Community Medicine Dr.

Wijdan

TUBERCULOSIS
• TB is a major cause of morbidity and mortality all over the world but the greatest
burden is borne by developing countries. TB is caused mainly by the bacterium
Mycobacterium tuberculosis (M. tuberculosis)

TB is a chronic infection. The great majority of infections are caused by M.

tuberculosis. TB can also be caused by M. bovis, which is acquired by drinking
unpasteurised milk from infected cows

TB is an ancient disease which remains a worldwide problem. The importance of

TB is evident in the following facts:

1. About 1 in 3 of the world’s population are infected with tubercle bacilli and
someone is newly infected every second

2. Although most infected people remain asymptomatic, TB causes illness in

about 8 million people every year

3. About 2 million people die from TB every year - more deaths than for any
other infectious disease.

Where does TB occur?

About 95% of the world’s cases of TB occur in the developing countries of South
East Asia, Sub-Saharan Africa and the Western Pacific. The largest number of
cases occur in South East Asia and this region accounts for 33% of incident cases
globally. The highest mortality from TB also occurs in this region. It is estimated
that 1-2% of the Indian population are infected with tubercle bacilli.

The global incidence of TB has increased in the last two decades. This has been
attributed to a number of factors, including:

 the HIV pandemic

 emergence of drug-resistant strains of M. tuberculosis

 poor national TB control programmes

 worsening socio-economic conditions in many countries

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GLOBAL BURDEN

• More than 2 billion people (about one-third of the world population) are
estimated to be infected with Mycobacterium tuberculosis . The global incidence
of tuberculosis (TB) peaked around 2003 and appears to be declining slowly. In
2007 there were an estimated 13.7 million chronic active cases, and in 2010, 8.8
million new cases, and 1.45 million deaths, mostly in developing countries. The
absolute number of tuberculosis cases has been decreasing since 2005 and new
cases since 2002.

• China has achieved particularly dramatic progress, with an 80 percent decline in

its TB mortality rate. The distribution of tuberculosis is not uniform across the
globe; about 80% of the population in many Asian and African countries test
positive in tuberculin tests, while only 5–10% of the U.S. population test positive.

• The incidence of TB varies with age. In Africa, TB primarily affects adolescents

and young adults. However, in countries where TB has gone from high to low
incidence, such as the United States, TB is mainly a disease of older people, or of
the immunocompromised.

Microbiology:

• M. tuberculosis is a non-motile, rod-shaped bacterium. It is an obligate aerobe,

which explains why it tends to be found in the well-aerated, upper lobes of the
lungs.

• It is a slow growing organism (dividing only every 16-20 hours) that lives within
tissue macrophages. Humans are the only reservoir of M. tuberculosis. Both cows
and humans serve as reservoirs for M. bovis.

The organism does not have the characteristics of either Gram positive or
negative bacteria.

The Ziehl-Neelsen stain is used to demonstrate the presence of the bacilli in a

smear. They appear as bright red rods against a contrasting background.
The cell wall is a major factor in the virulence of the organism. It resists
destruction by many antibiotics, acids, alkalis, osmotic lysis and oxidation and
enables the organism to survive inside macrophages.

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How is TB transmitted?
Nearly all TB infection is acquired by inhalation of respiratory droplets from an
infectious contact. Air droplets 3-5 μm diameter coughed, sneezed or spat out by
an “open” case of TB. The droplets are inhaled by a close contact. This may lead
to a lung infection which then may go on to develop into disease – in the lungs
and/or in other organs.

Abdominal TB can also result from drinking unpasteurised cow’s milk infected
with M. bovis.

Between 70-90% of individuals exposed toTB will not develop any symptoms or
signs of infection.

The reasons for this are unclear but, in view of the known risk factors for
infection, they may include inhalation of an insufficient number of organisms to
cause infection or adequate immunity to prevent an infection becoming
established.

Following inhalation, TB bacilli settle in the alveoli. This results in a small focus
of local inflammation in the lung parenchyma. This primary focus usually occurs
in the upper lobes in adults but may occur in any of the lung lobes in children.
More than one focus may occur in the same patient.

The organisms then spread via the local lymphatics to the nearest hilar lymph
nodes, which may then enlarge.

The primary focus and the enlarged regional lymph nodes form the primary
complex or “Ghon complex”.

What happens next depends on the size of the infecting dose and the resistance of
the host. Most commonly, the primary focus is “walled-off” by the immune
system and lies dormant for years. The infection may be reactivated years later if
the immune system of the host becomes weakened.

