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Making Sense of ... Tuberculosis

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Tuberculosis

What is tuberculosis?

Tuberculosis (tubercle bacillus - TB) is an infectious disease caused by Mycobacterium tuberculosis. Tuberculosis most commonly affects the lungs (pulmonary tuberculosis), but other systems can be affected, including the central nervous system, the lymphatic system, circulatory system, the skeletal system and the genitourinary system.

This article discusses pulmonary tuberculosis
Pulmonary tuberculosis is the form of the disease that presents by far the greater risk, as it is highly infectious - spread by airborne droplets - and this article will be confined to this form of the disease.

Where is tuberculosis usually found?

Tuberculosis is endemic throughout the world - the World Health Organization has estimated that a third of the world's population are living with tuberculosis.

As person to person spread is the usual route of transmission, the disease has become associated with poverty, overcrowding, poor living conditions; a predominantly urban disease. Advances in medicine, such as the survival of many people with auto-immune conditions - and low resistance to infection - has created a new group of people who are highly susceptible to the disease; there are many cases of such individuals catching the infection while in hospital.

In recent years, the emergence of drug-resistant forms of the disease has further complicated the situation, and means that the general risk of infection is rising.

How common is tuberculosis?

Over one third of the world's population probably carris the bacterium; but not all these people will develop full-blown tuberculosis.

Up to nine out of ten carriers of asymptomatic tuberculosis (latent infection) will not develop active disease. But of those who do go on to 'active' disease, over half will die if the disease is untreated. In 2004, almost fifteen million people had active tuberculosis; nine million new infections were diagnosed, and almost two million people died, mostly in developing countries.

How is tuberculosis transmitted?

Tuberculosis is spread by droplets which are expelled when an infected person exhales (including cough, sneezes, and speaking), and another person inhales the bacteria. There is only a risk with open pulmonary tuberculosis, when the infected person has the bacteria in their sputum.

Who is most at risk?

People living in high-density housing, institutions (such as prisons). People with reduced immunity, such as those living with HIV, are at serious risk. People living in poverty are at greater risk because of the greater likelihood of contact with untreated disease, plus a likelihood of general ill health with lower resistance to infection.

What are the symptoms of tuberculosis?

A persistent cough is often an early sign. it isusually a 'moist' cough, often large amounts of phlegm. Blood staining may occur early, and significant blood with expectoration is a coomon feature of more advanced disease.

As the disease spreads into the lymphatic system, there may be swollen glands, especially in the neck.

Tiredness and listlessness are common, usually accompanied by a loss of appetite. Severe weight loss is a featrure of TB.

Night sweats may be profuse.

Pain on breathing in may occur; this is caused by infection of the membranes surrounding the lungs (pleurisy).

Before the disease process was fully understood, TB was known as consumption; as the disease could accurately be described as consuming the sufferer.

What are the long term effects of tuberculosis?

Long term effects include the possibility of latent disease recurring later, effects of the disease itself, and effects of medicines and surgical intervention.

High dose medication can lead to liver damage, which can have long term implications, but the major effect is on the lungs; lung capacity may be severely reduced, with scar tissue further damaging lung function. In some cases this may mean a permanent productive cough, with occasional haemoptisis, and increased risk of lung infections.

Most people have little or no problems post effective treatment for TB.

What is the mortality rate for tuberculosis?

Tuberculosis remains the leading infectious disease cause of death. bases on 2005 figures, there are over 1.5 million deaths per year, some 24 per 100,000 population, though there is much variation around the world.

TB mortality is much higher among people who also have HIV, and this shows in the statistics, particularly in Africa, where the diseases have progressed in tandem.

How is tuberculosis diagnosed?

Because TB presents in many ways, medical evaluation where pulmonary TB is suspected includes a medical history, a physical examination, a chest X-ray and microbiological examination of sputum. It may also include a tuberculin skin test, other scans and X-rays, and surgical biopsy.

The medical history usually reveals a productive cough over at least three weeks, possibly with chest pain, and hemoptysis, that is not responsive to conventional antibiotic therapy. Systemic symptoms can include fever, chills, night sweats, appetite loss, weight loss, and easy fatigability.

Prior TB exposure, infection or disease; past TB treatment; demographic risk factors for TB; and medical conditions that increase risk for TB disease, such as HIV infection, will assist in formaing a provisional diagnosis.

Sputum is tested for acid-fast bacilli if the patient is producing sputum; this provides a strong indication of the presence of TN; a definitive diagnosis of tuberculosis is made by culturing Mycobacterium tuberculosis from a specimen taken from the patient.

Is there a treatment for tuberculosis?

