Question 1. What Is Tb?
Tuberculosis (TB) is a serious bacterial disease. It is a particular public health concern because it can spread through the air when a person with TB disease coughs, sneezes, laughs, sings, or even speaks. TB is found most often in the lungs, but can spread to other parts of the body. Untreated, it can destroy lung tissue and make breathing difficult or impossible. Left untreated or improperly treated, TB can be fatal.
Question 2. What Is Tb Disease?
TB disease develops when the immune system cannot keep tuberculosis bacteria under control, and bacteria begin to rapidly multiply and destroy tissue in the body: the bacteria can actually create a cavity or hole in the lung. People with TB disease are sick, and usually have symptoms.
TB disease can develop very soon after infection, or may appear many years after infection. People with TB disease can spread TB to others.
People with TB Disease:
- Usually have signs and symptoms
- Usually feel sick
- May spreads TB bacteria to others
- Usually have a positive TB test
- May have an abnormal chest x-ray, or positive sputum smear or culture
- Need treatment to stop the disease
TB disease normally affects the lung and is known as pulmonary TB. When TB occurs outside the lung it is referred to as extra-pulmonary TB. TB in the lungs or throat can be infectious, meaning the bacteria can be spread to other people. People with TB disease are most likely to spread it to those they spend time with every day, including family members, friends, coworkers, classmates, commuters, etc. TB disease in other parts of the body – such as the kidney or spine – is usually not easily spread to others.
The likelihood that TB will be transmitted heavily depends on the following factors:
- Infectiousness of the person with TB disease
- Environment in which exposure occurred
- Duration of exposure
- Virulence of the organism
Question 3. If Millions Of People Have Tuberculosis, Why Is Speaker’s Case Different?
- Unlike most tuberculosis patients, Speaker has multidrug-resistant tuberculosis (MDR TB). He was earlier thought to have extensively drug-resistant tuberculosis (XDR TB), which is even rarer.
- Multidrug-resistant TB doesn’t respond to the first preferred tuberculosis drugs. XDR TB doesn’t respond to the first and second preferred drug treatments.
- Speaker’s case also garnered instant attention when the CDC ordered him into isolation for medical treatment and alerted the public about his travels so that passengers on his transatlantic flights could get TB tests.
Question 4. If Tuberculosis Is Contagious, Why Doesn’t Speaker’s Wife Or Friends Have Tuberculosis?
“It sounds like he’s probably somebody who was in a pretty early state of TB,” says Hamilton, cautioning that she isn’t personally familiar with Speaker’s case.
“He wasn’t horribly sick because he felt like going on his honeymoon and he was what’s called ‘smear negative.’ In those situations, often people aren’t very infectious,” says Hamilton.
Question 5. How Does Tb Spread?
TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks and sings. People nearby may breathe in these bacteria and become infected. TB is most commonly spread to others in confined, poorly ventilated spaces. Although anyone can be exposed to TB disease, certain groups are at higher risk for exposure, including health care professionals, the homeless, and individuals from countries where TB is highly prevalent.
TB is NOT spread by:
- Shaking someone’s hand
- Sharing food or drink
- Touching bed linens or toilet seats
- Sharing toothbrushes
Question 6. What Is “smear-negative” Tb?
“What that means is that when he coughed up a specimen to give to the doctors to test for TB, the laboratory looked under the microscope [and] they didn’t see any TB bacteria. It was only when [the sample] was cultured that then they figured out, ‘Oh, there really is TB here’ and then it took some weeks to figure out it was drug resistant,” says Hamilton.
In contrast, smear-positive TB patients “have so much TB in their lungs that when the laboratory looks directly into the microscope, they can see the bacteria right there. Those people tend to be a lot more infectious or contagious to others than someone who really has disease but doesn’t yet have enough built up that they’re really coughing out a whole lot at a time.”
When TB bacteria keep growing, eventually “you can see it under a microscope, and that’s associated with easily infecting other people,” Hamilton says.
