The Community Health Surveillance Nurse attached to Chest Clinic does an initial investigation. All household and close contacts are identified at this time and screened by mantoux test followed by chest X-rays, as appropriate. For mass mantoux screening, chest X-rays are done if the mantoux is 10mm or larger.

After the index case is discharged from hospital, the nurse visits the home regularly to emphasize the importance of chemotherapy and clinic attendance for clients on treatment as well as their contacts that are on prophylaxis. Household contacts are observed for any sign of clinical manifestations of TB.

Clients on anti-tuberculosis therapy should participate in DOT Programme. Drug compliance is closely monitored. (Cases or contacts who have defaulted are requested to attend the Medical Follow-up Clinic on Fridays.)

Diagnosis is based on a combination of:

• Clinical history.
• Chest x-ray.
• Sputum examination.

Management

Collect 3 consecutive early morning sputum for AFB smear
Begin anti-tuberculosis medications

Outpatient Management & Follow-up

Patients with proven or suspected TB are seen at the clinic:

• Every week for 1 month.
• Then every 2 weeks for 4 visits.
• Then once per month for 3 visits.
• Then every 2 months for 3 visits.

In uncomplicated cases, this regiment should bring patients to completion of treatment. Clients should then be followed up every 6 months for 2 visits, then once per year for 3 visits, and finally discharged if condition is satisfactory.

Repeated X-ray examinations are done at 3, 6 and 12 months and on completion of treatment, after which, X-rays are done on a yearly basis until patient is discharged. Additional X-rays may be requested if clinically indicated.

Sputum tests are repeated every 2 months after the start of treatment to determine the patient’s response to the medication. Finally, at the end of treatment, sputum tests are again done to verify and document that the client has been cured.

Blood investigations are done 1 month after the start of treatment and then as necessary, based on the patient’s monthly, medical examination.

Patient with suspected clinical TB are initially given 2 week appointments until culture reports are available. Should culture be positive, then follow up as outlined above. Patients who have negative cultures (that is, TB bacteria not grown or isolated) are evaluated to determine if TB is still likely to occur.

Routine Investigation

• Mantoux test.
• Sputum test for AFB smear/culture.
• Chest x-ray.
• Blood tests.
• U & E.
• FBC with differential.
• Liver function test.
• HIV.

Routine Follow-up of Contacts

• All household contacts to have mantoux and chest x-ray.
• Contacts with normal x-ray and positive mantoux (up to age 35 years) are given prophylactic treatment for 1 year (Inah 10mg per kg body weight – up to 300mg daily). All adults having Inah must be given vitamin B6 daily.
• Contacts with suspicious x-ray must be admitted to hospital for further investigations to rule out TB disease.
• For contacts with normal x-rays and negative mantoux (except young children who are close contacts), no treatment is required, but tests are repeated after 3 months.
• Young children who are close contacts of smear positive patients should have prophylactic treatment regardless of test findings, for a minimum of 3 months.
• Contacts that are not close to the patient and have test results that remain negative after 3 months may be discharged.
• Converters, or persons who have mantoux tests that become positive when the test is repeated, must be given prophylactic treatment for 1 year.

Family Island Notification of TB

All suspected cases of TB should be reported to the nearest Community Health Clinic, and referred to New Providence or Grand Bahama for further investigation. Upon receipt of notification, the Medical Officer is informed by telephone and follow-up letter, after which, the usual control measures, investigation and follow-up care are carried out.

Nursing Care/Patient Education

• Notify the Department of Public Health, TB Control Unit.
• Isolation for the first 2 weeks of treatment.
• Dispose of sputum in tissue wrapped in a plastic bag.
• Vital signs q4h, if hospitalised.
• Anti-pyretic measures to control fevers.
• Administer anti-TB medication using Directly Observed Therapy (DOT).
• Bi-weekly weigh-in, prescribe high calorie/high protein diet.
• Occupational therapy as necessary.
• Education regarding the importance of medication compliance. (Should the patient miss or stop at any time, he or she is referred back to the clinic for reassessment.).
• Patients should avoid extreme cold and adhere to proper diet.
• Keep clinic appointments for follow-up care and evaluation.

Protocol for Drug Therapy

• Inah 300mgs. Daily (10 – 20 mg/kg body weight).
• Ethambutol 1200 mgs daily (15 – 25 mg/kg body weight, evaluate for red/green colour blindness), not recommended for infants and small children.
• Rifampin 600 mgs daily (10 – 20 mg/kg body weight).
• Pyrazinamide 1500 mgs daily (15 – 30 mg/kg body weight).
• Vitamin B6 daily.
• Streptomycin 0.75 mgs IM daily in some cases (20 – 40 mg/kg body weight). Patients on streptomycin should be observed for adverse effects.
• Anti-TB medication is prescribed for a minimum of 6 months.
• Patients with both TB and HIV are treated with anti-TB medication for minimum of 12 months.
• Patients with latent TB and HIV are treated with Inah and vitamin B6 for a minimum of 1 year.