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

• 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

• Northern Territory tuberculosis guidelines