Social Diseases-1

Tuberculosis
Ercan KULAK, MD, Public Health Medicine Specialist
Department of Public Health, English Medical School, Biruni
University
 Tuberculosis (TB)
(Gathered from Health Ministry Documents of Türkiye and WHO)
Learning objectives
• Tell the social importance of TB
• List the main components of TB control
• Count the risk factors for TB
• Tell when to suspect TB
• Count the principles of directly observed treatment in TB
• Define who is a TB contact
• Tell the principles of managing TB contacts
• Interpret tuberculin test results
• Count preventive health services in TB
• Count duties of tuberculosis department of Public Health in Health Ministry of Turkey (will
be discussed in the health management lesson while the Turkish Health System is studied)
• Tell about the surveillance system and reporting TB in Turkey
 Social Diseases in the Context of Public Health
Medicine
• Social diseases, also known as "diseases of poverty," are
illnesses significantly influenced by social, economic, and
environmental factors.
• These diseases are not solely biological phenomena; their
prevalence, distribution, and control are deeply intertwined with
the conditions in which people live, work, and interact.
• Tuberculosis (TB), malaria, and rabies are classic examples of
social diseases, as they disproportionately affect disadvantaged
and marginalized populations.
 Characteristics of Social Diseases

Strong Association with Social Determinants of Health

 Poverty: Limited access to nutrition, housing, and healthcare

increases susceptibility.
 Education: Low levels of health literacy hinder preventive
measures and timely treatment.
 Living Conditions: Overcrowded housing and poor sanitation
facilitate disease transmission.
 Characteristics of Social Diseases

Disproportionate Burden on Vulnerable Populations

• Children, the elderly, and individuals with weakened immune
systems are at higher risk.
• Marginalized groups, such as migrants and refugees, face
barriers to diagnosis and care.
Cyclical Relationship with Poverty
• These diseases can push families into deeper poverty by
reducing earning capacity and increasing healthcare costs.
 Public Health Perspective on Social Diseases

Prevention-Oriented Approach
• Focuses on addressing the root causes, such as poverty and
poor living conditions.
• Implementing vaccination programs (e.g., BCG for tuberculosis)
and promoting health education.
Surveillance and Control Measures
• Early detection and treatment to prevent the spread of diseases.
• Contact tracing and community-based interventions to manage
outbreaks.
 Public Health Perspective on Social Diseases

Multisectoral Collaboration
• Involves health, education, housing, and social welfare sectors
to create sustainable solutions.
Global and National Strategies
• Programs like WHO’s “End TB Strategy” and Türkiye’s
Tuberculosis Dispensaries emphasize comprehensive care,
from prevention to rehabilitation.
 Why Are Social Diseases Relevant
in Public Health Medicine?

• Social diseases highlight the critical role of social determinants

in health outcomes, emphasizing the need for equity-driven
policies and interventions.
• They demonstrate the interplay between individual health and
broader societal factors, underscoring the importance of
integrating social justice into health systems.
• Understanding and addressing these diseases provide a
blueprint for tackling other health challenges shaped by
socioeconomic disparities.
 What is Tuberculosis (TB) Disease?

“It is a disease caused by the bacillus called

Mycobacterium tuberculosis” “in humans, which
can affect all organs, is contagious and can result
in death if not treated.
 How is it transmitted?

Resourse Air way Healthy

Individual
TB bacilli Infected with
Diseased person spread with the TB bacilli
cough, taken by the
sneezing and respiratory
speaking organs
 Droplet Core in spreading of disease

• 0-210 particules while speaking

• 0-3.500 particules while
coughing 1

• 4.500-1.000.000 particules with

sneezing
Transmission occurs by inhalation of particles (droplet nuclei), 1-5
micron in size and containing 1-3 live bacilli, expelled by a TB patient. 2

TB bacilli in the droplet core at standard temperature and humidity

60-70% can survive for three hours, 48-66% for six hours, and 28-32%
for nine hours. 3

1 Duguid J. Expulsion of pathogenic organisms from the respiratory tract. Br Med J

1946;1:245
2 Riley RL, O’Grady F. Airborne infection: transmission and control. New York: Macmillan,
1961
3 Loudan RG, Roberts RM.Droplet expulsion from the respiratory tract. Am Rev Respir Dis.
1967:95
 How Does Tuberculosis Disease
Occur?

Inhaled tuberculosis bacillus causes tuberculosis infection.

This is not a disease condition. It is a condition in which the
bacillus stays silent in the body and is almost imprisoned.
People who are infected;
-5% of them become tuberculosis patient in the f ir st 1-2
years
-In 5% of cases, at any time after the 2nd year, when the
body resistance decreases, the bacilli waiting in the body
multiply and cause tuberculosis disease.
- In 90%, the disease does not develop, the bacillus remains
silent in the body.
Tuberculosis Infection and Disease

Encounter and inhalation of tuberculosis

bacillus

5% of them become
Not Infected active tuberculosis patient
Infected in the first 1-2 years
TB Patient

5% after the first 2 years TB Patient

at any time in their life
may have active tuberculosis.
90%
remained as
infected
 Risk Factors for the Development of
Tuberculosis Infection

