Tuberculosis:

preventive interventions

Lecturer: Ph.D
M.G.Dolynska
 Chain of Transmission

Index case Early

Diagnosis
BCG
vaccination Adequate
Treatment
Preventive
Chemotherapy Environmental
Control

contact

Jaap Veen, MD,

PhD
KNCV
 Risk Groups Risk Factors

Persons at risk for infections

high risk environment riskgroup

Prevalence of infectious cases (household)

contacts
foreign born
Crowding homeless
drug addicts
alcoholics
prisoners
Patient care facilities Health Care
Workers
 Risk Groups Risk Factors

Persons at risk once infection has occurred

Individual risk factors riskgroup
Recency of infection contacts
Medical risk factors

diabetes mellitus

gastrectomy

renal failure

malnourishment

malignancy

HIV infection HIV infected

Age

children

adolescents

>= 65 years residents

nursing homes
 Risk

 Risk Factors
 Risk Group
 HIV if incidence is
 IUATLD>100/100,00
 diabetes
0
 cancer
 Netherlands>
 malnutrition 50/100,000
 age  Veen: 5 x
 etc incidence
 INTERVENTIONS

1. Diagnosis
 passive case detection

(symptomatic)
 active screening (risk groups)*

* ONLY IF SYMPTOMATICS CAN BE CURED

 INTERVENTIONS

2. Treatment
Early start of adequate treatment *

* combination of drugs
sufficient duration
direct observation of rifampicin intake
 INTERVENTIONS
3. Environmental control

Dilution of infectious particles from

the air *
* ventilation
filtration
UV irradiation
 In the hotbed:
 Disinfection
 Crowding avoiding
 Sanitary standards enhansment
 Preventive chemotherapy
 Bacteria excharger isolation and

treatment
 INTERVENTIONS
4. Preventive chemotherapy

Contact tracing *

* only if good system is in place

following the ‘Stone-in-the-Pond
Principle
 Preventive chemotherapy

 Primary (for non-infected persons exposed

by close contact)
 Secondary (for infected persons exposed
by close contact or other risk factors)
How to avoid drug resistance?

Selection doesn’t occur if bacteria

amount is less than 106 – all
cases of latent tuberculosis
 Drugs and dosages
 Isoniasid - 5-10 mg/kg (0,3-0,45 g per day)
 for exposed by MDR-TB –ethambutol 15-20
mg/kg (0,8-1,2 g per day) and pyrasinamide 20-
25 mg/kg (1-1,5 g per day)
 for exposed by simple resistance - isoniasid - 5-10
mg/kg (0,3-0,45 g per day) and rifampicin 10
mg/kg (0,45-0,60 g per day) g
 for exposed by XDR-TB – according the sensitivity
profile, including fluoquinolons.
 INTERVENTIONS
5. BCG vaccination

Newborns *
* only in high incidence countries
High risk groups *
* only if no other means of protection
 BCG vaccine
 Alive
 Artificial strain received by a series of
M.Bovis passages
 Immunity properties
 Active
 Non-sterile
 Expressed within 3-5 years
 BCG vaccination

Newborns *
* only in high incidence countries
High risk groups *
* only if no other means of protection

Jaap Veen, MD,

PhD
KNCV
Recombinant BCG vaccine
Vaccination procedure
In 4-6 weeks

pustule
In 6-8 weeks

crust
In 2-4 months

cicatrix
BCG-vaccine – one of the
safest

Total complications
prevalence – not more than
0.06% of all vaccinated
 Complications (BCG-related
diseases) classification
(WHO, 1984)
 Local (the most frequent) – cold abscess,
ulcer, regional lymphadenitis.
 Disseminated BCG-infection (ostitis,
lupus).
 Generalized BCG-infection with lethal
outcomes.
 Post-BCG syndrome (cheloid cicatrix,
nodular erythema, allergic rash).
Complication: caseotic
lymphadenitis
Complication: ulcer
Complication: cheloid cicatrix
Ethical and Legal aspects of
Interventions
 Screening:
Mandatory or Voluntary ?

 If voluntary:
how much pressure may be
exercised ?