).
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THE ISTC
Intended to facilitate the effective engagement of all care providers in delivering high quality care for patients of all ages. intended to complement, not replace, national and local recommendations. The ISTC should be viewed as a living document that will be revised as technology, resources, and circumstances change.
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Introduction
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ISTC TB Training Modules 2009
Microbiologic Diagnosis of TB
Significance of microbiologic testing for public health goals and patient care:
WHO global target of 70% case detection of new smearpositive cases Rapid and accurate case detection coupled with effective treatment is essential to reduce the incidence of TB Failure to perform a proper diagnostic evaluation before initiating treatment potentially:
Exposes the patient to the risks of unnecessary or wrong treatment May delay accurate diagnosis and proper treatment
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ISTC TB Training Modules 2009
ISTC Standard 1
All persons with otherwise unexplained productive cough lasting two-three weeks or more should be evaluated for tuberculosis
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ISTC Standard 2
All patients (adults, adolescents, and children who are capable of producing sputum) suspected of having pulmonary TB should have at least two sputum specimens obtained for microscopic examination in a quality-assured laboratory. When possible, at least one early morning specimen should be obtained.
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ISTC Standard 3
For all patients (adults, adolescents, and children) suspected of having extrapulmonary TB, appropriate specimens from the suspected sites of involvement should be obtained for microscopy, culture, and histopathological examination.
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NTP
Extra-Pulmonary TB (EP)
A patient with at least one mycobacterial smear/culture positive from an extra-pulmonary site (organs other than the lungs: pleura, lymph nodes, genito-urinary tract, skin, joints and bones, meninges, intestines, peritoneum, and pericardium, among others) A patient with histological and/or clinical evidence consistent with active extra pulmonary TB and there is a decision by a physician to treat the patient with anti-TB drugs All EP cases shall undergo DSSM prior to treatment.
NTP MOP 2005
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ISTC Standard 4
All persons with chest radiographic findings suggestive of tuberculosis should have sputum specimens submitted for microbiological examination.
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ISTC Standard 5
The diagnosis of sputum smear-negative pulmonary tuberculosis should be based on the following criteria: At least two negative sputum smears (including at least one early morning specimen) Chest radiography findings consistent with tuberculosis Lack of response to a trial of broad-spectrum antimicrobial agents (Note: Because the fluoroquinolones are active against M. tuberculosis complex, and thus may cause transient improvement in persons with tuberculosis, they should be avoided.)
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ISTC Standard 5
For such patients, sputum cultures should be obtained. In persons who are seriously ill or have known or suspected HIV infection, the diagnostic evaluation should be expedited and if clinical evidence strongly suggests TB, a course of antituberculosis treatment should be initiated.
ISTC TB Training Modules 2009
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ISTC Standard 6
In all children suspected of having intrathoracic (i.e., pulmonary, pleural, and mediastinal or hilar lymph node) TB, bacteriological confirmation should be sought through examination of sputum (by expectoration, gastric washings, or induced sputum) for smear microscopy and culture. In the event of negative bacteriological results, a diagnosis of TB should be based on: The presence of abnormalities consistent with TB on chest radiography A history of exposure to an infectious case, evidence of TB infection (positive tuberculin skin test or interferon gammarelease assay), and Clinical findings suggestive of TB
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ISTC Standard 6
For children suspected of having EPTB, appropriate specimens from the suspected sites of involvement should be obtained for microscopy and for culture and histopathological examination.
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Diagnosis of TB
Direct demonstration of AFB in sample Growth of TB bacilli in culture Skin Test Nucleic Acid Amplification tests
(NAATs) T-cell-based interferon-gamma release assay (IGRAs) X-Ray
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Sputum smear microscopy is the most important test for the diagnosis of pulmonary TB in many areas of the world Direct smears (unconcentrated specimen) are most common Fluorescence microscopy and chemical processing can increase sensitivity Assessment of laboratory quality is essential
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carbolfuchsin/phenol as the primary dye Smear is then decolorized with acid (HCI) alcohol and counter-stained with methylene blue
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Fluorochrome stained smears require a fluorescent microscope Generally read at 250X-450X magnification which allows rapid scanning of the smear Auramine-rhodamine is an example of such a stain where the AFB appear yellow against a black background
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Auramine-rhodamine Stain
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Limitations of Microscopy
Can not distinguish between dead or live
bacteria
Can not do species identification Can not perform Drug Susceptibility Testing
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Fluorescence Microscopy
Advantages:
More accurate: 10% more sensitive than light microscopy, with specificity comparable to ZN staining Faster to examine = less technician time Disadvantages:
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Culture: Advantages
Higher sensitivity than smear microscopy (culture
can make diagnosis despite fewer bacilli in specimen) If TB suspected and sputum smears are negative, culture may provide diagnosis Allows for identification of mycobacterial species Allows for drug susceptibility testing
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Culture: Disadvantages
Cost Technical complexity May take weeks to get results Requires ongoing quality assurance
Solid media have the advantage that organisms (colonies) can be seen on the surface of the medium Types most commonly used are:
Lowenstein-Jensen: egg-based Middlebrook 7H 10 or 7H11: agar-based Ogawa
ISTC TB Training Modules 2009
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Rate of growth Colonial morphology Pigmentation Biochemical tests There is a battery of 8 12 biochemical tests used to differentiate M.tb within the genus Nitrate reduction and niacin production are definitive for M.tb
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Culture: Cross-Contamination
Be aware that faulty technique can lead to laboratory crosscontamination of specimens (difficult to verify without access to more technical testing). Adequate quality control is an essential component of any mycobacteriology laboratory.
