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ANDRES BONIFACIO COLLEGE

SCHOOL OF NURSING
College Park, Dipolog City

A CASE PRESENTATION ON

TUBERCULOSIS

Submitted by:

Submitted to:

Ms. ALEGADO, Dwine Clarilou L.

Mr. CASOCOT, Henry Mark T.,

RN, Llb

Mr. LOPEZ, Christian Christopher D.

Clinical Instructor

ANDRES BONIFACIO COLLEGE


INSTITUTIONAL VISION AND MISSION

VISION:
A center of excellence in instruction, research, technology, extension, athletics and arts.

MISSION:
We commit to provide affordable quality education with values in industry, intelligence, integrity and undertake
relevant research and socially-responsive community service using innovative technologies.

School of Nursing Mission


The School of Nursing shall generate, competent, safe and compassionate professional nurses committed to:
a. Practice high standards of nursing care utilizing research and evidence-based practices that are
culturally appropriate and sensitive.

b. Active involvement in local, national and global issues affecting nursing, peoples health and the
environment.
c. Ongoing holistic growth and development of the self and others.

Table of Contents
I.

Learning Objectives

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II.

Introduction

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13

III.

Anatomy and Physiology

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15

17

IV.

Pathophysiology

20

V.

Nursing Care Plans

21

VI.

Related Articles

32

VII. Bibliography

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18

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25

33

24

I.

Learning Objectives

General Objectives:
At the end of the Case Presentation, the learners shall improve their understanding, increase their knowledge, enhance their
independent and collaborative skills and manifest desirable attitude in providing immediate and holistic care to patients with
Ovarian Cancer.

Specific Objectives:
After 2 hours, the listeners will be able to:
1. Identify what is Tuberculosis
2. Enumerate the manifestations of the disease appropriately.
3. Identify factors that can lead to Tuberculosis
4. Review the Anatomy and Physiology of the Respiratory System
5. Discuss the disease process and its pathophysiology effectively.
6. Enumerate the manifestations of the disease appropriately.
7. Identify and discuss its appropriate management effectively.
8. Learn new updates related to Tuberculosis.

II.

Introduction

Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis that are spread through the air from
person to person. If not treated properly, TB disease can be fatal. People infected with TB bacteria who are not sick may still need
treatment to prevent TB disease from developing in the future. Learn to recognize the symptoms of TB disease and find out if you
are at risk.
Tuberculosis (TB) is a potentially serious infectious disease that mainly affects your lungs. The bacteria that cause
tuberculosis are spread from one person to another through tiny droplets released into the air via coughs and sneezes.
Many strains of tuberculosis resist the drugs most used to treat the disease. People with active tuberculosis must take
several types of medications for many months to eradicate the infection and prevent development of antibiotic resistance.
Signs and Symptoms
Although your body may harbor the bacteria that cause tuberculosis, your immune system usually can prevent you from
becoming sick. For this reason, doctors make a distinction between:

Latent TB. In this condition, you have a TB infection, but the bacteria remain in your body in an inactive state and cause no
symptoms. Latent TB, also called inactive TB or TB infection, isn't contagious. It can turn into active TB, so treatment is
important for the person with latent TB and to help control the spread of TB. An estimated 2 billion people have latent TB.

Active TB. This condition makes you sick and can spread to others. It can occur in the first few weeks after infection with
the TB bacteria, or it might occur years later.

Signs and symptoms of active TB include:

Coughing that lasts three or more weeks

Coughing up blood

Chest pain, or pain with breathing or coughing

Unintentional weight loss

Fatigue

Fever

Night sweats

Chills

Loss of appetite

Tuberculosis can also affect other parts of your body, including your kidneys, spine or brain. When TB occurs outside your
lungs, signs and symptoms vary according to the organs involved. For example, tuberculosis of the spine may give you back pain,
and tuberculosis in your kidneys might cause blood in your urine.

Pulmonary TB
If a tuberculosis infection does become active, it most commonly involves the lungs (in about 90% of cases). Symptoms may
include chest pain and a prolonged cough producing sputum. About 25% of people may not have any symptoms (i.e. they remain
"asymptomatic"). Occasionally, people may cough up blood in small amounts, and in very rare cases, the infection may erode into
the pulmonary artery or a Rasmussen's aneurysm, resulting in massive bleeding. Tuberculosis may become a chronic illness and
cause extensive scarring in the upper lobes of the lungs. The upper lung lobes are more frequently affected by tuberculosis than
the lower ones. The reason for this difference is not clear. It may be due to either better air flow, or poor lymph drainage within the
upper lungs.