Treat for most people with TB willinvolve long-term drug treatment, and will almost always be at home, not in hospital. Only where the patient is seriously ill, or has other problems requiring in-patient treatment, will the hospital be necessary.

Standard drug therapy for active TB will last for several months, involving combinations of anti-mycobacterial antibiotics - isoniazid, rifampin, and pyrazinamide. Ethambutol or streptomycin may also be used.

The treatment will be ineffective unless taken consitently over a long period; indeed, the most common cause of treatment failure is failure to comply with the drug regimen.

This is a very serious issue, as TB is endemic among homeless, rootless and highly mobile populations of many cities, causing the emergence of drug-resistant organisms.

Another important aspect of tuberculosis treatment is contact tracing, as the disease is so contagious; relatives, friends and even casual contacts may need to undergo skin tests and chest x-rays or be asked for sputum specimens..

Is there a way to prevent infection?

Prevention of TB is a world poverty issue, a world health issue and a local public health issue, and eradication will depend on global co-operation, which is notable for it's verbal agreement and insufficient commitment.

TB is a preventable disease, and the most effective practical measure against it is the efficient diagnosis and treatment of those who carry the disease, before it can spread further.

Measures open to the individual include:

  • Keeping the immune system healthy.
  • Get tested regularly, for those who have any disease that weakens the immune system or live or work in a prison or any long-term care institution. Certain health care workers have an increased risk of exposure to the disease.
  • Consider preventive therapy or vaccine.
  • If someone close to you is diagnosed, assist and encourage them to stick closely to their treatment protocol.

For those who are diagnosed with TB:

  • Cough into tissues, and dispose of these safely.
  • Cover your mouth. It will be two to three weeks before the treatment stops the risk of contagion. Wearing an approved mask when people are around, during the first three weeks, may help reduce the risk of transmission.
  • Stay at home. Stay away from people. Don't go to work or school or sleep in a room with other people during the first few weeks of treatment for active TB.
  • Ensure adequate ventilation. Open the windows whenever possible, day and night.
  • Finish the entire course of medication, however well you may feel. This is the single most important step you can take to protect yourself and others from TB. If treatment is interrupted, or stopped too soon, TB bacteria may mutate into more therapy-resistant strains which are at best much more difficult to treat, and at worst, fatal.

What is the tuberculosis vaccine?

The vaccine contains a live, attenuated TB bacteria, (Baceille-Calmette-Guerin - BCG).
# Vaccination against TB is included in the childhood vaccination programme,
# Children are usually vaccinated when 10 to 14 years, but children born in high risk communities like certain immigrant groups should be vaccinated at birth.
# PHLS BCG vaccine fact sheet.

# BCG vaccination is considered in
# The vaccine gives a small open wound, which heals over 4 to 6 weeks.

In the USA, people at higher risk of TB have regular skin tests, and are treated if the skin test becomes positive. As fewer than 10% of people infected with TB go on to develop the disease, many people may be given a course of drugs unnecessarily.

What is the protocol for tuberculosis vaccination?

In some countries, including the UK, TB vaccination was routine for 15 year old school children. Despite the rise of TB - including highly resistant strains - this practice was discontinued in 2005 'allowing health resources can be more effectively targeted' - in other words, to save money.

Who should get vaccinated against tuberculosis?

BCG vaccine is used for infants and adults in high-risk communities, in most countries where the vaccine is available, and may be available for previously unvaccinated travellers intending to stay in endemic areas for long periods.

Are there adverse reactions to the tuberculosis vaccine?

The vaccine leaves a small open wound, which heals over a few weeks, often leaving a scar.

Can tuberculosis be controlled environmentally?

No.

While TB has many environmental factors; more prevalent combined with poverty, or with HIV, more common in poorer countries than richer ... TB is too contagious for containment to work as a disease control measure, and in an age of cheap flights, it travels too easily and too fast.

What can be learned from history?

Tuberculosis has been responsible not only for millions of deaths, but also untold suffering among those who have lived with the disease for years.

We should have learned that it is too bad a disease to be allowed to spread again throughout the western world - not to mention too bad a disease to be allowed to remain rampant in the developing world.

And yet therapy-resistaant strains are indeed spreading, with morbidity and mortality increasing year-on-year.

Bibliography and Further Information Sources

If this article hasn't answered your question, email me at the address below, and I'll try to get the information you seek. I regret I cannot assist with individual cases or essays and school projects, but if it's something I've missed, I'll be happy to try and help.

Article written by Andrew Heenan BA (Hons), RGN, RMN

First Published: 10 January 2008
Last updated: 7 March 2012
© Andrew Heenan 2008 et seq
 

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