• Living in a place with a high TB incidence

• The probability of encountering TB bacillus
• (health personnel
• public living area
• crowded places, etc.)
• TB bacillus contact time
• Sensitivity of the person
 Conditions That Increase the
Transformation of Tuberculosis Infection
into Tuberculosis Disease
• Children under 15 years old (especially 0-2 years old)
• People with HIV infection (50-100 times more risk)
• People taking immunosuppressive therapy
• Those with silicosis, diabetes mellitus, chronic kidney
failure, leukemia, lymphoma or head and neck cancer,
lung cancer
• Those who use tobacco (cigarette, hookah, etc.),
alcohol use or drug addiction
• Malnutrition, low body weight (more than 10% under
ideal weight-Body mass index ≤20)
Factors Affecting Infectiousness
Patient factors
• Those with pulmonary and laryngeal tuberculosis are
contagious.
• The high number of bacilli in the sputum increases the
transmission (patients with smear positive are more
contagious).
• The formation of aerosol from sputum or other materials
(cough, watery sputum, use of nebulizer) increases
transmission.
• The high number of live bacilli increases the transmission
(Contamination decreases with anti-tuberculosis drugs).
• The virulence of the bacillus affects transmission.
Factors Affecting Infectiousness
Environmental Factors
• Contamination is high in narrow and closed areas.
• Ventilation of the environment dilutes the bacillus.
• The ventilation system that gives the same air back again
without HEPA filtering or UV application, increases
contamination.
• Ultraviolet and sunlight reduce the number of live bacillus.
• Being close to the source increases the probability of
encountering bacillus (latent infection and disease in
family members is higher than in distant contacts).
Factors Affecting Infectiousness

Factors about the person in contact

• Personal resistance to disease/bacilli (previous disease,

preventive treatment, BCG, non-TB mycobacterial
infections) reduces transmission.
• Sickness-enhancing conditions and other diseases can
increase transmission.
• Transmission increases as the time spent with the source
of bacilli (active TB patient) increases.
Transmission by Proximity of Contact

Random contact

famil
y
patient

Friends, relatives

Not infected
Infected * Veen 1992
Hans L. Rieder. Epidemiologic Basis of Tubeculosis Control, IUATLD, 1999. S:21
Is Tuberculosis Still a Major Problem?

Tuberculosis continues to be an important public

health problem in our country and in the world.
 Tuberculosis in the World

According to WHO estimates;

Worldwide, approximately 10.6 million new tuberculosis
patients were identified in 2021 and 1.6 million people
died due to tuberculosis.
About a quarter of the world's population is infected
with TB bacillus.
Active disease develops in 5-10% of those infected.
Multidrug resistant TB patients continue to be a
problem.
COVID-19 worsen the TB
management

• 1.The COVID-19 pandemic continues to have a damaging impact on

access to TB diagnosis and treatment and the burden of TB disease
• 2.Progress made in the years up to 2019 has slowed, stalled or
reversed, and global TB targets are off track
• 3.Intensified efforts backed by increased funding are urgently
required to mitigate and reverse the negative impacts of the
pandemic on TB
• 4.The need for action has become even more pressing in the
context of war in Ukraine, ongoing conflicts in other parts of the
world, a global energy crisis and associated impacts on food security,
which are likely to further worsen some of the broader determinants
of TB
Reductions suggest that the number of people with undiagnosed and
untreated TB has grown, resulting first in an increased number of TB deaths
and more transmission of infection and then, with some lag-time, increased
numbers of people developing TB
 Estimated TB Incidence Rates by Country,
2021 (World Health Organization, Global TB
Report 2022)

Turkey's estimated incidence rate for 2021 is 18 per hundred thousand

Estimated TB Data by WHO Regions, 2021
2021
District İncidence Mortality
(hundred thousand) (hundred thousand)

Africa 212 43,0

South Asia 234 38,2
Eastern
112 11,4
Mediterranean
West Pasific 98 6,6
Europe 25 3,0
Türkiye* 18 1,2
Americas 30 3,2
World 134 19,4
*Türkiye is in the European Region of WHO
 Treatment Success Rates
by WHO Regions, 2020
Treatment Success in Treatment Success in
District New and Recurrent Previously Treated
Cases (%) Cases* (%)
Africa 86 67
South Asia 86 79
Eastern Mediterenian 92 80
West Pasific 88 78
Europe 72 60
Türkiye* 81 47
Americas 72 42
World 86 74

*Previously treated cases; are the cases that come from treatment failure and are not
followed up and return.
TB Incidence by Years, 2005-2021 Türkiye*
35.0
29.4 28.8

New and reoccurance case rate

30.0 27.3
25.3
23.6
25.0 22.0
20.6
19.0
20.0 17.2 16.9
15.9 15.3
14.6 14.1
15.0 13.5
10.6 10.7
10.0

5.0

0.0
05

06

07

08

09

10

11

12

13

14

15

16

17

18

19

20

21
20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20
Total cases by cities, 2021

31
 2005
Total number of TB cases: 20,535
Total TB case rate: 29.8 per hundred
thousand

2021
Total number of TB cases: 9.156
Total TB case rate: 10,8 per hundred
thousand
In New Disseminated (+) Lung TB Cases
Treatment Success by Province, 2020
Tuberculosis Diagnosis
 DIAGNOSIS - Symptoms
Respiratory Systemic
• Cough • Fever (intermittent)
• Expectoration • Night sweats
• Hemoptysis • Loss of appetite,weight loss
• Chest pain • Weakness, fatigue
• Back-side pain Extrapulmonary organ tuberculosis:
There are findings specific to the organ
• Shortness of breath where the disease is present (lymph
• Hoarseness gland enlargement, blood in the urine,
swelling in the joint).

Cough lasting more than 2-3 weeks and pulmonary findings do not
improve with antibiotic therapy, tuberculosis should be investigated
 DIAGNOSIS - Disease
History and Contact
•
Investigation
Onset and course of complaints
• Previous examinations and treatments for complaints
• Whether there is a previous diagnosis and treatment for TB
• Presence of TB patient in family and close circle
• Susceptibility for the disease (HIV(+), Diabetes Mellitus,
silicosis, Chronic Kidney Failure, steroid use, some cancer
types and treatments, alcohol addiction, nutritional status,
stress, etc.)
• Other risk factors: staying in prison, nursing homes, shelters;
homeless people, healthcare workers, having too many
people indoors, etc.
 DIAGNOSIS -
Bacteriology
Bacteriological diagnosis is essential in tuberculosis.

