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How serious a problem is tuberculosis in the world?
According to the World Health Organization(WHO), nearly 2 billion people—one–third of the world’s population—have tuberculosis. Annually,8 million people become ill with tuberculosis, and 2 million people die from the disease worldwide. In 2004,around 14.6 million people had active TB disease with 9 million new cases. The annual incidence rate varies from 356 per 100,000 in Africa to 41 per 100,000 in the Americas.Tuberculosis is the world’s greatest infectious killer of women of reproductive age and the leading cause of death among people with HIV/AIDS.
How about the problem in the Philippines?
In the Philippines, TB is a major health problem. It is the sixth leading cause of death and illness. In 2011, WHO estimates there are 260 000 incident cases in the country, and 28 000 die in a year. TB prevalence is high among the high risk groups such as the elderly, urban poor, smokers and those with compromised immune systems such as people living with HIV, malnutrition and diabetes. It is estimated that 10 600 patients have multi-drug resistant TB (MDR-TB) in 2011. This situation leads to substantial socio-economic losses to the country.
Symptoms of TB in the lungs may include:
•A bad cough that lasts 3 weeks or longer
•Weight loss
•Coughing up blood or mucus
•Weakness or fatigue
•Fever and chills
•Night sweats
TB Testing in the Laboratory
According to the World Health Organization(WHO), nearly 2 billion people—one–third of the world’s population—have tuberculosis. Annually,8 million people become ill with tuberculosis, and 2 million people die from the disease worldwide. In 2004,around 14.6 million people had active TB disease with 9 million new cases. The annual incidence rate varies from 356 per 100,000 in Africa to 41 per 100,000 in the Americas.Tuberculosis is the world’s greatest infectious killer of women of reproductive age and the leading cause of death among people with HIV/AIDS.
How about the problem in the Philippines?
In the Philippines, TB is a major health problem. It is the sixth leading cause of death and illness. In 2011, WHO estimates there are 260 000 incident cases in the country, and 28 000 die in a year. TB prevalence is high among the high risk groups such as the elderly, urban poor, smokers and those with compromised immune systems such as people living with HIV, malnutrition and diabetes. It is estimated that 10 600 patients have multi-drug resistant TB (MDR-TB) in 2011. This situation leads to substantial socio-economic losses to the country.
Symptoms of TB in the lungs may include:
•A bad cough that lasts 3 weeks or longer
•Weight loss
•Coughing up blood or mucus
•Weakness or fatigue
•Fever and chills
•Night sweats
TB Testing in the Laboratory
Latent TB infection
Testing for Mycobacterium tuberculosis may begin with a TB skin test for latent TB infection. This is not used as a general screen but is targeted at those who are at a high risk for contracting the disease and at those who work or live with high-risk patients. The TB skin test may also be done as part of a physical examination prior to starting school or a new job. The test is performed on the patient’s skin by injecting a purified protein derivative (PPD) solution just under the skin. This provokes a hypersensitivity skin reaction (a red raised bump) in those who may have been infected by M. tuberculosis. The reaction is evaluated by a healthcare worker at 48 or 72 hours. Positive results may indicate a latent TB infection and should be followed by other tests, such as chest X-rays, to look for signs of active disease.
The QFT-G (QuantiFERON® - TB Gold Test) is a relatively new blood test that can be used as an alternative or follow-up to the TB skin test to help diagnose a latent TB infection. It is not affected by previous QFT-G, TB skin tests, or by BCG (Bacille Calmette-Guérin) vaccination. It does not require the patient to return in 48 to 72 hours for evaluation, and there is no local skin reaction. However, the blood sample must be collected and processed for testing within 12 hours, and there is limited data on its use with children and those with suppressed immune systems. A positive QFT-G must be followed up in a similar fashion to a positive TB skin test.
Active Tuberculosis
To diagnose TB of the respiratory tract, 3 to 5 sputum specimens are collected first thing in the morning on different days when they are most likely to contain the most mycobacteria. If extrapulmonary TB is suspected, samples are collected based upon where in the body the infection is likely to be. Multiple samples of gastric (stomach) washings/aspirates or urine may be collected and submitted to the laboratory. Sometimes cerebral spinal fluid (CSF), biopsied tissue, or other body fluids are also collected.
A presumptive diagnosis of TB can be made by examining a smear of the patent's specimen under the microscope after it has been treated with a special stain to detect acid fast bacteria (AFB). Positive AFB smears are likely to indicate a TB infection, since M. tuberculosis is the most common acid-fast bacillus in the lungs, but the smears cannot distinguish between the different species of "acid-fast" bacilli.