Question 7. What Are The Symptoms Of Tb?
The general symptoms of TB disease include feeling tired, weight loss, loss of appetite, fever, and night sweats. The symptoms of TB disease of the lungs also include a bad cough that does not improve and which lasts 3 weeks or more, chest pain, and coughing up blood. Symptoms of TB disease occurring outside of the lungs depend on the area affected.
Since symptoms of TB usually start gradually, often TB is not suspected, or is misdiagnosed as another illness.
Question 8. Speaker Has Said He Felt Fine And Had Been Exercising With No Obvious Symptoms. How Is That Possible? Is That Because He Was In The Early Stages?
- “That’s definitely how that’s possible,” says Hamilton.
- She recalls the case of a surgeon who operated on a patient who was later found to have TB and who was also exposed to TB while working in Africa.
- “He had TB,” Hamilton says. “In talking with him, he said, ‘well, when I do my five-mile runs, I might have noticed I was slightly more out of breath than usual.’ In other words, [he was] healthy, working, running, totally fine,” Hamilton says.
- “I feel quite certain that as time went on, he would have become ill. He just wasn’t quite there yet,” she says. “It goes to show that these diseases can kind of sneak up on people.”
Question 9. How Is Tb Disease Treated?
TB disease can be treated by taking anti-tuberculosis drugs for 6 to 12 months or longer. It is very important that people who have TB disease finish this medicine, and take their drugs exactly as ordered. If they stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly, the germs that are still alive may become resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat.
In Mississippi the local health department staff meets regularly with patients who have TB to watch them take their medications. This is called directly observed therapy (DOT). DOT helps the patient complete treatment in the least amount of time. Treatment is usually divided into two phases: the initial phase and the continuation phase. The initial phase begins with four drugs given daily for fourteen consecutive days. The remainder of the initial phase (usually about 2 months) may be daily or twice weekly depending on the patient’s drug tolerance and the extent of the disease or the patient’s other conditions. The continuation phase typically will last an additional 4 to 7 months with not less than 2 drugs. Laboratory testing is performed at regular intervals or as needed to monitor the patient’s progress and drug tolerance.
Question 10. Do Most Tb Patients Have Symptoms, And What Are Tuberculosis Symptoms?
“That’s what we think, that most people eventually have some kind of symptom,” says Hamilton.
When people get sick with tuberculosis, their symptoms may include fever, night sweats, cough, appetite loss, weight loss, bloody phlegm, and loss of energy.
Question 11. Can Anyone Catch Tb?
- “Yes, if they are in close association with someone who has tuberculosis,” says Hamilton.
- “That means not just walking past them in Hartsfield Airport in Atlanta,” she adds.
- “Usually it’s sharing an office with them, living in the same household with them, being in a homeless shelter with them and sleeping in a bed next to them — [spending] time with that person.”
- “Tuberculosis is around,” Hamilton says. “Does that mean people should be nervous about going to the mall? No. It’s not horribly common. Now, if people travel to countries where there’s still a lot of TB, then your risk is increased.”
Question 12. What Is Tb Infection?
When a person is diagnosed with TB infection, it means that they have been exposed to someone with TB disease, have inhaled TB bacteria, and become infected with TB. About 5% of infected people progress to TB disease within the first two years after becoming infected. Another 5% will develop disease later. People who are infected:
- Have no symptoms
- Don’t feel sick
- Cannot spread TB to others
- Usually have a positive TB skin test or TB blood test (Interferon Gamma Release Assay)
- May develop TB disease if not treated for TB infection
People at greater risks of progressing to TB disease usually have a weakened immune system. Older people; children under the age of 5; people with chronic illness (especially diabetes), lung diseases, or certain cancers; those who smoke, abuse substances, or take immune suppressive medications such as TnF inhibitors; or those with HIV infection have much higher risk of developing TB disease if not treated.