Samples that can be examined: Sputum, induced sputum,

fasting gastric juice, bronchoscopic aspiration fluid, CSF,
pleural fluid, urine, joint fluid, biopsy material, etc.

Microscopy: ARB examination with Ziehl-Neelsen staining

in morning sputum extracted on 3 consecutive days.
Culture: Inoculation of the microscopy material into
Löwenstein-Jensen solid and/or automated liquid
medium.
Drug susceptibility test: Investigation of susceptibility to
anti-tuberculosis drugs used in treatment in cultured
bacteria.
 DIAGNOSIS - Radiology

Infiltration in
• The sensitivity of PA the left lung

chest films in the

diagnosis of active TB
is 70-80%.
• TB cannot be
diagnosed by
Cavity in the upper right area
radiology alone.
 DIAGNOSIS - Molecular tests

• The tests recommended by the

World Health Organization are used.
• They have high sensitivity and
specificity.
• Results are available within a few
hours.
• Molecular test positivity establishes
the definitive diagnosis.
 DIAGNOSIS – Tuberculin Skin Test (TDT-PPD)

İntradermal injection The enduration that occurs

after 48-72 hours is measured.

A positive PPD (Purified Protein Derivative) test indicates that the

person is infected (infected), it DOES NOT indicate a definitive
disease.
Reference: Self-Study Modules on Tuberculosis, CDC,
2010
 Tuberculin Skin Test (PPD) evaluation
With BCG vaccine
0-5 mm Considered negative
6-14 mm Considered negative (May be due to BCG or TDMs)

15 mm and over Considered positive

Without BCG vaccine
0-5 mm Considered negative
6-9 mm Considered negative (May be due to TDMs)

10 mm and over Considered positive

 5 mm and above are considered positive in immunocompromised individuals.

TDM: Non-Tuberculosis Mycobacteria

 Organs Affected by the Disease
Pulmonary tuberculosis: Tuberculosis disease involving the lung
parenchyma or the tracheobronchial tree.
• The disease affects 60-70% lungs
• Pleural effusion or lymph node enlargement in the mediastinum
without involvement of the parenchyma is considered
extrapulmonary.
Extrapulmonary tuberculosis: Patients with ARB in samples taken from
organs other than the lung parenchyma or with histological and clinical
findings consistent with tuberculosis.
• Lung membranes, lymph nodes, bones, kidneys, brain membranes are
most commonly involved.
• It can cause disease in all organs of the body.

Some patients have both pulmonary and extrapulmonary tuberculosis

together.
Notification and Registration

• Tuberculosis is a notifiable disease.

• Definitively diagnosed TB patients are reported within 24 hours

by logging in to IZCI (for hospitals) and National Tuberculosis
System software.

• Diagnosed patients must be registered in Tuberculosis

Dispensaries.
Tuberculosis Dispanseries (Verem Savaş
Dispanserleri)
(Totally 173)
 Treatment of
Tuberculosis
It is the duty of the health system
and health workers
• to determine the treatment
regimen of the tuberculosis
patient,
• to provide the drugs and
• to complete the treatment by
ensuring that they use them
regularly during the treatment.
 Treatment
Principles of Drug Treatment:
1. Short-term standard treatment regimens should be chosen.
2. Medications should be used regularly
DOTS; directly observed therapy short course
[DOĞRUDAN GÖZETİMLİ TEDAVİ (DGT)].
1. Medicines should be used for a sufficient time.
2. With a regular treatment, 95-99% improvement is achieved.
3. It is assumed that the contagiousness disappears within 2-3 weeks
after treatment is started.
 Treatment

First Choice Drugs Used in Tuberculosis Treatment:

Isoniazide (H)
Rifampicin (R)
Pyrazinamide (Z)
Ethambutol (E)
Streptomycin (S)
6-Month Standard Treatment for Non-Drug-
Resistant Adult Patient

2 Months 4 Months
 What is Resistant
Tuberculosis?
 If tuberculosis patients do not use their drugs regularly and for a sufficient period (6-9 months),
tuberculosis bacteria may become resistant to drugs.

 Treatment of resistant TB patients takes longer (18-24 months), more drugs are needed, and
sometimes the patient dies.

patient without drug resistance

patient with drug resistance
one-day medicine bag
one-day medicine bag
 Patients Recommended to be Hospitalized

A smear positivity
• Those with poor general condition
alone is not a reason
• Those with advanced disease
for hospitalization.
• Patients with tuberculosis meningitis
The patient should be
• Those with significant hemoptysis
hospitalized if there is
• Suspicious cases whose diagnosis should be
a health problem or
confirmed
social need that
• Homeless people in need of care
requires hospitalization.
Patients Recommended to be Hospitalized

• Cases whose diabetes cannot be controlled

• Those with chronic kidney or chronic liver disease
• Cases with drug allergy, drug-induced hepatitis and other
drug side effects requiring hospital treatment
• Those with additional disease requiring hospitalization
 Requirements for Ensuring Treatment
Compliance
• Knowledgeable, motivated and friendly healthcare professionals
• Good education of the patient about the disease and the continuity of
this education
• Making and implementing a DOT plan with the patient
• Assigning a family member to the treatment
• Social and economic status determination and address verification by
making home visits
• Rewarding the patient throughout the treatment, providing social and
economic support
• Complete supply of medicines, free of charge treatment
 DOT:directly observed therapy
Doğrudan Gözetimli Tedavi (DGT)
Tuberculosis patients take each dose of drug every day within the control of a
healthcare worker or a trained volunteer and it is recorded.
It has been recommended by the World Health Organization to increase the
success of treatment. Since 2006, DOT has been applied all over the country.