Extrapulmonary TB
In 1520% of active cases, the infection spreads outside the lungs, causing other kinds of TB. These are collectively denoted as
"extrapulmonary tuberculosis". Extrapulmonary TB occurs more commonly in immunosuppressed persons and young children. In
those with HIV, this occurs in more than 50% of cases. Notable extrapulmonary infection sites include the pleura (in tuberculous
pleurisy), the central nervous system (in tuberculous meningitis), the lymphatic system (in scrofula of the neck), the genitourinary
system (in urogenital tuberculosis), and the bones and joints (in Pott disease of the spine), among others.
Spread to lymph nodes is the most common. An ulcer originating from nearby infected lymph nodes may occur and is
painless, slowly enlarging and has an appearance of "wash leather".

When it spreads to the bones, it is known as "osseous tuberculosis", a form of osteomyelitis.[10] A potentially more serious,
widespread form of TB is called "disseminated tuberculosis", also known as miliary tuberculosis. Miliary TB currently makes up
about 10% of extrapulmonary cases.

Diagnosis
During the physical exam, your doctor will check your lymph nodes for swelling and use a stethoscope to listen carefully to
the sounds your lungs make while you breathe.
The most commonly used diagnostic tool for tuberculosis is a simple skin test, though blood tests are becoming more
commonplace. A small amount of a substance called PPD tuberculin is injected just below the skin of your inside forearm. You
should feel only a slight needle prick.
Within 48 to 72 hours, a health care professional will check your arm for swelling at the injection site. A hard, raised red
bump means you're likely to have TB infection. The size of the bump determines whether the test results are significant.
Results can be wrong
The TB skin test isn't perfect. Sometimes, it suggests that people have TB when they really don't. It can also indicate that
people don't have TB when they really do.
A false-positive test may happen if you've been vaccinated recently with the bacillus Calmette-Guerin (BCG) vaccine. This
tuberculosis vaccine is seldom used in the United States but is widely used in countries with high TB infection rates.
False-negative results may occur in certain populations including children, older people and people with AIDS who
sometimes don't respond to the TB skin test. A false-negative result can also occur in people who've recently been infected with
TB, but whose immune systems haven't yet reacted to the bacteria.
Blood tests

Blood tests may be used to confirm or rule out latent or active tuberculosis. These tests use sophisticated technology to
measure your immune system's reaction to TB bacteria. QuantiFERON-TB Gold in-Tube test and T-Spot.TB test are two examples of
TB blood tests.
These tests require only one office visit. A blood test may be useful if you're at high risk of TB infection but have a negative
response to the skin test, or if you've recently received the BCG vaccine.
Imaging tests
If you've had a positive skin test, your doctor is likely to order a chest X-ray or a CT scan. This may show white spots in your
lungs where your immune system has walled off TB bacteria, or it may reveal changes in your lungs caused by active tuberculosis.
CT scans provide more-detailed images than do X-rays.
Sputum tests
If your chest X-ray shows signs of tuberculosis, your doctor may take samples of your sputum the mucus that comes up
when you cough. The samples are tested for TB bacteria.
Sputum samples can also be used to test for drug-resistant strains of TB. This helps your doctor choose the medications that
are most likely to work. These tests can take four to eight weeks to be completed.

When to see a doctor


See your doctor if you have a fever, unexplained weight loss, drenching night sweats or a persistent cough. These are often
signs of TB, but they can also result from other medical problems. Your doctor can perform tests to help determine the cause.
The Centers for Disease Control and Prevention recommends that people who have an increased risk of tuberculosis be
screened for latent TB infection. This recommendation includes:

People with HIV/AIDS

IV drug users

Those in contact with infected individuals

Health care workers who treat people with a high risk of TB

Causes
Tuberculosis is caused by bacteria that spread from person to person through microscopic droplets released into the air. This
can happen when someone with the untreated, active form of tuberculosis coughs, speaks, sneezes, spits, laughs or sings.
Although tuberculosis is contagious, it's not easy to catch. You're much more likely to get tuberculosis from someone you live
with or work with than from a stranger. Most people with active TB who've had appropriate drug treatment for at least two weeks
are no longer contagious.
HIV and TB
Since the 1980s, the number of cases of tuberculosis has increased dramatically because of the spread of HIV, the virus that
causes AIDS. Infection with HIV suppresses the immune system, making it difficult for the body to control TB bacteria. As a result,
people with HIV are many times more likely to get TB and to progress from latent to active disease than are people who aren't HIV
positive.
Drug-resistant TB

