Tuberculosis is not a thing of the past, it kills millions of people every year

Tuberculosis - TB or tuberculosis. It is not a thing of the past and kills many people every year. Find out the biggest myths and important facts with us.

The disease is mostly attributed to Roma people, socially weak individuals, homeless people, alcoholics or smokers.

The reason for the persistent, unjustified stigmatisation and condemnation of TB patients is the low public awareness of this serious diagnosis and the misconception that it can only affect the socially weaker classes or people with low hygiene standards.

These risk groups have the highest concentrations of the disease (poor conditions, weakened immunity). However, this does not mean that it only affects them!

People at risk:

• People living in endemic areas (source of infection, long exposure)
• socially vulnerable individuals (poverty, poor conditions)
• Roma and other minority ethnic groups (poverty, poor hygiene and discipline)
• homeless people (poverty, inadequate conditions, often alcoholism)
• migrants (temporary substandard conditions, cross-border migration)
• Prisoners (temporarily inadequate conditions, close-knit community)
• alcoholics, smokers and drug addicts (weakened immunity, physical factors)
• immune diseases (HIV/AIDS)
• patients in hospitals (close community, long exposure)
• young children and the elderly (low immunity)

Basic myths and facts about tuberculosis

Tuberculosis is a bacterial disease that primarily affects the lungs (90%) and extrapulmonary structures. It causes respiratory and organ-related problems.

It has killed many people in the past. Later it was mistakenly thought to be eradicated and then appeared in a more resistant form.

What is true about tuberculosis and what is not?

MYTH: The main myth or misinformation about TB is that the disease belongs to patients with poor socio-economic backgrounds.
FACT: TB can make life miserable for any of us, regardless of social status.

MYTH: Tuberculosis is a disease that occurred in the distant past.
FACT: Although its incidence is much lower compared to history, tuberculosis has not been completely eliminated even today.

MYTH: Tuberculosis is highly contagious.
FACT: To become infected, a person must be in close proximity to a patient with an active form of tuberculosis. In addition, there must be prolonged exposure.

MYTH: Tuberculosis is exclusively a lung disease.
FACT: Tuberculosis attacks other organs (bones, brain, heart, kidneys...) in addition to the lungs.

MYTH: Tuberculosis is incurable. If infected, death is imminent.
FACT: The truth is that despite the increasing number of multidrug-resistant forms of tuberculosis, tuberculosis is still a curable disease.

MYTH: You think the science and research in treating TB is reversed. This also takes away the chance of any progress.

What is tuberculosis and what causes it?

Tuberculosis (abbreviated TB) is a serious infectious disease caused by a bacterial agent. It is currently most commonly caused by a strain of Mycobacterium tuberculosis hominis, also known as Koch's bacillus, after its discoverer.

Other mycobacteria can also cause the disease:

• Mycobacterium abscessus
• Mycobacterium africanum
• Mycobacterium asiaticum
• Mycobacterium avium complex
• Mycobacterium bovis
• Mycobacterium canetti
• Mycobacterium caprae
• Mycobacterium fortuitum
• Mycobacterium gordonae
• Mycobacterium haemophilum
• Mycobacterium chelonei
• Mycobacterium kansasii
• Mycobacterium malmoense
• Mycobacterium marinum
• Mycobacterium microti
• Mycobacterium pinnipedii
• Mycobacterium scrofulaceum
• Mycobacterium simiae
• Mycobacterium szulgai
• Mycobacterium xenopi

How is TB transmitted and what happens in the body?

Tuberculosis is a disease that is not highly contagious. It even has a very low transmission rate.
It affects only humans and some animals. It is transmitted from person to person.

Prolonged exposure, especially in a confined space and by a patient with an active form of the disease (household, means of transport, prison, etc.) is an important aspect of transmission. TB is, however, transmitted in several ways.