DOT Treatment Packages

one-day medicine bag of patient

without drug resistance (left)
with drug resistance (right)
 Why DOT?
• Tuberculosis bacillus is transmitted through the air.
• Breathing the same air with the patient is sufficient for
the bacillus to be transmitted.
• It is impossible for healthy people to protect themselves
all their lives.
Therefore, the goal is:
Finding sick people as soon as possible and
by ensuring that they are treated,
prevent them from infecting other people
 Video Observed DOT (VOT)
Video Gözetimli DGT (VGT)
If the patient, who cannot come to the
health institution every day,
• video-connection to a health worker
while patient taking his medicine
• or, DGT, which is applied as sending
the video recording (showing he is
taking the drug) to the healthcare
worker
• Recommended method in the
pandemic!
 Reasons for Non-Compliance with
Treatment
• Difficulty taking medication every day for at least 6 months
• Complaints disappear and feel good within a month or two
of starting treatment.
• Variables such as educational status, social position, living
environment, age, gender
• Not being informed about possible side effects etc.

For such reasons, patients use their medications

irregularly and are excluded from follow-up.
 Possible Consequences of
Irregular Treatment and Stopping
Treatment
 Recurrence of the disease
 Inability to heal
 Continuing contagion
 Development of drug resistance and
transmission of resistant microbe to other
people
 Increased risk of death
 Increasing cost of treatment
 Termination of Treatment
o The patient is checked after using the drugs in the treatment
regimen appropriate to the characteristics of the disease for a
sufficient period of time and regularly.
o The medication of the patient, who is determined to be cured, is
stopped and he/she is told to come to the controls after the
treatment.
o If he/she has similar complaints again, he/she is advised to
apply to the health institution immediately.
o All files and records in the dispensary are stored in the archive
indefinitely.
 Successful Treatment Results
Cure (Kür): In pulmonary TB patient with a bacteriological diagnosis at the
beginning, together with clinical and radiological improvement; It is the
demonstration of smear or culture negativity at least twice, once in the
continuation period of the treatment and the other within the month when the
treatment is completed.
Treatment completion (Tedavi tamamlama): In cases where sputum analysis
cannot be performed during the maintenance period of the treatment or at the
end of the treatment in a patient who has completed the prescribed treatment
within the prescribed period, it is the termination of the treatment by considering
the clinical and radiological findings as successful.
*If the treatment result is successful in non-pulmonary TB cases, it is added to
this group.
Treatment Success (Tedavi başarısı): It is the sum of the cure and the completion
of the treatment.
 Other Treatment Results
Takip Dışı Kalan (Eski adı Tedaviyi Terk):
Out of Follow-up (Formerly «Terminated Treatment»):
It is the case that the TB patient does not take their medication for two
consecutive months or more during the treatment or the treatment has not been
started for 2 months.

Tedavi başarısızlığı:
Treatment failure: It is the detection of sputum smear or culture positivity in the
5th month of treatment and after.
* The positivity may continue during the treatment or it may become negative and
re-positive.

Ölüm:
Death: Death of a tuberculosis patient for any reason during treatment.
* TB cases that died without any treatment are also recorded in Tuberculosis
dispensary (VSD) and the «treatment result» part is recorded as "death".
Examination of
Contacts
 Examination of Contacts

Contact: A contact person is someone who

shares the same air with a TB patient and is
exposed to TB bacillus.
Purpose of contact examination is to identify:
a) the source (index) case,
b) persons infected with bacilli by the patient
c) to identify other people who gets the bacilli
from the same sourse with the diseased
person
 Who are the contacts?
• Domestic close contacts: Living in the same house with the
contagious patient; they share the same air.
• Close contacts outside the home: Persons who regularly share the
same air with the source case for a long time; like a close friend,
colleague…
• Other contacts: Those who spend a certain amount of time in the
same environment with the infectious patient; The people you
associate with in the classroom, at work, in the association…
• When a tuberculosis patient is identified in public places such as
schools, student dormitories, barracks, detention houses and prisons,
people sharing the same room are considered to be in contact.
• Those who make an eight-hour flight with a contagious TB patient
are also considered contact and are screened.
Transmission by Proximity of Contact

Random contact

famil
y
patient

Friends, relatives

Not infected
Infected * Veen 1992
Hans L. Rieder. Epidemiologic Basis of Tubeculosis Control, IUATLD, 1999. S:21
In a study* closeness of the contact;
 20% in domestic contact,
 3.7% in close friendship,
 0.3% in co-workers
has been shown to be contagious.
* Van Geuns HA, etal. Results of contact examination in Rotterdam 1967-1969. IUAT Bull 1975; 50: 107

In a study on the importance of contact examination **;

When the tuberculosis patient is diagnosed;

• 41% of the contacts were found to be infected,
• active disease was detected in 6% of them.

**Vidal R, Miravitles M, et al. Increased risk of tuberculosis transmission in families with micrepidemics.
Eur Respir J 1997;10:1327-1331
How to Screen the Contacts of
Tuberculosis Patients?

 Contact is questioned whether

he/she has any complaints.
 Lung graphies are taken.
 Tuberculin skin test (TDT/PPD) is
done; test performed on the
forearm is evaluated after 48-72
hours.
Protection and Prevention
of Tuberculosis
 Protection and Prevention of
Tuberculosis
Community protection
• Finding and effectively treating TB patients who
are contagious
• Preventing transmission within healthcare
institutions
Personal protection
• Vaccination with BCG
• Chemoprophylaxis
 Vaccinating with BCG
 The protection of the vaccine is up to 80%
in various studies.*
 This protection lasts for 5-6 years on
average, but there are some who report
that it lasts for 15 years.**
 It is more protective against miliary
tuberculosis and tuberculous meningitis,
which are fatal, especially in infants and
children.