Another reason tuberculosis remains a major killer is the increase in drug-resistant strains of the bacterium. Since the first
antibiotics were used to fight tuberculosis more than 60 years ago, some TB germs have developed the ability to survive, and that
ability gets passed on to their descendants.
Drug-resistant strains of tuberculosis emerge when an antibiotic fails to kill all of the bacteria it targets. The surviving
bacteria become resistant to that particular drug and frequently other antibiotics as well. Some TB bacteria have developed
resistance to the most commonly used treatments, such as isoniazid and rifampin.
Some strains of TB have also developed resistance to drugs less commonly used in TB treatment, such as the antibiotics
known as fluoroquinolones, and injectable medications including amikacin, kanamycin and capreomycin. These medications are
often used to treat infections that are resistant to the more commonly used drugs.
RISK FACTORS
Anyone can get tuberculosis, but certain factors can increase your risk of the disease. These factors include:
Weakened immune system
A healthy immune system often successfully fights TB bacteria, but your body can't mount an effective defense if your
resistance is low. A number of diseases and medications can weaken your immune system, including:

HIV/AIDS

Diabetes

Severe kidney disease

Certain cancers

Cancer treatment, such as chemotherapy

Drugs to prevent rejection of transplanted organs

Some drugs used to treat rheumatoid arthritis, Crohn's disease and psoriasis

Malnutrition

Very young or advanced age

Traveling or living in certain areas


The risk of contracting tuberculosis is higher for people who live in or travel to countries that have high rates of tuberculosis
and drug-resistant tuberculosis, including:

Africa

Eastern Europe

Asia

Russia

Latin America

Caribbean Islands

Poverty and substance abuse

Lack of medical care. If you receive a low or fixed income, live in a remote area, have recently immigrated to the United
States, or are homeless, you may lack access to the medical care needed to diagnose and treat TB.

Substance abuse. IV drug use or alcohol abuse weakens your immune system and makes you more vulnerable to
tuberculosis.

Tobacco use. Using tobacco greatly increases the risk of getting TB and dying of it.

Where you work or live

Health care work. Regular contact with people who are ill increases your chances of exposure to TB bacteria. Wearing a
mask and frequent hand-washing greatly reduce your risk.

Living or working in a residential care facility. People who live or work in prisons, immigration centers or nursing
homes are all at a higher risk of tuberculosis. That's because the risk of the disease is higher anywhere there is overcrowding
and poor ventilation.

Living in a refugee camp or shelter. Weakened by poor nutrition and ill health and living in crowded, unsanitary
conditions, refugees are at especially high risk of tuberculosis infection.

Complications
Without treatment, tuberculosis can be fatal. Untreated active disease typically affects your lungs, but it can spread to other parts
of your body through your bloodstream. Examples of tuberculosis complications include:

Spinal pain. Back pain and stiffness are common complications of tuberculosis.

Joint damage. Tuberculous arthritis usually affects the hips and knees.

Swelling of the membranes that cover your brain (meningitis). This can cause a lasting or intermittent headache that
occurs for weeks. Mental changes also are possible.

Liver or kidney problems. Your liver and kidneys help filter waste and impurities from your bloodstream. These functions
become impaired if the liver or kidneys are affected by tuberculosis.

Heart disorders. Rarely, tuberculosis can infect the tissues that surround your heart, causing inflammation and fluid
collections that may interfere with your heart's ability to pump effectively. This condition, called cardiac tamponade, can be
fatal.

III. Anatomy and Physiology of Respiratory System


The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system
and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways
(trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue.

The lungs are divided into lobes; the left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant
next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes.

The Nose
The uppermost portion of the human respiratory system, the nose is a hollow air passage that functions in breathing and in the
sense of smell. The nasal cavity moistens and warms incoming air, while small hairs and mucus filter out harmful particles and
microorganisms. This illustration depicts the interior of the human nose. The prominent structure between the eyes that serves as
the entrance to the respiratory tract and contains the olfactory organ. It provides air for respiration, serves the sense of smell,
conditions the air by filtering, warming, and moistening it, and cleans itself of foreign debris extracted from inhalations.

The Trachea, Bronchi Alveolar Ducts and Alveoli


The trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the right, at the level of the
sternal angle at the anatomical point known as the carina. The right main bronchus is wider, shorter, and more vertical than the
left main bronchus. The right main bronchus subdivides into three lobar bronchi while the left main bronchus divides into two. The
lobar bronchi divide into tertiary bronchi, also known as segmental bronchi, each of which supplies a bronchopulmonary segment.
A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum..
This property allows a bronchopulmonary segment to be surgically removed without affecting other segments. There are ten
segments per lung, but due to anatomic development, several segmental bronchi in the left lung fuse, giving rise to eight. The
segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to
several respiratory bronchioles, which go on to divide into 2 to 11 alveolar ducts. There are 5 or 6 alveolar sacs associated with
each alveolar duct. The alveolus is the basic anatomical unit of gas exchange in the lung.
There is hyaline cartilage present in the bronchi, present as irregular rings in the larger bronchi (and not as regular as in the
trachea), and as small plates and islands in the smaller bronchi. Smooth muscle is present continuously around the bronchi.
In the mediastinum, at the level of the fifth thoracic vertebra, the trachea divides into the right and left primary bronchi. The
bronchi branch into smaller and smaller passageways until they terminate in tiny air sacs called alveoli.