The transmission itself depends on several factors:

• the infectiousness of the source
• distance from the source
• the duration of exposure in the vicinity of the source
• the amount of bacteria inhaled
• the state of the immune system
• associated diseases

Interesting:
Not every patient with TB is infectious.
The latent form of TB is non-infectious.
Infection occurs provided the patient has an active infection and is not taking treatment. When coughing and sneezing, the patient expels live bacteria into the environment.
If properly treated, even with the active form, transmission to another person may not occur.

Inhalation mode of transmission

The term inhalation mode of transmission refers to transmission that occurs after inhalation of a pathogen.
Inhalation occurs by dry and wet routes.
Dry inhalation involves inhalation of infected dust.
Wet inhalation occurs when infected droplets of lung or nasal secretions are inhaled by a sick person.

Interesting:
The dispersion of infected droplets reaches a distance of 0.5 to 1 metre during normal communication with a sick person.
The dispersion of infected droplets increases to a distance of up to 3 metres, for example during coughing or sneezing.

Transmission by inoculation

The term inoculation transmission refers to transmission that occurs by direct contact with infectious material through broken skin.
Healthcare workers are most commonly infected in this way. Infection occurs by cutting oneself with an infected object or by pricking oneself with a contaminated needle.

Transmission via the alimentary route

The term alimentary transmission refers to transmission that occurs through the mucous membrane of the digestive tract.
Infection can occur through dirty hands or food.
The source of infection was once unpasteurised milk and dairy products from a diseased animal.
Infection occurs primarily during the production and processing of these products or secondarily when they are consumed.

Transplacental transmission

Transplacental transmission refers to the transmission of the disease from the mother to the fetus via the placenta.
In mild forms of the disease and with proper treatment, the course of pregnancy is not significantly affected.
It occurs rarely, only in severe forms of maternal TB.

Tuberculosis occurs on a much smaller scale compared to the past. Treatment is available, so is vaccination.

So why are we so worried about it?

The disease is mostly considered a lung infection. Although the main target organ of mycobacteria is the lungs, they can also invade other extrapulmonary structures.

It often causes serious complications, mainly because it is not thought of as the first possible diagnosis.

Classification of TB according to the International Classification of Diseases (ICD-10):

1. Respiratory tuberculosis confirmed bacteriologically or histologically
2. respiratory tuberculosis not confirmed bacteriologically or histologically
3. tuberculosis of the nervous system
4. tuberculosis of other organs
5. miliary tuberculosis
6. infections caused by other mycobacteria
7. late sequelae of tuberculosis

Based on the organ affected, tuberculosis is divided into three basic categories, namely pulmonary tuberculosis, extrapulmonary tuberculosis and combined tuberculosis.

Table with basic categorization of TB by target organ:

Dangerous forms of extrapulmonary tuberculosis

Tuberculosis of the brain or spinal cord is a very dangerous form, and rare due to the BCG vaccine. It occurs rarely, mostly in third world countries.

When the brain and its membranes are affected, TB is similar to encephalitis and meningitis.
This is the so-called meningeal or encephalitic form of TB, which affects mainly young children under 3 years of age.
Patients have high fevers, are weak, suffer from severe headaches, dizziness and vomiting.
Typically, the neck muscles are stiff (neck opposition). When trying to bend the head downwards or bring the chin to the chest, movement is restricted and painful. Hypersensitivity to light is common.

In nervous system involvement, neurological lesions are also present.
These include localised spasms, partial paralysis of the limbs (palsy, paresis) or failure of specific brain nerves (optic nerve - visual impairment, oculomotor nerve, facial nerve).

Tuberculosis and pregnancy

In the past, pregnant women with tuberculosis were advised to terminate the pregnancy early. Today we know that this is absolutely not necessary. Discipline and caution in pregnancy is sufficient to give birth to an intact baby, despite the mother's illness.

Transplacental transmission of tuberculosis to the child is possible but rare. It occurs by haematogenous spread through the placenta and umbilical cord.

Infection of the fetus can also occur by inhalation of amniotic fluid. However, only a few cases of congenital infection have been described.

TB does not affect preterm birth, spontaneous abortion and there is no evidence that it causes fetal anomalies.

What impact has tuberculosis had on humanity in the past?