Sometimes people are given treatment to prevent TB infection even if their TB test is negative. This is often done with infants, children and HIV-infected people who have recently spent time with someone who has infectious TB disease. These groups are at very high risk of developing serious TB disease soon after they are exposed to TB bacteria. If you are prescribed treatment for TB infection, it is important that you take all of your pills exactly as prescribed. You should follow-up regularly with your health care provider while on medication so they can monitor how you are doing.
Question 13. What Tests Determine Whether A Person Has Tb? Are Those Tests Safe If You Are Pregnant Or Are Trying To Conceive?
“The tests are safe whether you’re pregnant or are trying to [conceive],” says Hamilton.
“The most common test is called the tuberculin skin test or PPD. That’s where a tiny, killed piece of TB is put right under the skin and you see if your body reacts to it or not. There’s a newer blood test called QuantiFERON that tells us about the same information. That test not available all over the place,” Hamilton says.
Since tuberculosis grows slowly, people get a follow-up test about two to three months after their initial test.
Question 14. How Is Tb Infection Treated?
A person with TB infection needs to take anti-tuberculosis drugs in order to kill the TB germs and prevent TB disease from developing in the future. Some people are more likely than others to develop TB disease once they have TB infection. This includes people with HIV infection, people who were recently exposed to someone with TB disease, smokers, people with certain medical conditions such as diabetes and kidney problems, and persons taking immunosuppressive drugs.
The newest and best treatment for TB infection requires two drugs given in one directly observed dose per week for 12 weeks. Other single drug treatment options take from four to nine months to complete.
Question 15. How Is Tb Treated?
- Ninety-five percent of people will respond to the combination of the four first-line drugs — ionized, revamping, pyrazinamide, ethambutol, Hamilton says.
- Drug-resistant tuberculosis is rarer and XDR TB is rarer still, affecting a few cases per year in the U.S., Hamilton says.
- But in other countries, it’s really increasing, Hamilton says. So it is true that it’s not that far away. Our TB program budgets have been cut every year, and so we get less and less able to respond to this sort of thing.
- Hamilton also warns that if our regular TB cases aren’t managed appropriately and aggressively, they can become drug resistant. While we don’t want to engender panic, it’s a real concern.
Question 16. What About Surgery?
- Surgery may be done to remove damaged areas of the lungs if drug treatments fail for XDR TB.
- Speaker got lung surgery on July 17 to remove parts of his lung affected by tuberculosis. The operation was performed at the University of Colorado Hospital at the Anschutz Medical Campus in Aurora, Colo., by John D. Mitchell, MD, chief of general thoracic surgery at the University of Colorado Hospital.
- Speaker’s operation was done with a minimally invasive technique called video-assisted thoracic surgery (VATS).
- In VATS, surgeons access the lung through a 2-inch incision in the patient’s side, as well as two incisions (each 1-centimeter long) for surgical instruments and a tiny, fiber optic camera.
- The infected part of Speaker’s lung has been described as roughly the size of a tennis ball, notes the National Jewish Medical and Research Center.
- Marvin Pomerantz, MD, director of the Center for the Surgical Treatment of Lung Infections at the University of Colorado at Denver Health Sciences Center, tells WebMD that he wouldn’t call lung surgery a last resort.
- “I’d call it part of the overall treatment of the difficult cases of tuberculosis,” with more antibiotic treatment after the operation, Pomerantz says.
Question 17. What Is Tb Exposure?
TB exposure occurs when a person shares air with someone who has active infectious TB disease. You may have been exposed to TB if you spent time near someone with TB disease of the lungs or throat. You can only get infected by breathing in TB germs that a person expels into the air. You cannot get TB from someone’s clothes, drinking glass, eating utensils, handshake, toilet, or other surfaces where a TB patient has been. Most people are never exposed to a person with active infectious tuberculosis disease for a period long enough to become infected.