*Akkaynak S. Tüberkülozda aşı ile immunizasyon, Tüberküloz ve Toraks 31; 40-49, 1983
**Styblo K. Epidemiology of Tuberculosis selected papers, vol:24 Royal Netherlands Tuberculosis Association, The Hague
(1991)
 Protection and Prevention of
Tuberculosis with
chemoprophylaxis

 Preventive treatment is given for those living in the

same house with the infected patient (spreading bacilli),
especially for children.

 A single drug (Isoniazid) is used in preventive treatment.

 The duration of preventive treatment is usually 6

months.
 Protection and Prevention of
Tuberculosis with
chemoprophylaxis
It is a preventive drug treatment applied
 in uninfected healthy people
To reduce the risk of being infected by bacilli
spread by infectious TB patients;
 in people who are infected but not sick
To reduce the risk of developing active
tuberculosis disease.
Generally Isoniazide is used in preventive treatment.

The duration of preventive treatment is usually 6 months.

 Persons Who Need to be Protected with
Medication (chemoprophylaxis)
1. Infectious TB patient contacts:
a. Babies born to mothers with tuberculosis
b. Close contacts under the age of 35
c. In the 35-year-old and older group, the risk of hepatotoxicity and the
benefit to be obtained from the treatment are compared for those
with LTBI (latent tuberculosis infection) and those with
immunosuppression, and a preventive treatment decision is made.
d. In the 35-year-old and older group, those who were not found to
have LTBI (latent tuberculosis infection) in the first test are repeated
two months later, and a decision is made according to this second
test.
 Persons Who Need to be Protected with
Medication (chemoprophylaxis)
2. TST or IGST positivity in children: Children younger than 15 years
of age who are not TB contacts but who are found to be positive for
TST (Tuberculin skin test) or IGRA (interferon gamma release assay)*.
3. Those with TST conversion: In the person who have a negative
(usually 0-4 mm) TST initially, within 24 months time it becomes
positive (6 mm increase appared or second measurement is >10 mm)
4. People who are immunocompromised and positive for TST or
IGST (due to increased risk of TB): HIV positive, Anti-TNF
medication will be started, corticosteroid used patients, CRF
patients on dialysis, organ or hematological transplant recipient and
donor candidates, silicosis patients.

TST=tuberculin skin test

IGST =interferon gamma release assay=In vitro test that measures the interferon gamma
release against tuberculosis spesific antigens)
TB Risk Groups
Active screening is recommended in high-risk groups
for TB.
• Contacts of tuberculosis patients
• Those staying in prisons and detention houses
• Health workers
• Those who have an immunosuppressive disease
(AIDS, chronic kidney failure, etc.) or those who
receive immunosuppressive treatment (those using
TNFα-inhibitors, using high-dose steroids, etc.)
• Persons from countries with a high incidence or high
drug resistance rate
Infection control measures

Patient Triage
• Guarantee that the coughing
patients wear a mask.
• Give priority to coughing
patients in the examination.
• Ensure that diagnostic tests
e.g. chest X-ray are carried
out without waiting in line

Surgical mask should be worn by tuberculosis

patient.
 Educate the patient:
How Can Tuberculosis Patients Protect People
Around From Disease?
 While sneezing and coughing, they should
definitely cover their mouth with a
handkerchief or arm.
 Hands should be washed after coughing
and sneezing.
 TB patients in the contagious period
should use a mask when they are in
closed environments and with other
people.
 They should use their medications
regularly and completely.
Infection control measures
Ventilation !!!!!
• In healthcare facilities, airflow should be directed from healthcare
professionals and non-TB people to the direction of TB patients.
• The windows of the rooms should be kept open in policlinics,
waiting rooms, etc. used by TB patients.
• Air exchange should be provided 6-10 times per hour.
• In inpatient services, the doors of the patient rooms should be
kept closed, windows or balcony doors should be opened
frequently and ventilated.
• In cases where windows cannot be opened, an extractor fan
should be installed on the window.
• In hospitals, patient rooms can be connected to the chimney and
external environment with a mechanically strengthened aspirator.
 Home Protection Measures
 VENTILATING the environments
where tuberculosis patients are
present, providing fresh air to
these environments, dilutes the
contagious droplets in the air
and reduces the possibility of
contamination.
 The SUN EXPOSURE of the
room kills the bacilli in the
environment.
 It is appropriate for the patient
to stay in a separate room, at
least until the sputum does not
produce bacilli.
 Infection control measures

Ultraviolet (UV) Lamps

• Upper room (protected) UV devices should be left open for 24
hours.
• The effectiveness of ultraviolet lamps should be checked
regularly with a UV meter.
• When insufficient ultraviolet is detected, the lamp should be
replaced.
• Ultraviolet lamps should be cleaned with 70% alcohol every
month.
• Care should be taken that ultraviolet lamps do not come into
contact with the eyes.
• The compliance of the amount of radiation received by the
employees and patients with the exposure limits should be
checked with a UV meter.
Infection control measures
Filtered Masks (FFP3/N95)
As a healthcare worker, always wear your filter
mask in the following situations:
• When contacting a smear positive
tuberculosis patient,
• During procedures (bronchoscopy, sputum
induction, etc.) that cause cough in a
tuberculosis patient,
• During the transport of a suspected or
definitively diagnosed infectious
tuberculosis patient,
• During emergency surgery or dental
treatment for a patient with suspected or
definitively diagnosed infectious
tuberculosis.
Thank you…
 Social Diseases (Malaria)