The cartilage and mucous membrane of the primary bronchi are similar to that in the trachea. As the branching continues
through the bronchial tree, the amount of hyaline cartilage in the walls decreases until it is absent in the smallest bronchioles. As
the cartilage decreases, the amount of smooth muscle increases. The mucous membrane also undergoes a transition from ciliated
pseudostratified columnar epithelium to simple cuboidal epithelium to simple squamous epithelium.

The alveolar ducts and alveoli consist primarily of simple squamous epithelium, which permits rapid diffusion of oxygen and
carbon dioxide. Exchange of gases between the air in the lungs and the blood in the capillaries occurs across the walls of the
alveolar ducts and alveoli.
The Lungs
The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of
providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in
and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each
bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up
of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of
elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The
pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and
provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli
also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those
muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very
small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at
the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes,
and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower
airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic
wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

Physiology of Gas Exchange


Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the
alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a
massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary
artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration
gradients.
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the
alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal
transfer across the membrane

IV. NURSING CARE PLANS


Nursing Diagnosis: Ineffective breathing pattern related to acute infection and decreased
lung capacity.
ASSESSMENT
DESIRED
NURSING
RATIONALE
EVALUATION
OUTCOME
INTERVENTIONS
SUBJECTIVE:

After 8 hours of 1. Monitor respiratory status, Respiratory


status
nursing intervention including vital signs, breathe assessment helps gauge the
The patient may
the patient will:
sounds, and skin color.
patients
severity
and
report:
whether its progressing.
1. Promote good 2. Administer oxygen therapy as
Past exposure to TB. respiratory function ordered.
To
provide
relief
from
Progressive fatigue
and treat infection
symptoms of hypoxemia and
Loss of appetite
2. Promote comfort 3. Monitor ABG levels and hypoxia.
Unexplained weight
oxygen saturation as ordered.
loss.
ABG levels and continuous
pulse oximetry measures the
OBJECTIVE:
bloods oxygen content and
are good indicators of the
Cough that may be
4. Place the patient in semi- lungs ability to oxygenate the
nonproductive at
fowlers position and place the blood.
first but later
diaphragm in proper position to
produces sputum
contract.
To increase chest expansion
and progresses to
and to alleviate dyspnea.
hemoptysis.
5. Collect sputum samples as
Crackles
ordered.
Pleuritc pain
To monitor the progress of the
Dyspnea
disease and treatment

After
8
hours
of
nursing
intervention
the patient was able to
demonstrate:
1. Breathing returned
to normal rate and
pattern
2. Minimal or no signs
of infection.

Nursing Diagnosis: Impaired Gas Exchange related to reduced effectiveness of surface lung

ASSESSMENT

DESIRED
OUTCOME

NURSING INTERVENTIONS

Subjective:

After 5 days of Independent


nursing
Galisud man ko ug intervention,
the 1. Assess dyspnoe, tachypnea,
ginhawa,
as patient will:
abnormal
respiratory
sounds.
verbalized by the
Increased
respiration,
chest
client.
1. Report absence expansion limitations and fatigue.
of/decreased
Rationale:
Objective:
dyspnea.
2.
Demonstrate
Decrease
in improved
effective
lung ventilation
and
surface, atelectasis
adequate
Destruction
of oxygenation
of 2. Evaluation of changes in the level
alveolar-capillary
tissues by ABGs of consciousness, noting signs of
membrane
within
acceptable cyanosis and changes in the skin,
mucous membranes and nail color.
Thick,
viscous ranges.
secretions
3.
Be
free
of
Bronchial edema
symptoms
of
respiratory distress. 3. Demonstrate / encourage the
patient to exhale with the mouth,
especially on the client with fibrosis
or
parenchymal
damage.
4. Suggest
activity.

to

bedrest

RATIONALE

After 5 days of nursing


intervention, goal was
Pulmonary TB can cause met, the patient:
widespread
reach
the
lungs
from
becoming 1. Reported absence
widespread
of/decreased dyspnea.
bronchopneumonia
2.
Demonstrated
inflammation,
necrosis, improved
ventilation
and widespread efusion and
adequate
pleural
fibrosis
with oxygenation of tissues
symptoms of respiratory by
ABGs
within
distress.
acceptable ranges.
3. Became free of
The
accumulation
of symptoms
of
secretions may interfere respiratory distress.
with oxygenation in vital
organs and tissues.

The increasing resistance


of air flow to prevent
airway
collapse
and
reduce the residue of the
reduce lungs.
Rationale: Reducing the
consumption of oxygen in
the respiration period.