Tuberculosis is a disease as old as mankind itself. Its occurrence dates back to prehistoric times, as evidenced by the remains of a bison some 18 000 years old.

It is not known whether it was primarily a human disease or whether it was transmitted to humans from infected animals - zoonosis.

Bone findings dating back to 7500 B.C. provide evidence of tuberculosis in the Stone Age.
Also, younger skeletal remains from the Neolithic period, about 5000 B.C., point to a bone form of it.
A similar finding comes from the spinal bones of Egyptian mummies dating back to 3500 B.C.

The first written references to it date from the time when people began to live in groups, units or small communities.
The pulmonary form of TB was described in detail by Hippocrates, and also mentioned by Galenos and Silvius.
Avicenna, in turn, pointed out its contagiousness and its effect on humans.

However, it was not until 1882 that the German physician Robert Koch discovered the causative agent of tuberculosis, thanks to a microscope. He even won a Nobel Prize for his discovery, and the bacterium causing TB is still called the Koch bacillus.

Tuberculosis has historically been the leading cause of death

There is much evidence that in the recent past, tuberculosis was one of the most common causes of death ever.

It was the cause of one in four deaths. Old age was second only to other diseases and injuries.

The reason for this high mortality rate was ignorance of what causes it and therefore the inability of doctors to treat it adequately.

Interesting:
Treatment was not only attempted by doctors and patients themselves.
For example, the owner of Mammoth Cave, John Croghan, tried to treat tuberculosis patients between 1838 and 1845 based on the temperature and purity of the air in his cave.
Neither survived.

The discovery of the TB pathogen

March 24, 1882 is a date that has gone down in history. It was on this date that the German physician Robert Koch discovered the causative agent of a hitherto mysterious disease.

The causative agent of tuberculosis, Mycobacterium tuberculosis, is still known in the literature as Koch's bacillus, after its discoverer.

Despite Robert Koch's huge discovery, tuberculosis patients continued to die.

In fact, it took an incredible 14 years to develop a vaccine. Another 15 years passed before vaccination began.

Interesting:
In 1894, Robert Koch discovered a substance called tuberculin, which he believed to be both a cure and a vaccine for TB.
However, this substance caused severe allergic reactions and death in patients.
Although tuberculin was not effective as a vaccine, it proved to be an excellent diagnostic tool.
It proves the presence of TB antibodies in the body - the tuberculin test.

BCG vaccine and TB treatment - a 19th century success story

The vaccine was discovered in 1906 by Albert Calmette and Camille Guérin. The vaccine, also known as BCG (Bacillus Calmette-Guérin), did not come into real use until 1921 in France and later in other countries.

An effective treatment for tuberculosis came much later, in 1943. It was in this year that Albert Schatz discovered the antibiotic streptomycin.

Treatment with streptomycin proved to be very effective until new resistant forms of tuberculosis began to appear.

Therefore, in 1993, the World Health Organisation declared a state of emergency.

A look at tuberculosis today

Tuberculosis is now seen as a global problem.

In the 1970s and 1980s, there was a temporary misconception among experts about the eradication, i.e. complete eradication, of the disease. This situation was the reason for reduced TB surveillance.

The 1990s showed that this was only a misconception. The number of TB cases began to increase again.

In addition, multidrug-resistant forms of the disease began to appear, which did not respond to conventional antibiotics and anti-tuberculosis drugs, or the disease required a combination of the two. The number of victims and deaths rose and continues to rise to this day.

The epidemiological situation today

In the EU alone, there are 1176 new cases a day, of which up to 168 result in death. Worldwide, approximately 1.3 million people die annually from tuberculosis and its associated complications. Without treatment, the disease has a mortality rate of up to 70%.

That is why the experts at the European Centre for Disease Prevention and Control (ECDC) are taking TB seriously.

There is a real threat of an outbreak of multidrug-resistant forms of the disease, as well as the introduction of the disease from countries at risk. The risks are increasing because of the high level of human migration today.

BCG vaccine at present

Tuberculosis is one of the diseases for which a vaccine has been developed. Vaccination against tuberculosis was one of the compulsory vaccinations in the past. However, due to the rapid reduction of the disease, vaccination has stopped across the board.