The primary focus is not contained and lung disease may develop in several
ways:

*The primary focus enlarges and undergoes central necrosis to form a cavity

*The infection can spread locally and result in tuberculous bronchopneumonia

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*Marked swelling of the mediastinal lymph nodes may compress large bronchi
and result in lobar collapse

*The enlarged lymph node may act like a one-way valve causing hyperinflation
of a lung or lobe

*The adjacent pleura can become infiltrated by M. tuberculosis resulting in a

hypersensitivity reaction characterised by granulomas composed mainly of
lymphocytes

*Pleural infiltration may result in a pleural effusion which is rich in lymphocytes

– a useful pointer to the diagnosis when pleural fluid is aspirated and analysed

Long term complications of the damage to lung tissue include emphysema and
bronchiectasis

Haematogenous dissemination of M. tuberculosis leads to granuloma formation

in many organs. Examples include:

• Diffuse infection of the lungs: “miliary” TB

• Brain: TB brain abscess

• Meninges: TB meningitis

• Bones: TB osteomyelitis – commonly affects the spine and is then called “Potts’
disease”

• Pericardium; TB pericarditis and pericardial effusion

Disseminated disease is most likely to occur in the immunocompromised patient

(e.g. HIV/AIDS, malnutrition) and at extremes of age.

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Natural history following TB exposure

What are the likely outcomes following exposure to open TB?

Exposure to TB

No infection Infection
(70-90%) (10-30%)

Dormant TB Active TB (10%)

(90%) ill
well likely to die if
no TB disease untreated
Activation of infection results
not infectious in disease infectious
to others

What are the symptoms and signs of TB?

1. Primary infection with no spread of the disease

Individuals with primary infection do not usually have any symptoms or signs of
ill health although some people develop a minor flu-like illness.

The response of the immune system to the infection may result in clinical signs of
hypersensitivity to M. tuberculosis in a minority of people, for example:

• erythema nodosum

• phlyctenular keratoconjunctivitis

They will also have a positive Mantoux test

2. Active infection: symptoms

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Symptoms of TB can be divided into general symptoms and those specific to the
organ infected.

TB can result in a myriad of symptoms depending on which organs are involved

and how their function is affected.

The lung is the predominant organ affected, being involved in over 75% of cases.

Commonly affected organs following haematogenous spread from the lung are
the abdomen, lymph nodes, spine, meninges, kidneys, bone and reproductive
organs.

TB lymphadenitis presents as painless enlargement of the superficial lymph

nodes. The neck is the commonest site involving the cervical, submandibular, pre
and post- auricular lymph nodes. The lymph nodes are non-tender, matted
together and rubbery in consistency. It is common for enlarged lymph nodes to
ulcerate and discharge.

3. Pulmonary and abdominal TB

Pulmonary TB (PTB)

The apical region is the most commonly affected in adults. Pulmonary

lesions may involve any part of the lung in infancy and childhood.

Examination of the respiratory system may be completely normal even in

active disease. Abnormalities which may be detected clinically include signs
of consolidation, collapse, pleural effusion and fibrosis

Abdominal TB

Pathology affects the mesenteric and the retroperitoneal glands, the

omentum and the gastrointestinal tract. Patients may present with weight
loss, diarrhoea or constipation, abdominal distension (from ascites) or
chronic intestinal obstruction. Enlarged mesenteric lymph nodes may be
palpable as multiple intra-abdominal masses.

• Tuberculosis of the spine – “Pott’s disease”

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TB commonly affects the spine, especially in young children, and usually

presents as a swelling on the back.

The lower thoracic and the upper lumbar vertebrae are the usual sites, however
any vertebra can be affected.

Diagnosis:

Diagnosis of TB is based on –

1. Typical history of chronic cough with the general symptoms of fever, malaise
and weight loss

2. Presence of general and specific clinical signs

3. Positive findings on relevant investigations – usually CXR and sputum smear

stained for acid-fast bacilli

It is important to note that specific symptoms and signs may be absent…

TB should be suspected in any chronically-ill person!

Sputum examination

Useful in adults with productive cough

• Sputum microscopy: Smear stained with the Ziehl-Nielsen stain to demonstrate

the presence of the acid and alcohol fast bacilli (AFB). When positive, patient is
referred to as “smear-positive” or “open TB” and risk of transmission of infection
to others is very high. However, the test often negative in patients with TB. Yield
is higher in patients with lung cavities.

• Sputum culture: Takes about 6-8 weeks and so is of limited use in clinical
diagnosis.

• Gastric washings examined for AFB: Carried out in children as they swallow
rather than cough-up sputum. The test aims to recover the swallowed AFB from
the stomach. Test positive in only about one third of children with TB.