Collaboration

EVALUATION

5. Monitor ABG.

6. Provide supplemental oxygen.

Decreased oxygen (PaO


2), saturation or increased
PaCO2 indicate the need
for
more
adequate
treatment or a change in
therapy.
Helps corrects hypoxemia
secondary which reduces
pulmonary ventilation and
reduced tension.

Nursing Diagnosis: Imbalanced Nutrition less than body requirements r/t anorexia s/t loss of
appetite
ASSESSMENT
Subjective:

DESIRED
OUTCOME

After 5 days of
nursing
Wala
koy
gana interventions,
the
mukaon,
as client will be able
verbalized by the to:
client.
1.
demonstrate
Objective:
progressive weight
Weight
10%20% gain
below
ideal
for 2. be free of signs
frame and height
of malnutrition

NURSING INTERVENTIONS
Independent
1. Assess and communicate the
nutritional status of clients and
families as recommended: Record
the
skin
turgor,
weight
measurement,
oral
mucosal
integrity, ability and inability to
swallow, the presence of bowel
sounds, a history of nausea,
vomiting
or
diarrhea.

RATIONALE

EVALUATION

After 5 days of nursing


interventions,
the
defines the extent of the client was able to:
problem and intervention.
1.
demonstrate
progressive
weight
gain
2. be free of signs of
malnutrition
3.
verbalize
Helps
interventions understanding
of

]Reported lack of
interest
in
food,
altered
taste
sensation
Poor muscle tone

3.
verbalize
understanding
of
causative factors
4.
demonstrate
behaviors
and
lifestyle changes to
regain or maintain
appropriate weight

specific needs, increasing causative factors


2. Assess the client's preferred diet / the dietary intake of 4.
demonstrate
disliked.
clients.
behaviors and lifestyle
changes to regain or
Measuring
the maintain appropriate
3. Monitor intake and output effectiveness of nutrition weight
periodically.
and fluids.
4. Note the presence of anorexia,
nausea, vomiting, and specify if it
has something to do with the
medication. Monitors the volume,
frequency, consistency of bowel
movements.

It can determine the type


of diet and identifying the
solution to increase the
intake of nutrients.

5. Encourage bedrest.

Helps
save
energy,
especially
when
the
occurrence of metabolic
fever.

6. Perform oral care before and after


therapy respiration.

Reduces bad taste from


sputum or drugs used for
treatment
that
can
stimulate vomiting.

VI. RELATED ARTICLES


The Threat of New Strains of Tuberculosis
BY DREW SMITH
Of all the diseases that decimated emerging cities, tuberculosis was the worst. If an epidemic breaks out TB could make our
progressive, innovation-driven society unsustainable.
We live in a world where continuous innovation is normal and unremarkable. We expect a constant stream of newer and
better things to power an ever-rising tide of growth and prosperity. But this was not always the case. From the dawn of history until
about 1800, everyone was a subsistence farmer, everyone was poor and there was precisely zero growth in the income of the
average world citizen. The innovation economy is a singularity in the history of humanity. Control of infectious disease is the portal
through which we reached the singularity.
Innovation happens when large numbers of people gather in close proximity and expose each other to their ideas and
inspirations. Innovation depends on personal contact and social networks. The dependence of innovation on the density of social
interactions can be accurately described by simple equations: the same equations that describe the spread of disease epidemics.
Like some innovations, certain diseases shape entire societies and cultures, define their limits and possibilities. A disease
can do more than just inflict suffering it can shut down innovation, civilisation and even a species.
We shouldnt be surprised, then, that the control of infectious disease was essential to developing our world of sustained
innovation. Before this control, the necessary concentration of minds also resulted in the spread of diseases that crippled
innovation. The largest cities of the Enlightenment world in 1800 had populations of only a few hundred thousand. Their
inhabitants died faster than new citizens were born and they sustained their modest sizes only by continual migration from the
countryside.
Of all the diseases that decimated emerging cities, tuberculosis (TB) was the worst. Decimation the taking of one in ten
is an understatement. TB accounted for a quarter of all deaths in European and North American cities in the early 19th century,
killing 80% of those it infected. Like AIDS today, TB was so destructive because its usual victims were young adults, the most
dynamic, productive and innovative members of society. TB is the reason why so many Georgian and Victorian novels feature
orphans and orphanages.