Ercan KULAK, MD, Public Health Medicine Specialist

Department of Public Health, English Medical School, Biruni University
 Learning objectives
at the end of the lesson the students are expected to know
•properties of malaria agent
•life cycle of malaria
•transmission of malaria
•epidemiology of malaria
•clinical presentatiton of malaria
•diagnosis of malaria
•case management and treatment of malaria
•prevention of malaria
• Currently, an estimated 99 countries are affected by malaria, with
approximately 40 percent of the world’s population exposed to this
preventable disease.
• Alphonse Laveran, a French Army physician serving in North Africa,
first identified the intraerythrocytic protozoan parasite,
Plasmodium, in 1880 from the blood of a soldier with acute malaria.
• Malaria is a complex and daunting problem with a complicated life
cycle and nuanced interplay of agent, host, vector, and environment
that is further complicated by challenging political, economic, and
social factors.
 Malaria agent
• Malaria is caused by protozoal organisms of the genus Plasmodium.

• While more than 100 species of Plasmodium can infect many

animals, such as reptiles, birds, and various mammals, historically,
only four species of Plasmodium were recognized to infect humans
in nature.

• A fifth species of malaria, the primate parasite P. knowlesi, though

first known to cause human infection in 1967, has recently emerged
as an important cause of zoonotic malaria in Southeast Asia.
 Malaria agent
• These five species of malaria differ in geographic distribution, clinical
manifestations, and details of their life cycle.

• The most important species in terms of virulence and global burden

is P. falciparum, which accounts for most deaths. However, the
impact of P. vivax has been increasingly recognized as considerable.
P. ovale and P. malariae have more limited distribution and
significance.
 Life cycle
• The life cycle of malaria is complex, slightly different for each
species, and necessarily involves both humans and Anopheles
mosquitoes.
• When a human host is bitten by a malaria-infected mosquito,
sporozoites are inoculated.
• The sporozoites will travel via the blood and infect liver cells where
they will mature into schizonts containing large numbers of
merozoites.
• The entire process of initial replication in the liver is referred to as
exoerythrocytic schizogony.
 Life cycle
• After this process is complete, schizonts will eventually rupture and
release merozoites that will enter red blood cells (RBCs).
• In a process known as erythrocytic schizogony, merozoites initially
form small ring stages, then larger trophozoites, and subsequently
form erythrocytic schizonts via asexual replication.
• These schizonts rupture, releasing merozoites, which invade other
erythrocytes. The cycle of rupturing merozoites will eventually
synchronize, flooding the bloodstream with parasitic material, and
resulting in many of the clinical manifestations of infection.
 Transmission
• Transmission of the malaria parasite occurs through the bite of an
infected female Anopheles mosquito.
• Malaria transmission can occur anywhere there are infected
humans, mosquitoes that are capable of being infected, and contact
between the two.
• Occasionally mosquito-borne transmission of malaria in non-
endemic areas has occurred, typically in small foci, when
parasitaemic individuals from endemic areas are bitten by
competent local vectors and subsequently transmit infection.
Traveler Categories at Greatest Risk for
Exposure & Infection
• Children
• Long-term travelers and expatriates
• Pregnant travelers
• Tourists, business travelers, and missionaries
• Travelers visiting friends and relatives in areas with malaria
 Clinical Presentation
• Malaria is characterized by fever and influenza-like symptoms,
including chills, headache, myalgia, and malaise; these symptoms
(particularly fever) can occur at intervals in a pattern that varies by
species.
• Malaria can be associated with anemia and jaundice, and can cause
kidney failure and an enlarged spleen.
• Infected red blood cells can clog small blood vessels in the brain,
resulting in cerebral malaria, which is particularly common in P.
falciparum infections, and can cause seizures, mental confusion,
coma, and death.
• People who survive cerebral malaria may have neurological sequel,
cognitive deficits and behavioral alterations.
 Clinical Presentation
• The clinical presentation of malaria very much depends on the level
of immunity to malaria in the patient.
• While some immunity can be due to innate factors, in endemic areas
immunity is mostly acquired through repeated exposure to
Plasmodium.
• As a result, in highly endemic areas populations at higher risk of
severe malaria are children aged under five years and pregnant
women.
 Clinical Presentation
• Due to a tendency of Plasmodium-infected cells to accumulate in the
placenta, malaria can also have negative effects on the growth and
development of unborn children and can even cause infant death.
• For people living in low endemic or epidemic-prone areas, and
travelers from non-malaria regions, all ages are at risk of infection
and severe disease.
 Diagnosis
• Blood Smear Microscopy

remains the most important method for malaria diagnosis. Microscopy

can provide immediate information about the presence of parasites,
allow quantification of the density of the infection, and allow
determination of the species of the malaria parasite—all of which are
necessary for providing the most appropriate treatment.
 Diagnosis
• Rapid Diagnostic Testing

detect antigens derived from malaria parasites. Malaria RDTs are

immunochromatographic tests that most often use a dipstick or
cassette format and provide results in 2–15 minutes. RDTs offer a
useful alternative to microscopy in situations where reliable
microscopic diagnosis is not immediately available.
 Diagnosis
• PCR Testing