People most likely to become infected are those that share air with a TB case for prolonged period of time, either in a single or group setting. Individuals more likely to be exposed to TB include health care workers, the homeless, persons living or working in congregate or long term care facilities, and persons traveling to or living in countries with high TB prevalence. An estimated 10-15 million U.S. residents and one-third of the world’s population are currently infected with the TB organism. A TB Interferon Gamma Release Assay (blood test) will identify TB infection.
Question 18. Is Tb Infection Dangerous?
Untreated, TB infection can progress to TB disease. A person with TB infection does not feel sick and has no symptoms. Persons with TB infection cannot spread the infection to others. A skin test or blood test can detect the presence of TB infection. TB infection should be treated to prevent it from progressing to TB disease which can be spread to others.
Question 19. How Can I Be Tested For Tb?
You can get a TB skin test or blood test at a local health clinic or your doctor’s office. The tests are quick and simple, and give results in only a few days. A blood test is the preferred test and is more specific than a skin test. A skin test can require two to four visits whereas the blood test can be performed with a single visit. (TB skin tests are typically not given on Thursdays because of the required time-frame for the follow-up visit.)
Question 20. Who Should Be Tested?
You should get a TB test if:
- You have spent time with a person who has active TB.
- You have the symptoms of TB: coughing for more than two weeks, pain in the chest, coughing up blood, and fatigue.
- You have a chronic disease such as diabetes, or another condition that weakens the immune system.
- You have lived or traveled in a foreign country where TB is common.
- You have lived or worked in a place where TB is common: migrant farm camps, prisons, homeless shelters or other crowded places where disease can spread.
- You use drugs injected with needles that may not be sterile.
- You have HIV infection.
- You are going to start a TNF inhibitor or other immunosuppressive therapy (get tested before starting).
- You are being evaluated for treatment with immunosuppressive drugs such as TnF inhibitors for arthritis.
Question 21. What Are Tb Reporting Requirements?
State laws and regulations require that TB infection, suspected TB, or cases of tuberculosis be reported to the Mississippi State Department of Health. Active TB must be reported within 24 hours of first suspicion. Specific information on reporting requirement may be found in the Rules and Regulations Governing Reportable Diseases. MSDH provides treatment and follow-up of all TB patients and contacts.
Question 22. How Is Tb Controlled In Correctional Facilities?
The transmission of Mycobacterium tuberculosis in correctional facilities presents a public health problem for correctional facility employees and inmates and the communities into which untreated inmates may be released. A primary reason for the high risk of TB infection and TB disease in correctional facilities is the disproportionate number of inmates who have risk factors for exposure to TB or, if infected, for development of active disease. These risk factors include crowded communal living, infection with HIV, substance abuse, and being a member of a lower socioeconomic population that has poor access to health care.
With this in mind, the Department of Health and the Department of Corrections work collaboratively to ensure all inmates and employees are tested for tuberculosis, and that those found to be infected are appropriately treated. This helps stop the spread of TB and helps protect all communities statewide. Additionally, the State TB Program has assigned nurses to all three state correctional facilities to ensure open communication with the facilities, address questions and concerns, monitor patient progress, ensure appropriate treatment and follow-up, and facilitate discharge planning for TB and HIV patients.
Question 23. What Is Multi-drug Resistant Tuberculosis (mdr-tb)?
Multi-drug resistant TB (MDR-TB) is tuberculosis disease in which the TB bacterium is resistant to isoniazid and revamping, the two strongest anti-tuberculosis medications. TB can become resistant to antibiotics when the drugs are misused or mismanaged, when patients do not complete their full course of treatment, when healthcare providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs; or when the drugs are of poor quality.
Treating MDR-TB is complicated and involves the use of second-line medications that carry greater risk of side effects and adverse reactions. Patients taking these drugs must be monitored closely throughout the course of treatment. The regimen usually requires at least 18-24 months and must be individualized based upon the patient’s medical history. Treatment for patients co-infected with HIV can be more complicated, usually further lengthening treatment time.