The golden age of public health roughly from 1860 to 1960 very much overlapped with the golden age of innovation and
this is no coincidence. Clean water and food, along with vaccines, made large dense cities habitable and enabled unprecedented
levels of innovation and creativity. The rapid drop in childhood deaths freed women from the necessity of bearing many children
and nursing them through repeated medical crises and women responded by demanding education and a role in public life. All of
this was new in human history.
TB deaths fell dramatically during this time, as did all other infectious diseases. From 1860 to 1950, deaths from infectious
diseases fell by nearly 90% in England and Wales and by similar amounts in other industrialised countries. This decline occurred
prior to the general availability of antibiotics. It can confidently be attributed to the implementation of public-health measures,
principally the provision of clean water and food and the development of vaccines. We know how to prevent the spread of
infectious disease a comforting thought in a world in which antibiotics are beginning to lose their invincibility.
There is one exception to this tidy story: we dont really know why TB declined. Some of the decline can be attributed to the
pasteurisation of milk, through which the bovine form of TB spread. TB is not otherwise spread through food and so cleaning up
slaughterhouses and developing refrigeration had no impact. TB, unlike yellow fever or malaria, is not transmitted by insects and
so draining swamps did not impede it. Clean water prevents the diarrheal diseases that carried away so many children, but does
not prevent TB, which is spread from person to person. Vaccines halted killers such as diphtheria and smallpox, but the TB vaccine
is not very effective.
Historians of medicine have proposed other causes. Once the contagious nature of TB was established by the German
physician Robert Koch in 1882, quarantines and sanatoria were established to break the train of transmission. But these efforts
were inconsistent and sporadic, and many scholars doubt whether they played more than a minor role in TB control. Because the
TB death rate was so high for so long, natural selection for innate immunity has also been proposed to account for its decline and
there is some evidence supporting this view.
Thomas McKeown, a British physician and medical historian, was skeptical of all these explanations. In the 1960s and 1970s,
he published a series of works arguing that TB was principally perhaps purely a social disease, one that responded not to
medical or public health interventions, but to the improved living conditions of the population. McKeowns argument was that TB
deaths began a steady decrease well before that of other transmissible diseases and that the rate of decrease correlated closely
with measures of social wellbeing and not at all with the introduction of various public health and medical interventions. He
became, despite his medical training, something of a medical nihilist, arguing that all medical interventions are worthless and that

the funds dedicated to research and the development of the Britains National Health Service would be better spent on feeding
and housing the poor.
McKeowns thesis has an intuitive appeal. TB largely disappeared from prosperous countries and is now considered a
disease of poverty. But subsequent scholarship, resting on more sophisticated analyses of demographic and economic data, do
not support McKeowns claims, and his thesis is now considered largely refuted. However, no other explanation has gained
widespread acceptance in its stead.
The arrival of anti-TB antibiotics in the late 1940s seemed to render these arguments irrelevant, of no interest to anyone
save medical historians. With the advent of streptomycin, then isoniazid, then rifampin, TB for the first time ever could actually
be cured. Its chain of transmission could be broken without resort to quarantine. Nor was there a need to engage in the daunting
task of providing adequate food and decent housing to the worlds poor. Antibiotics were effective and cheap. If they could be
given to every patient, then the threat of TB to human health and civilisation could be ended, perhaps forever.
The emergence of antibiotic resistance in TB thus constitutes a singular threat, different and much greater than the threat
posed by the so-called superbugs. Most multiply-resistant bacteria display reduced virulence defined as the ability to infect and
sicken a host and rarely infect otherwise healthy people. For most of these pathogens MRSAs, CREs, VREs, ESBLs the principal
risk factors for serious infections and death are old age, hospitalisation, immunosuppression, and recent antibiotic use. They
attack the old and sick, not the young and healthy.
Multiple drug-resistant (MDR) TB is different its acquisition does not make TB less virulent. Most victims are between 25
and 45 years old, in what should be the prime of life. The main risk factors for infection with MDR-TB are previous TB treatment
and refugee status. MDR-TB is treatable, but treatment is arduous and expensive and often not effective. Half a million people fell
ill with MDR-TB in 2015 and only a quarter of these received adequate treatment, getting well.
Most organisms become less virulent as they spread, but it is plausible that MDR-TB will become more virulent in highdensity settings. If this occurs, we are in deep trouble. We have no credible Plan B for containing an outbreak of TB strains that are
both drug-resistant and more virulent. We cannot quarantine millions of people. Better public sanitation will do no good because
the disease is spread person-to-person by coughing, sneezing or even speaking. Perhaps natural selection has made us less
susceptible to infection than our ancestors, but this is a hope, not a plan.
At a certain tipping point, TB could make our progressive, innovation-driven society unsustainable. The same interactions
between makers, who we rely on to drive our economy, will also spread a deadly, difficult-to-treat disease. The hardest-hit among

us will be young adults whose lives and careers are cut short, causing immense strains to our social fabric. Our highly
interconnected economic system that has reduced poverty to the lowest levels in history will begin to collapse, creating a positive
feedback cycle of more disease and disruption.
None of this might happen of course. But consider a worst-case scenario: the new strains of TB combined with climate-driven
crop failures, resulting in mass migrations. The result could spawn an essentially unstoppable epidemic that would put an end to
the modern economy. We are more vulnerable than we realise; the White Death might walk among us once again.