Read also:
Biomatics, beware! Vaccination is important, don't put your child at risk - compulsory vaccination
Non-compulsory vaccination, when it is advisable
Vaccination, its importance before travelling abroad - foreign diseases

At the moment, however, it is becoming a problem again. Because of new multidrug-resistant forms of tuberculosis and antibiotic resistance, our numbers of patients are increasing.

According to the World Health Organisation, up to 8 million new cases occur each year. Approximately 2.8 million of these end in death. It also recommends universal vaccination if there are more than 12 cases per 100 000 inhabitants in a particular country.

The BCG vaccine is individually recommended for people who are at higher risk of developing the disease, particularly in countries with a higher incidence and risk of spreading this serious disease.

Who is recommended for tuberculosis vaccination?

• Tuberculosis vaccination is given to tuberculin-negative people who have been in contact with active tuberculosis
• tuberculosis vaccination shall be given to tuberculin-negative persons under 30 years of age who are professionally exposed to an increased risk of infection before entering employment
• tuberculosis vaccination shall be given to tuberculin-negative employees of wards of medical establishments specialising in the treatment of TB and other respiratory diseases
• tuberculosis vaccination is carried out in tuberculin-negative employees of pathology, forensic medicine, microbiology laboratories exposed to an increased risk of TB infection
• vaccination against tuberculosis is carried out in tuberculin-negative persons working in veterinary establishments and in the treatment or killing of animals infected with tuberculosis
• tuberculosis vaccination shall be carried out in tuberculin-negative persons who, in the course of their work, come into direct contact with tuberculosis in humans or animals

Diagnosis and treatment of TB

The diagnosis of TB is based on the patient's medical history (travel history to endemic countries, abuses, comorbidities, contact with a patient with an active form, symptomatology) and physical examination (X-ray, CT scan). When the disease is suspected, specific investigations are subsequently carried out (tuberculin test, bacteriological examination, culture).

Cerebrospinal fluid examination, tuberculin test, microscopic and culture evidence of mycobacteria are used in the diagnosis. Imaging methods (lung X-ray, magnetic resonance imaging) are also used.

Biological material used in the diagnosis of TB:

• Blood
• coughed sputum (phlegm)
• laryngeal swab
• pleural punctate
• cerebrospinal fluid
• fistula swabs in the cutaneous form
• pericardial fluid
• fluid from ascites
• gastric juice
• BALT
• stool
• urine
• prostatic secretion
• synovial fluid
• other biological material obtained by biopsy

The tuberculin test is a skin test that can be evidence that the patient has tuberculosis.
However, there are many reasons for its negativity despite the patient being infected (vaccination, age).

Two tuberculin PPD units are injected under the skin into the forearm.

Tuberculin is a protein fraction, abbreviated PPD, stands for purified protein derivative, which is obtained from the filtrate of a bacterial culture of M. tuberculosis.

A skin reaction is read after 72 hours.

There may be redness on the forearm, but an induction of blood vessels larger than 5 mm represents a positive result. More recently, the so-called IGRA tests (Interferon Gamma Release Assay Tests) are used, which are based on the detection of interferon gamma production.

TB treatment in a nutshell

The treatment of tuberculosis is very lengthy indeed. It is a time-consuming process. It sometimes takes a year or two. The patient is given medication for a long time and regular follow-up tests are carried out to determine the effectiveness of the therapy.

The patient should be hospitalized in the infectious disease ward for at least 2 months once the disease is detected.

This two-month period is not an invention, but the minimum length of hospitalisation. In cases that require it, this period is extended to that required in the particular case.

The number one drug remains antituberculosis drugs. These should be given as early as possible, and already at the time of suspicion of TB. Because of bacterial resistance, several drugs or combinations of drugs may be tried at the start of treatment. The main drugs used are preparations such as isoniazid.

Comprehensive corticosteroid therapy is also part of the treatment, which together with antituberculosis drugs is very effective. It also reduces the number of deaths.