Tuberculosis

  • Caused by bacteria — most often affects lungs but can also affect other parts of body
  • Spread from person to person through the air when a person with lung tuberculosis (TB) coughs, sneezes or spits
  • Two TB-related conditions
    • Latent TB infection (LTBI)
    • TB disease (active TB)
  • Most people infected with TB have LTBI and don't get sick — but they usually still need treatment so they don’t get sick later

People at high risk of latent TB infection (LTBI)

  • People from areas with high rates of TB
    • Aboriginal community with recent cases of TB
    • Migrants from countries where TB is common
  • Identified contacts of people known to have TB

People at high risk of developing TB disease (active TB) if infected

  • Infants and children less than 5 years
  • People within 2 years of being infected with TB
  • Regular heavy drinkers of alcohol
  • People with poor nutrition who are very thin
  • People who smoke
  • People with diabetes
  • People with weakened immune system, eg HIV, kidney disease
  • People on medicine that weakens immune system, eg corticosteroids
  • People with cancer — particularly of the head and neck, lymphatics or blood

Consider TB if any of

  • Cough for more than 2 weeks plus any of
    • Cough with blood-stained sputum
    • Unexplained weight loss, poor appetite
    • Fever or night sweats
    • Persistent, painless enlargement of lymph glands
    • Close contact or relative with infectious TB
    • Other symptoms, if from high-risk group
    • CSLD or bronchiectasis

Ask

  • Take history including
    • Contact with TB
    • Cough with blood-stained sputum
    • Weight loss
    • Fever, night sweats
    • Travel to countries with high rates of TB

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe check — with attention to
    • Lymph nodes
    • Any part of body with symptoms
  • Lung sounds especially
    • Over apices (top of lungs)
    • Dullness from pleural fluid collection in bases
  • Collect 3 sputum specimens as soon as possible (minimum 8 hours apart) for MC&S and AFB
    • Best to collect one early morning specimen — try for 1 straight away, 1 early next morning and 1 afternoon of second day — label with date and time collected
    • Collect sputum outside away from other people — do not collect in toilet or communal space
    • For child — TB unit consult — fasting gastric aspirates can be collected instead of sputum
    • Collect a spot sputum (one sputum collected when seen) for AFB in any person at high risk of TB infection
    • Keep specimens out of sunlight. If room bright — put in brown paper bag then in biohazard bag
    • If delay expected before reaching lab — store samples in fridge and transport within 3 days

Do

  • TB unit consult about patients with known history of past TB disease, known latent TB infection (LTBI) or TB (active TB) contact
  • Always arrange chest x-ray — even if TB suspected outside lungs
    • TB unit at PHU can help arrange travel and x-rays
    • Make sure x-ray reviewed by radiologist before person leaves
  • If TB diagnosed or highly suspected — talk with PHU about sending to hospital
    • If diagnosed early and person not infectious and getting treatment — may not need to go to hospital
  • If infectious TB of lungs suspected (cough and sputum production)
    • Tell retrieval team to send to hospital with infection control precautions
    • Infected person wears surgical mask and clinic staff caring for person wear P2/N95 masks to prevent spread of infection until person is isolated in hospital

Treatment of TB disease (active TB)

  • TB can be cured by completing all treatment — takes at least 6 months
    • Treatment must be directly observed therapy (DOT) — where tablets are seen to be swallowed to ensure compliance
    • Document this in notes and on DOT card from PHU
  • If diagnosed in hospital
    • Person should receive education about TB before discharge
    • Will be sent home when no longer infectious, medically well and able to take medicine without side effects — may take weeks
    • Must have care plan on discharge — if no care plan ask for one
  • After discharge TB treatment may be given as DOT daily or at higher doses DOT 3 times a week
    • For TB without drug resistance — 4 medicines are given for 2 months THEN 2 medicines for rest of treatment time
    • First line TB medicines are rifampicin, isoniazid, pyrazinamide, ethambutol
    • Pyridoxine (vitamin B6) given to prevent side effects from isoniazid
  • Person with TB and carer need good support and education to successfully complete treatment — person will feel well but must still complete all treatment. Community education can also help
  • Person needs to understand side effects of medicines and come to clinic straight away if any occur
  • If new symptoms — urgent TB unit consult 
  • Monthly reviews — check medicine doses and for side effects, take bloods for LFTs as per care plan. Ask if household contacts or friends have symptoms

Prevention of TB

  • All close contacts of person with active TB should be checked for TB — contact tracing. Talk with TB unit about doing this
    • Contacts who have latent TB infection (LTBI) but not TB disease (active TB) may be offered preventive treatment to stop them getting active TB — they are not infectious
  • BCG immunisation is no longer recommended for all Aboriginal newborns — may be considered for newborns or children from communities with high rates of TB or as advised by TB unit
    • Not recommended for adults living in the NT

Supporting resources