Spread of highly drug-resistant tuberculosis sparks concerns


By HELEN BRANSWELL
Theres more bad news on the antibiotic resistance front.
A new study reveals that strains of tuberculosis that evade most of the drugs typically used to treat the bacterial infection
have been spreading in South Africa, which already has a high rate of tuberculosis infection.
Extensively drug-resistant tuberculosis known by the short form XDR TB is highly concerning to health authorities
because of the way tuberculosis spreads. Infected people expel bacteria from their lungs when they cough, sneeze, even speak.
The bacteria can float for hours under the right conditions, infecting people who breathe them in.
The research, published Wednesday in the New England Journal of Medicine, does not suggest that extensively drug-resistant
tuberculosis is spreading rapidly. But it does suggest that, of those tuberculosis cases in South Africa, far more are the result of
transmission from person to person than previously known, rather than the result of improper medical treatment. The scientists
from the US and South Africa found that in about 400 people studied, most had become infected by contracting the bacteria
from someone else.
We all know that tuberculosis is something that spreads between people, but it just hasnt been as big a focus with XDR and
MDR [multi-drug resistant] TB because thereve been so many treatment failures that have caused [new] cases, said Dr. Michael
Gardam, who runs a TB clinic at Torontos University Health Network. Gardam was not involved in the study.
But this case is showing this can spread quite nicely between people, and thats even more terrifying in a way. Because you
could just be in the wrong place at the wrong time.

Extensively drug-resistant tuberculosis is still rare in the US, with fewer than five cases a year in the country, said Dr. Peter
Cegielski, team lead for TB at the Centers for Disease Control and Prevention.
Several of the scientists responsible for the study work in Cegielskis department. Cegielski and his colleague, Dr. Sarita
Shah, reported the first cases of extensively drug-resistant tuberculosis TB in 2005, and Shah is the lead author on the new study.
Extensively drug-resistant TB is both difficult and costly to treat and treatment is often not successful. The fatality rate is
between 50 percent and 80 percent, the study noted. The combination of XDR TB and HIV is particularly deadly.
Even though XDR TB is highly concerning to health authorities, TB is not as contagious as some other airborne pathogens,
things like measles or chickenpox. Still, it is a major global threat, and one of the top 10 causes of death worldwide, according to
the World Health Organization.
Tuberculosis is a bacterial infection that most often attacks the lungs. Most infections are latent; the bacteria are harbored in
the body but dont cause disease. The WHO estimates that about a third of the worlds population has latent TB.
People with latent tuberculosis have a 1 in 10 risk of developing active disease at some point. Symptoms of active disease
are initially mild and include coughing, fever, night sweats, and weight loss. But untreated tuberculosis can be fatal.
The WHO estimates that in 2015, 10.4 million people were sickened by tuberculosis and 1.8 million died.
In this study, researchers from the CDC and a number of universities investigated 404 XDR TB patients to see if they were
infected by others or had developed the resistance on their own. The scientists searched medical records and studied the genetic
sequences of samples of bacteria collected from the patients. Closely related bacteria indicate transmission, not acquired
resistance.
Inadequate treatment accounted for at most 31 percent of the cases, they reported. Some of the XDR TB transmission
occurred in hospitals a known risk but some occurred in the community, they noted.
Its not a surprise that theres so much transmission of tuberculosis, even highly drug-resistant tuberculosis going on in
institutions. But I think its very important that they were able to quantify it using these state of the art scientific methods,
Cegielski said of the study.

He said a lot of work is underway to develop better methods of treating XDR TB cases and preventing transmission of this
infection in hospitals. The findings, he noted, suggest we need to redouble our efforts.
That is true not just about XDR TB but tuberculosis in general, said Dr. Philip Lederer, an infectious diseases specialist at
Massachusetts General Hospital and Harvard Medical School.
This study points to the critical importance of transmission and the critical need for more funding and resources at all
levels, from WHO to national TB programs, to research, to advocacy, Lederer said. Its very neglected by the global health
community.

Tuberculosis: Deadly as ever


By Henrylito D. Tacio - JANUARY 20, 2017

A vaccine that prevented tuberculosis would merit a Nobel Prize, but its just very difficult to develop. Tom Frieden
Since time immemorial, tuberculosis (TB) has been a public health threat. As early as 460 BC, Hippocrates, the famous
Greek physician, identified TB as a widespread and highly fatal disease. At that time, no one knew what caused TB and how to
treat it. TB spread uncontrollably killing most of its victims.
During the 19th century, TB was regarded a romantic disease. The reason: some of its famous victims include fiction
writer Edward Bellamy, poet Elizabeth Barrett Browning, novelist Franz Kafka, composer Frederic Chopin, inventor Alexander
Graham Bell, entertainer W.C. Fields, and nurse Florence Nightingale.
Brazilian poet Manuel Brandeira contracted TB in 1904 and expressed the effects of the disease in his life in many of his
poems. American author Dashiell Hammet got the disease during World War II. American country composer Jimmie Rodgers sang
about the woes of TB and ultimately died of the disease days after a New York City recording session.
World leaders were not spared from TB: Charles IX of France, Edward VI of England, American presidents Ulysses S. Grant
and Andrew Jackson, Louis XII of France, Napoleon II of France, Pedro I of Brazil, and our very own Manuel L. Quezon.