ISTC TB Training Modules 2009
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Nucleic acid amplification tests (NAAT): These tests are designed to amplify and detect DNA specific to M.tb Enables direct detection of M.tb in clinical specimens
ISTC TB Training Modules 2009
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Immunological tests
Serologic tests for antibody, antigens, and immune complexes; not currently accurate enough to replace microscopy and culture.
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Molecular beacons
Bacteriophage-based assays
*Barnard et al. Am. J. Respir. Crit. Care Med 2008; 177: 787-792
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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NTP
Case finding, which is the identification and diagnosis of TB cases among individuals with suspected signs and symptoms of TB, is a basic step in TB control. Fundamental to case finding is the detection of infectious cases through direct sputum smear microscopy (DSSM).
DSSM results serve as basis for categorizing TB symptomatics according to standard case definition, monitor progress of patients with sputum smear-positive TB while they are receiving antiTB treatment These are also used to confirm cure at the end of treatment.
NTP MOP 2005
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NTP
National TB Reference Laboratory
Objectives of QA program:
ensure that the reported results are accurate identify practices that are potential sources of error ensure that appropriate corrective actions are initiated
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4. Engaging all care providers 5. Empowering patients and communities 6. Enabling and promoting research
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Infection
Active Disease
Inactive Disease
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Benefits of DOTS
Produces cure rates of up to 95 % Prevents new infections
Prevents the development of MDR-TB
Cost effective
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Diagnosis
Treatment Follow-up
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Role of Laboratory
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Policy and technical support: AO 2008-0018: Guidelines for the Implementation of PMDT Implementing guidelines and training modules for PMDT Mainstreaming of MDR-TB services to the NTP Public-private collaboration from diagnosis to management of cases
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ISTC Standard 12
Patients with or highly likely to have tuberculosis caused by drug-resistant (especially MDR/XDR) organisms should be treated with specialized regimens containing 2nd-line antituberculosis drugs The regimen chosen may be standardized or based on suspected or confirmed drug susceptibility patterns At least four drugs to which the organisms are known or presumed to be susceptible, including an injectable agent, should be used, and treatment should be given for at least 1824 months beyond culture conversion
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Laboratory Network
Central Laboratory
Intermediate laboratories
Peripheral Laboratories
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Peripheral Laboratory
Located within a general dispensary,
clinic or hospital
Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
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Intermediate Laboratory
Regional/provincial or large hospital Services for TB diagnosis
Sputum specimen collection Sputum smear microscopy Culture and identification of MTB
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Central Laboratory
Country/regional level Services for TB diagnosis Sputum smear microscopy Culture and identification of MTB Drug susceptibility testing of TB Support for the laboratory network Advice on procurement Organization and participation in training, supervision, EQA of sputum smear microscopy Other activities Participation in operational research Drug resistance surveillance
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Source: http://wwwn.cdc.gov/dls/ila/acidfasttraining/section4.aspx
NO TREATMENT NO DOTS
NO TB CONTROL
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Summary
What is TB and how it is transmitted? What are the ISTP Standards for Diagnosis? What are the goals of NTP? Why is microscopy an effective diagnostic
technique?
References
1.
2. 3. 4. 5.
PTSI,DOH,RITM,NTRL, Training Manual (Training course on Direct Sputum Microscopy http://wwwn.cdc.gov/dls/ila/acidfasttrainin g/section1.aspx#training International Standards for Tuberculosis Care, 2009 http://www.who.int/tb/strategy/en/ NTP MOP 2005
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