Tuberculosis

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Tuberculosis is a communicable disease caused by a tubercle bacillus. The site of infection is the lung however, almost every organ of the body can be affected. Sierra Leone is among the top 30 high TB burden countries in the world.

Causes

Mycobacterium tuberculosis complex (M. tuberculosis, M. africanum, M. bovis etc.) Most infections are transmission through inhalation of droplet nuclei containing virulent strains of the tubercle bacillus.  Almost every organ of the body can be affected. 

Note: (see the national TB guideline of the National TB and Leprosy Control Programme for more details)

Signs and symptoms

Pulmonary TB

       The cardinal symptoms are:

• Cough for two weeks or more. In the case of people living with HIV, current cough
• Weight loss
• Fever
• Profuse night sweats

Other symptoms are

• Chest pain
• Coughing of blood
• Shortness of breath

A patient may not present with all the symptoms but any of them is particularly meaningful if accompanied with cough lasting more than two weeks.

Extra-Pulmonary TB

Depends on the organ involved.  The most common are:

• Painless swelling of lymph nodes (lymphadenitis)
• Pain while breathing in, dull lower chest pain., slight cough (Pleurisy)
• Pain and swelling of joints
• Gibbous or newly developed neurologic disorders of the lower limbs (spondylitis)
• Headache, stiffness of the neck, vomiting and later mental confusion (meningitis)

Investigations

• Microscopy: sputum smear for acid fast bacilli. Should be done for all patients
• Culture: sputum culture is the goal standard. Not widely available
• Molecular techniques: Xpert® MTB/RIF using Gene Xpert. Eligible TB suspect include: Patients treated for TB in the past, HIV patients with suspected TB, patients with TB treatment failure and contacts of patients with drug resistant TB

Treatment objectives

• To cure the patient
• Improve the quality of life of patients
• Prevent the spread of infections
• To prevent relapse and resistance to treatment
• To prevent death

Nonpharmacological treatment

• Provide appropriate nutrition
• Advice to stop smoking, alcohol use and substance abuse
• Advice on improving shelter

Pharmacological treatment

DOTS – Directly Observed Treatment Short Course

Classification

• New patient
• Retreatment

General principles

• Treatment of all TB cases should be weight-based
• Never treat a patient with probable pulmonary TB without examining the sputum
• Never give a single TB drug alone for treatment purposes as drug resistance usually follows and is permanent.
• Always examine the sputum in suspected case
• Use recommended combinations
• Counsel the patient on the need for full compliance
• Supervise TB therapy
• Ethambutol use is safe in children and should be added to their treatment.

Essential Anti-TB Medicines

Medicine	Recommended dose
Isoniazid(H)	5mg/kg (4-6)
Rifampicin (R )	10 mg/kg (8-12)
Pyrazinamide(Z)	25 mg/kg (20-30)
Ethambutol (E)	15 mg/kg (15-20)

Note: Single dose regimens are being replaced by Fixed Dose Combinations

Available Fixed Dose Combinations

• Rifampicin/Isoniazid/Pyrazinamide/Ethambutol (RHZE – 150/75/400/275mg)
• Rifampicin/Isoniazid/Pyrazinamide (RHZ 75/50/150mg)- Paediatric
• Rifampicin/Isoniazid (RH 75/50mg) - Paediatric
• Rifampicin/Isoniazid (150/75mg)

Recommended Treatment Regimen for Adults

TB Patient Description	TB Treatment regimens (months)
	Initial Phase (daily)	Continuation Phase
Pulmonary and most extrapulmonary TB cases	2 months (HRZE) FDC	4 months RH
Bone and joint TB, miliary TB, Meningeal TB	2 months (HRZE) FDC	10 months (HRZE) FDC

 

Number of tablets for adults and children above 25kg

Body weight (Kg)	Intensive Phase (RHZE)	Continuation Phase (RH)
25 -29	2	2
30 -39	2	2
40 -54	3	3
55- 70	4	4
71 and above	5	5

 

Number of Tablets for children below 24kg

Body	Intensive Phase		Continuation Phase
Kg	RHZ (75/50/150mg)	E 100mg	RH 75/50mg
4-7	1	1	1
8 -11	2	2	2
12-15	3	3	3
16-24	4	4	4
>25	Adult Regimen