A genetic probe or molecular TB test can add additional information. It amplifies/replicates genetic components of the bacteria and can narrow the identification to a group of mycobacteria (of which M. tuberculosis is the most common). While AFB smears and genetic tests may be available the same day that the samples are submitted, both positive and negative results must be confirmed with AFB cultures.
AFB cultures are performed on respiratory samples that are decontaminated of normal respiratory bacteria, digested of mucus, and concentrated to increase the ability to detect them in the culture. Nutrients and incubation provide a supportive environment for the slow growing mycobacteria. The results of cultures are definitive: they can tell your doctor what organisms are present and what drugs are likely to kill them, but they take time - days to several weeks for positive samples. Cultures are held for six to eight weeks before being reported as negative.
A new liquid culture method called Microscopic-Observation Drug-Susceptibility (MODS) assay is in development. This method takes only about 7 days to diagnose TB and finds the best antibiotic treatment at the same time. It can recognize the presence of mycobacteria much more quickly than routine culture and can help health care providers diagnose and treat the disease at an earlier stage. It has the potential to help control the spread of infectious TB, but the benefits and limitations of this test are still being evaluated.
Once M. tuberculosis has been identified and treatment has begun, AFB smears and cultures are used to monitor the effectiveness of treatment.
Non-Laboratory Tests
X-rays are often used as a follow-up to positive TB skin tests to look for signs of mycobacteria growth and to help determine whether someone has active tuberculosis or a latent TB infection. Infection with TB can cause a number of characteristic findings on x-rays, including cavities (holes) and calcification in organs such as the lungs and kidneys.
Treatment
Prevention
Prevention of the spread of TB lies primarily in identifying, isolating, and treating those who have it before they pass it on to others.
A vaccine, called BCG (Bacille Calmette-Guérin), is routinely administered in parts of the world where TB is common, although studies have shown that this vaccine will not prevent every case of TB. BCG vaccination results in a positive TB skin test, so that a positive reaction is no longer indicative of a recent TB infection. The incidence of TB in the U.S. is low, so U.S. health authorities do not recommend the use of the BCG vaccine.
Early Detection
Early detection depends on identifying those at risk and testing them at regular intervals for latent TB infection. It also depends on recognizing, diagnosing, and treating those who progress to active tuberculosis.
Latent
The decision to treat latent TB infection is up to you and your doctor. If follow-up testing reveals no indication of active tuberculosis and you are not considered at a high risk for developing active TB, your doctor may decide to simply monitor your health at regular intervals (since about 90% of those with latent infections never develop active tuberculosis).
If, however he is of the opinion that you are at risk of developing active TB, you may be treated with a six to nine month course of an antibiotic called isoniazid. It is necessary to take it faithfully for the entire treatment period to ensure that all of the bacteria have been killed. Your doctor may use lab tests to monitor your liver during this time period, as isoniazid may affect liver function.
Active Tuberculosis
Active tuberculosis must always be treated. Once M. tuberculosis has been positively identified, your doctor will start you on a treatment program that involves taking several drugs for several months. The length of treatment depends on the results of the AFB smears and cultures used to monitor the effectiveness of treatment.
Although your symptoms will often go away after several weeks, it is crucial that you continue to take your drugs for the entire time period. There are a large number of mycobacteria to kill and it takes several months to make sure that all of them have been eradicated. If treatment is not continued, the TB can come back, and this time it may be more difficult to treat. It may now be resistant to the first choice drugs, requiring treatment for several more months with drugs that have more side effects.
The health community strongly recommends that those with active tuberculosis participate in DOT (directly observed therapy). This involves taking your medication each day, or several days a week, under the supervision of medical personnel. This increases patient compliance with treatment and decreases the number of people that have to be treated again because their TB has returned.
The QFT-G (QuantiFERON® - TB Gold Test) is a relatively new blood test that can be used as an alternative or follow-up to the TB skin test to help diagnose a latent TB infection. It is not affected by previous QFT-G, TB skin tests, or by BCG (Bacille Calmette-Guérin) vaccination. It does not require the patient to return in 48 to 72 hours for evaluation, and there is no local skin reaction. However, the blood sample must be collected and processed for testing within 12 hours, and there is limited data on its use with children and those with suppressed immune systems. A positive QFT-G must be followed up in a similar fashion to a positive TB skin test.