Other investigations

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Other investigations are indicated depending on the organs/ systems affected by

the disease

 Spinal radiographs in Pott’s disease

 Lymph node aspirate (microscopy, culture and cytology) or biopsy (histology and
culture) in TB lymphadenitis

 Lumbar puncture for cerebrospinal fluid analysis in TB meningitis (microscopy,

biochemical analysis and culture)

Treatment
• Administration of a single antibiotic in the treatment of TB has been shown to
lead to the development of mycobacteria resistant to that drug

• Combination chemotherapy is the treatment of choice; effective regimens for

the treatment of TB must contain multiple drugs to which the organisms are
sensitive

• Using drug combinations minimises the development of drug-resistant strains

• Treatment: DOTS

• DOTS means Directly Observed Therapy Short Course.

• It involves the administration of a combination of antituberculous drugs to a TB

patient under the supervision of a healthcare personnel. DOTS helps to ensure
compliance, reduce transmission by shortening the period of infectivity, improve
the cure rate and reduce the risk of drug resistance
There are many regimens for treating TB, but commonly used drugs include:
• Intramuscular streptomycin
• Oral rifampicin
• Oral isoniazid (INH)
• Oral pyrazinamide
 Oral ethambutol may be substituted for IM streptomycin in patients that are
above the age of 6 years
 Treatment lasts for 6 months (but IM streptomycin / oral ethambutol and oral
pyrazinamide are usually given during the first 60 days of treatment only.

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Prevention and Control

The World Health Organisation has declared TB a global health emergency

Several other organisations are involved in TB control, including the

International Union Against TB and Lung Disease, the Center for Disease
Control (USA) and the Global Plan to Stop TB (GPSTB).

TB control remains a worldwide challenge. There is a need to improve DOTS

coverage and meet the emerging challenges of TB occurring in people with
HIV/AIDS and multidrug resistant TB.

TB Control Strategies include –

Case finding: aims to identify TB cases promptly and treat them with effective
drugs.

Contact tracing: Close contacts of TB cases are screened for evidence of

infection. Mantoux positive cases are treated with oral isoniazid for 6-9 months
to prevent them from developing the disease.

BCG vaccination: Although the efficacy of BCG vaccination in protecting

against TB is controversial, it is generally accepted that BCG is more effective in
preventing disseminated disease and death, than pulmonary TB.

• Medication resistance

• Primary resistance occurs in persons infected with a resistant strain of TB. A

person with fully susceptible TB develops secondary resistance (acquired
resistance) during TB therapy because of inadequate treatment, not taking the
prescribed regimen appropriately, or using low-quality medication. Drug-
resistant TB is a public health issue in many developing countries, as treatment is
longer and requires more expensive drugs.

• Multi-drug-resistant tuberculosis (MDR-TB) is defined as resistance to the two

most effective first-line TB drugs:rifampicin and isoniazid.

• Extensively drug-resistant TB (XDR-TB) is also resistant to three or more of the

six classes of second-line drugs.

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• Totally drug-resistant TB (TDR-TB), which was first observed in 2003 in Italy,

but not widely reported until 2012, is resistant to all currently-used drugs.

• BCG Vaccine

Recommendations

Children. BCG vaccination should only be considered for children who have a
negative tuberculin skin test and who are continually exposed, and cannot be
separated from, adults who:

1. Are untreated or ineffectively treated for TB disease (if the child cannot be
given long-term treatment for infection); or

2. Have TB caused by strains resistant to isoniazid and rifampcin.

• Health Care Workers. BCG vaccination of health care workers should be

considered on an individual basis in settings in which

• A high percentage of TB patients are infected with M. tuberculosis strains

resistant to both isoniazid and rifampcin;

• There is ongoing transmission of such drug-resistant M. tuberculosis strains to

health care workers and subsequent infection is likely; or

• Comprehensive TB infection-control precautions have been implemented, but

have not been successful.

• Health care workers considered for BCG vaccination should be counseled

regarding the risks and benefits associated with both BCG vaccination and
treatment of Latent TB Infection (LTBI).

Contraindications

• Immunosuppression. BCG vaccination should not be given to persons who are

immunosuppressed (e.g., persons who are HIV infected) or who are likely to
become immunocompromised (e.g., persons who are candidates for organ
transplant).

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• Pregnancy. BCG vaccination should not be given during pregnancy. Even

though no harmful effects of BCG vaccination on the fetus have been observed,
further studies are needed to prove its safety.

Iraq is one of the countries in WHO Eastern Mediterranean Region (WHO-

EMRO) with the highest tuberculosis (TB) burden. The estimated incidence of
TB is about 130 new cases / 100.000 population / year [WHO / MOH 2003], with
about 30.000 new cases per year among which 12600 new smear positive
pulmonary Tuberculosis (PTB).

• Control of TB is a top priority for Iraqi Ministry of Health (MOH) and a most
challenging task. the Directed Observed Therapy – Short Course (DOTS) has
been adopted in

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