In those days, TB was considered as the deadliest disease. The cure until the late 1940s was basically rest, Andrea
Barrett once wrote. It was fresh, cold air, lots of food five meals a day, lots of sleep, not very much talking, and for some people,
complete stillness.
Then, in 1944, 21-year-old Patricia with progressive, far-advanced pulmonary TB received the first injection of
streptomycin. She improved dramatically during the ensuing five months and was discharged in 1947. She was evaluated in 1954
and found to be healthy and the happy mother of three children.
This injection began the age of modern anti-TB treatment and led until recently to dramatic reductions in TB in
industrialized countries, says the Geneva-based World Health Organization (WHO).
Other anti-TB drugs were introduced in subsequent years: thioacetazone (first released in 1946), isoniazid and pyrazinamide
(both first tried in 1952), and ethambutol (used for the first time in 1961). The most recent one, rifampicin, was released in 1966.
With all those drugs now available, TB can already be cured. The usual treatment course for TB is between six and nine
months of continuous medicines, wrote Dr. Willie T. Ong in his column, Mind Your Body. Once active TB is treated with the
appropriate drugs, the person is no longer contagious after three weeks. That is why those who are being treated for TB are
advised to rest during the first month.
Because TB bacteria are very slow-growing, the antibiotics must be taken for the whole duration of the treatment.
Treatment must be continued long after the person feels completely well, otherwise, the disease tends to relapse because it was
not fully eliminated, warns Dr. Dominic Garcia, an infectious disease specialist.
Government health officials also admitted that many of those who are suffering from TB refuse to consult a doctor because
of the stigma attached to the disease. The problem is that most Filipinos ignore their symptoms, continue to roam around, and
spread the infection, says an official of the health department. Oftentimes, they consult only when there is blood coming out
when they cough.
According to the United Nations health agency, TB prevalence in the Philippines is high among the elderly, urban poor,
smokers, and those with compromised immune systems such as people living with human immunodeficiency virus (HIV),
malnutrition and diabetes.

Treatment of TB may not change a persons chest x-ray results back to normal, says Ong. Studies show that once
treatment for TB is completed, a repeat chest x-ray may show the following results: 30 percent of chest x-rays will revert to normal
(good news), 30 percent of chest x-rays will improve but will still show a scar (still cant pass job test), 30 percent of chest x-rays
will remain the same.
In the Philippines, TB treatment is coordinated through the National TB Program of the health department. Medications are
said to be available at government health services and public hospitals around the country.
Disease of poverty
Unfortunately, adhering to and completing treatment can sometimes be difficult, especially when the ones who are most
vulnerable have little access to health care and no funds to support treatments, writes Dr. Maya Santos in her column, which
appeared in Vital Signs.
Sixty-year-old Tina is very sick and her disease had been complicated by TB. Being poor, she was brought to a government
hospital. Although TB medicines are free, she must pay for other antibiotics and vitamins prescribed. A few weeks ago, her only
son received from a nurse a new list of medicines to buy.
The son said that he had to file leave of absence to take care of his mother. And if he doesnt work, he wont be able to buy
the medicines, which the doctor prescribed. The impact on our finances is really big, he lamented.
Resistant strains
Another challenge in combatting TB is the emergence of multidrug resistant TB (MDR-TB). This new superbug probably
arose because TB patients did not adhere to their drug regimen, which means that they didnt take their medicines religiously for
the usual six months, laments Ong. Because of this, the TB bacteria developed a resistance to the first-line drugs.
MDR-TB is difficult and expensive to treat. The world needs to acknowledge the serious threat of drug-resistant tuberculosis
before it overwhelms health systems, said Dr. Alimuddin Zumla, director of the Centre for Infectious Diseases and International
Health at University College London Medical School.
If MDR-TB is bad enough, scientists have discovered a third more terrible strain of TB. These nasty bacteria are called
extensively drug-resistant TB or XDR-TB. This means that XDR-TB is resistant even to the special drugs developed for MDR-TB,

Ong says. Be forewarned: The WHO has reported that XDR-TB cases have been confirmed in 58 countries, including the
Philippines.
Even today, TB is still considered as a disease of poverty. The poor are not another race of creatures bound on other
journeys, Charles Dickens wrote. They are fellow passengers to the grave.

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