also are available to detect malaria parasites. These tests are more
sensitive than routine microscopy, but results are not usually available
as quickly as microscopy results, thus limiting the utility of PCR for
acute diagnosis and initial clinical management. Use of PCR testing is
encouraged to confirm the species of malaria parasite and detect
mixed infections.
 Case management and treatment
• Anti-malarial treatment policies vary between countries, and
depend on the epidemiology of the disease, transmission, patterns
of drug resistance, and political and economic contexts.
• There is no universal treatment scheme.
• The drugs currently available for malaria treatment include
chloroquine, amodiaquine, primaquine, sulfadoxine-pyrimethamine,
mefloquine, atovaquone-proguanil, quinine, doxycycline, and
artemisinin derivatives often used in combination therapy.
 Prevention
• Malaria prevention consists of a combination of mosquito avoidance
measures and chemoprophylaxis.
• Prevention measures must address all malaria species in the travel
area and apply to both short-term and long-term travelers.
• Although highly efficacious, interventions are not 100% effective, so
all febrile persons returning from malaria-endemic areas should be
tested for malaria even if they took chemoprophylaxis.
 Prevention
• Because of the nocturnal feeding habits of Anopheles mosquitoes,
malaria transmission occurs primarily between dusk and dawn.
• Travelers can reduce contact with mosquitoes by remaining in
enclosed air-conditioned rooms or well-screened areas, sleeping
under mosquito nets (preferably insecticide-treated), using an
effective insecticide spray or mosquito coils in living and sleeping
areas during evening and nighttime hours, and wearing clothes that
cover most of the body.
 Prevention
• All travelers should use an effective mosquito repellent, such as
those that contain DEET (N,N-diethyl-meta-toluamide).
• Repellents should be applied to exposed parts of the skin.
• If travelers are also wearing sunscreen, they should apply sunscreen
first and insect repellent second.
• In addition to using a topical insect repellent, a permethrin-
containing product can be applied to mosquito nets and clothing for
additional protection against mosquitoes.
• Mosquito repellant–impregnated clothing also is available.
 Prevention
• All recommended primary prophylaxis regimens involve taking a
medicine before, during, and after travel to an area with malaria.
• Beginning the drug before travel allows the antimalarial agent to be
in the blood before the traveler is exposed to malaria parasites.
• In choosing a prophylaxis regimen before travel, the traveler and the
travel health provider should consider several factors, including the
presence of antimalarial drug resistance in the area of travel, length
of travel, the patient’s other medical conditions, allergy history,
other medications prescribed or already being taken (to assess
possible drug interactions), potential side effects, and the cost of the
antimalarial.
 Prevention
• No antimalarial drug is 100% protective; therefore, travelers must
combine prophylaxis with mosquito avoidance and personal
protective measures (e.g., insect repellent, long sleeves, long pants,
sleeping in a mosquito-free setting, using an insecticide-treated
mosquito net).
 Blood Donation After Travel to Malaria-
Endemic Areas
• People who have been in an area where malaria transmission occurs
should defer donating blood after returning from the malaria-
endemic area to prevent transmission of malaria through blood
transfusion.
• A travel health provider advising a traveler going to a country with
relatively low malaria transmission for a short period of time and
engaging in low-risk behaviors might suggest the traveler use only
mosquito bite precautions and no prophylaxis. Upon the traveler’s
return, however, a blood bank might still choose to defer blood
donations from that traveler for 1 year because of travel to an area
where transmission occurs.
 Vaccination

• WHO updated its recommendation for malaria vaccines in October

2023. This applies to both RTS,S/AS01 and R21/Matrix-M vaccines.

• WHO recommends the use of malaria vaccines for the prevention of P.

falciparum malaria in children living in malaria endemic areas,
prioritizing areas of moderate and high transmission.

• The malaria vaccine should be provided in a schedule of 4 doses in

children from around 5 months of age.
 Last words…

• There is a need for continuous malaria surveillance, preparedness,

and prevention.
• Clinicians’ awareness about malaria in travelers should remain a focus
of attention, as the main risk of malaria in the EU/EEA is for travelers
to malaria-endemic countries.
• Early diagnosis and prompt treatment of imported and introduced
cases are the basic elements of malaria control in the EU/EEA,
including active case finding.
 Last words…

• Vaccines are recommended by the World Health Organization for

children living in areas with moderate to high transmission.
• Healthcare providers should be aware that healthcare-associated
transmission of malaria is possible.
 Social Diseases (Rabies)