Question 24. What Is Extensively Drug Resistant Tuberculosis (xdr-tb)?
Extensively drug resistant TB (XDR-TB) is a relatively rare type of MDR-TB. XDR-TB is defined as TB which is resistant to ionized and revamping, plus resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). Because XDR-TB is resistant to first-line and second-line drugs, patients are left with treatment options that are much less effective and may require prolonged treatment.
Question 25. Can People Contract Bovine Tuberculosis?
Yes. Bovine tuberculosis refers to infection with bacteria called Mycobacterium bovis, and M. bovis. Mycobacterium bovis is related to another organism that causes tuberculosis in humans, Mycobacterium tuberculosis, but M. bovis is found most commonly in cattle and other animals. People can become infected with M. bovis when they consume raw milk and unpasteurized dairy products.
Symptoms of bovine tuberculosis in people depend on the parts of the body infected; most infections result in no or only mild symptoms, including fever, night sweats, abdominal pain, and diarrhea. A comprehensive testing program conducted by the U.S. Department of Agriculture, state animal health agencies, and livestock ranchers has virtually eliminated bovine tuberculosis from cattle in the United States. However, bovine tuberculosis remains common in many developing countries, and persons should refrain from consuming imported dairy products that are not pasteurized.
Question 26. What Is A Tb Contact?
A TB contact is a person that has been exposed to TB. TB contacts are ranked from high priority to low. High priority means either the person has had prolonged exposure, or that the person is highly susceptible to becoming infected and progressing to TB disease — children under the age of 5 or persons infected with HIV or on immunosuppressive therapy. Contacts should be promptly tested once exposure is known, and tested again about 10 weeks after the last known exposure. If either test is positive, the person is considered infected and requires additional follow-up and treatment.
Question 27. What Is The Incubation Period Of Tuberculosis?
From infection to development of a positive TB test (the incubation period) can take 2 to 10 weeks. The risk for developing active disease is the highest in the first two years after infection. If not treated, a risk continues throughout your lifetime.
Question 28. What Is Dot?
DOT (directly-observed therapy) means that a trained health care worker or other designated individual (excluding a family member) provides the prescribed TB drugs and watches the patient swallow every dose. DOT is the most effective strategy for making sure patients take their medicines. Mississippi was the first state to adopt DOT as the standard of care. It is now recommended by the Centers for Disease Control and World Health Organization as the standard for treating TB.
Question 29. Why Use Dot?
- We cannot predict who will take medications as directed, and who will not. People from all social classes, educational backgrounds, ages, genders, and ethnicities can have problems taking medications correctly.
- Studies show that 86-90% of patients receiving DOT complete their therapy, compared to 61% for those on self-administered therapy.
- DOT helps patients finish TB therapy as quickly as possible, without unnecessary gaps.
- DOT helps prevent TB from spreading to others.
- DOT decreases the risk of drug-resistance resulting from erratic or incomplete treatment.
- DOT decreases the chances of treatment failure and relapse.
Question 30. Who Can Provide Dot?
- A nurse or other trained health care worker from the patient’s county public health department normally provides DOT.
- In some situations, it works best for clinics, home care agencies, correctional facilities, treatment centers, schools, employers, and other facilities to provide DOT, under the guidance of the local health department.
- Family members should not be used for DOT. DOT providers must remain objective.
- For complex regimens including IV/IM medications or twice daily dosing, home care agencies may provide DOT or share responsibilities with the local health department.
- If resources for providing DOT are limited, priority should be given to patients most at risk.
- In some cases observed therapy may be performed using live streaming video.
Question 31. How Can A Dot Provider Build Rapport And Trust?
- “Start where the patient is.”
- Protect confidentiality.
- Communicate clearly.
- Avoid criticizing the patient’s behavior; respectfully offer helpful suggestions for change.
- Be on time and be consistent.
- Adopt and reflect a nonjudgmental attitude.
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