Active Tuberculosis
To diagnose TB of the respiratory tract, 3 to 5 sputum specimens are collected first thing in the morning on different days when they are most likely to contain the most mycobacteria. If extrapulmonary TB is suspected, samples are collected based upon where in the body the infection is likely to be. Multiple samples of gastric (stomach) washings/aspirates or urine may be collected and submitted to the laboratory. Sometimes cerebral spinal fluid (CSF), biopsied tissue, or other body fluids are also collected.
A presumptive diagnosis of TB can be made by examining a smear of the patent's specimen under the microscope after it has been treated with a special stain to detect acid fast bacteria (AFB). Positive AFB smears are likely to indicate a TB infection, since M. tuberculosis is the most common acid-fast bacillus in the lungs, but the smears cannot distinguish between the different species of "acid-fast" bacilli.
A genetic probe or molecular TB test can add additional information. It amplifies/replicates genetic components of the bacteria and can narrow the identification to a group of mycobacteria (of which M. tuberculosis is the most common). While AFB smears and genetic tests may be available the same day that the samples are submitted, both positive and negative results must be confirmed with AFB cultures.
AFB cultures are performed on respiratory samples that are decontaminated of normal respiratory bacteria, digested of mucus, and concentrated to increase the ability to detect them in the culture. Nutrients and incubation provide a supportive environment for the slow growing mycobacteria. The results of cultures are definitive: they can tell your doctor what organisms are present and what drugs are likely to kill them, but they take time - days to several weeks for positive samples. Cultures are held for six to eight weeks before being reported as negative.
A new liquid culture method called Microscopic-Observation Drug-Susceptibility (MODS) assay is in development. This method takes only about 7 days to diagnose TB and finds the best antibiotic treatment at the same time. It can recognize the presence of mycobacteria much more quickly than routine culture and can help health care providers diagnose and treat the disease at an earlier stage. It has the potential to help control the spread of infectious TB, but the benefits and limitations of this test are still being evaluated.
Once M. tuberculosis has been identified and treatment has begun, AFB smears and cultures are used to monitor the effectiveness of treatment.
Non-Laboratory Tests
X-rays are often used as a follow-up to positive TB skin tests to look for signs of mycobacteria growth and to help determine whether someone has active tuberculosis or a latent TB infection. Infection with TB can cause a number of characteristic findings on x-rays, including cavities (holes) and calcification in organs such as the lungs and kidneys.
Treatment
Prevention
Prevention of the spread of TB lies primarily in identifying, isolating, and treating those who have it before they pass it on to others.
A vaccine, called BCG (Bacille Calmette-Guérin), is routinely administered in parts of the world where TB is common, although studies have shown that this vaccine will not prevent every case of TB. BCG vaccination results in a positive TB skin test, so that a positive reaction is no longer indicative of a recent TB infection. The incidence of TB in the U.S. is low, so U.S. health authorities do not recommend the use of the BCG vaccine.
Early Detection
Early detection depends on identifying those at risk and testing them at regular intervals for latent TB infection. It also depends on recognizing, diagnosing, and treating those who progress to active tuberculosis.
Latent
The decision to treat latent TB infection is up to you and your doctor. If follow-up testing reveals no indication of active tuberculosis and you are not considered at a high risk for developing active TB, your doctor may decide to simply monitor your health at regular intervals (since about 90% of those with latent infections never develop active tuberculosis).
If, however he is of the opinion that you are at risk of developing active TB, you may be treated with a six to nine month course of an antibiotic called isoniazid. It is necessary to take it faithfully for the entire treatment period to ensure that all of the bacteria have been killed. Your doctor may use lab tests to monitor your liver during this time period, as isoniazid may affect liver function.
Active Tuberculosis
Active tuberculosis must always be treated. Once M. tuberculosis has been positively identified, your doctor will start you on a treatment program that involves taking several drugs for several months. The length of treatment depends on the results of the AFB smears and cultures used to monitor the effectiveness of treatment.
Although your symptoms will often go away after several weeks, it is crucial that you continue to take your drugs for the entire time period. There are a large number of mycobacteria to kill and it takes several months to make sure that all of them have been eradicated. If treatment is not continued, the TB can come back, and this time it may be more difficult to treat. It may now be resistant to the first choice drugs, requiring treatment for several more months with drugs that have more side effects.
The health community strongly recommends that those with active tuberculosis participate in DOT (directly observed therapy). This involves taking your medication each day, or several days a week, under the supervision of medical personnel. This increases patient compliance with treatment and decreases the number of people that have to be treated again because their TB has returned.
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