Ercan KULAK, MD, Public Health Medicine Specialist

Department of Public Health, English Medical School, Biruni University
 Learning objectives
at the end of the lesson the students are expected to know
•properties of rabies agent
•transmission of rabies
•epidemiology of rabies
•clinical presentatiton of rabies
•diagnosis of rabies
•case management and treatment of rabies
•prevention of rabies
• Rabies is caused by a neurotropic virus of the family Rhabdoviridae,
genus Lyssavirus, subgroup rabies virus.
• Globally, rabies is designated a Neglected Tropical Disease by the
World Health Organization and accounts for over US$8 billion in
annual economic costs.
• Children of poor and rural areas are predominantly affected, and
Africa and Asia shoulder 95% of associated deaths.
• The average cost of rabies postexposure prophylaxis (about US$100)
puts lifesaving treatment tragically out of reach for much of the
world.
• The virus commonly is transmitted via saliva that contaminates
bites, scratches, and wounds, and, recently, via mucosal exposure.
• Rabies transmission via transplanted neurologic tissues (corneas)
and solid organs also has been documented.
• One case of rabies was reported in China after exposure of an open
wound to the blood of a person bitten by a dog; the exposed person
succumbed to rabies after seeking no medical care, while the bitten
individual received postexposure prophylaxis and did not develop
rabies.
• Rabies is a highly neurotropic virus that evades immune surveillance
by its sequestration in the nervous system.
• Upon inoculation, it enters the peripheral nerves.
• A prolonged incubation follows, the length of which depends on the
size of the inoculum and its proximity to the CNS.
• The rabies virus spreads quickly, at a rate of 200-400 mm per day,
into the CNS, and spread is marked by rapidly progressive
encephalitis.
• Thereafter, the virus spreads to the periphery and salivary glands,
where it may be transmitted to others.
• Global reservoirs of rabies virus are as follows
 Europe - Foxes, bats
 Middle East - Wolves, dogs
 Asia - Dogs
 Africa - Dogs, mongooses, antelopes
 North America - Foxes, skunks, raccoons, insectivorous bats
 South America - Dogs, vampire bats
A: Human deaths from rabies;
 B: Death rates per capita (per 100 000 population);
countries shaded in grey are free from canine rabies
 Clinical presentation
• The rabies virus is segregated from the immune system during the
incubation period, and no antibody response is observed. The
infected individual remains asymptomatic during this period. The
average duration of incubation is 20–90 days. In more than 90% of
cases, incubation is less than 1 year.
• The virus enters the CNS. The duration of this period is 2-10 days.
• Nonspecific symptoms and signs develop, including fevers and flulike
illness. Paresthesia, pain, or intense itching at the inoculation site is
pathognomonic for rabies; this may be the individual’s only
presenting sign.
 Clinical presentation
• Symptoms may include the following:
 Malaise, Anorexia, Headaches
 Fever, Chills, Pharyngitis
 Nausea, Emesis, Diarrhea
 Anxiety, Agitation, Insomnia, Depression
If the patient presents with encephalitis
and suspected rabies
 Skin biopsy from the nape of the neck
 Corneal touch impression
 Viral cultures and polymerase chain reaction (PCR) assay (Saliva,
Cerebrospinal fluid, Brain tissue)
 Blood gas analysis
 Hematology studies
 Imaging studies
 Electroencephalography
 Cardiac monitoring
 Emergency treatment of rabies
• Treatment of rabies should be based on history and exposure. One
should not withhold treatment while waiting for diagnostic tests.
• Postexposure prophylaxis (PEP) consists of wound cleaning,
vaccination, and administration of rabies immunoglobulin.
• Immediate therapy, provided prior to the administration of vaccine
and immunoglobulin, consists of the thorough cleaning of all bite
and scratch wounds with soap and water, 2% benzalkonium
chloride, and/or a virucidal agent (ie, povidone-iodine solution).
 Emergency treatment of rabies
• The 2 rabies vaccines are the human diploid cell vaccine (HDCV,
Imovax) and the purified chick embryo cell vaccine (PCECV,
RabAvert).
• Both are made for intramuscular administration and are equal in
efficacy and safety. The vaccine takes 7-10 days to induce an active
immune response, with immunity lasting approximately 2 years.
• Passive immunization with human rabies immunoglobulin (HRIG,
HyperRab S/D, KedRab, Imogam Rabies-HT) provides immediate
protection.
• The immunoglobulin elicits neutralizing antibodies and has a half-life
of 21 days.
 Emergency treatment of rabies
• Postexposure Prophylaxis in Previously Unvaccinated
Immunocompetent Persons
 Human rabies immunoglobulin
 1 dose (20 IU/kg)
 on Day 0 at the same time as the vaccine
 If not immediately available, the HRIG should be administered as
soon as it becomes available up until and including day 7 of
treatment.
 Emergency treatment of rabies
• Postexposure Prophylaxis in Previously Unvaccinated
Immunocompetent Persons
 Vaccine
 Four doses (1 mL each) of either HDCV or PCECV vaccine should be
administered on Days 0, 3, 7, and 14
 The first dose should be administered as soon as possible after
exposure.
 It should be given intramuscularly into the deltoid muscle of adults.
 Emergency treatment of rabies
• Postexposure Prophylaxis in Previously Unvaccinated
Immunocompromised Persons
 should receive HRIG and the vaccine as described above but should,
in addition, receive a fifth dose, on Day 28.
 Any immunosuppressive agents should be stopped during rabies PEP
unless necessary and essential for management of another
condition.
 Additionally, serum should be tested to document seroconversion 1-
2 weeks after completing PEP.
 Emergency treatment of rabies
• Postexposure Prophylaxis in Previously Vaccinated Persons
 Previously vaccinated persons include those who have received the
3-dose preexposure series of HDCV, rabies adsorbed virus (RVA), or
PCECV; a full PEP; or a previous vaccination with any rabies vaccine
with a documented history of seroconversion.
 HRIG should not be administered.
 For the vaccine, administer 2 doses (1 mL each) into the deltoid
muscle on Day 0 and Day 3.
 Deterrence and Prevention
• The control and vaccination of domestic animals
• The vaccination of individuals who may be exposed to rabies in their
occupation
• Avoiding contact with unfamiliar or wild animals
• Cleansing of any injury or bite from any animal (may reduce the risk
of rabies transmission)
• Promoting educational efforts at home and at schools teaching
children about safety procedures and precautions regarding pets
and wild animals
 Deterrence and Prevention
• Teach children at an early age not to handle stray animals or wildlife
• Report any animals that are sick or acting strange to local public
health authorities
• Keep pets indoors at night and fenced in or on a leash when
outdoors
• Keep pet food and water dishes indoors
• Handle sick or dead animals with heavy gloves and shovels
• Wash hands with soap and water after contact with wildlife
 Deterrence and Prevention
• Rabies postexposure prophylaxis of healthcare workers is indicated
only for high-risk exposures as determined with the assistance of
local infection control and public health authorities.
• Pretransplantation screening for potential rabies infection or
exposure should be performed on organ donors.
• Recipients of corneal and neurally derived tissues are at highest risk
for rapid development of rabies.
• Because rabies is a zoonosis, primary prevention requires control of
rabies in the animal population.
The end…