Descriptive Epidemiology Project: Tuberculosis in the. United States. MPH 510: Applied Epidemiology. Summer A 2014

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1 Descriptive Epidemiology Project: Tuberculosis in the United States MPH 510: Applied Epidemiology Summer A 2014 June 1, 2014

2 1 The white plague affected thousands upon thousands of people in the 18 th century. This ancient disease, currently known as tuberculosis and more easily referred to as TB, is still claiming the lives of more than a million people yearly around the world making it one of the leading disease killers (National Institutes of Health [NIH], 2012). In 2010, the United States reported 569 deaths from tuberculosis, a major decrease since national reporting of tuberculosis cases and deaths began (Centers for Disease Control and Prevention[CDC], 2013). Tuberculosis, a disease of poverty, has no discrimination thus affecting people of all races and ethnicities, men, women, and children, and of all ages. A disease that at one time was thought by experts could be eradicated, made a deadly comeback that is still affecting people around the world. What is Tuberculosis? Tuberculosis (TB), most often found in the lungs, is a bacterial infection that can spread from the lymph nodes to the blood stream, and therefore to any organ in the body (WebMD, 2014). Nodules, called tubercles grow in the tissues of the body, causing the tissues to die (WebMD, 2014). The picture below shows the bacteria of TB found in the lungs of a human. WebMD, 2014

3 2 When contracted, TB can live in an inactive form in the body, referred to as latent TB, and can show no symptoms to the carrier (Mayo Clinic, 2013). When the immune system becomes weakened, as in the elderly or those with HIV, the TB bacteria can become active and begin killing the tissue of the organs it has infected (WebMD, 2014). When an infected person has active TB, the bacteria are transmitted via droplets in the air from sneezing, coughing, laughing, spitting, and even singing and talking (Mayo Clinic, 2014). Although TB is not an easy disease to catch, it is contagious if contact with someone with an active form of TB not receiving appropriate treatment, occurs. Most often when someone is taking treatment for TB, and taking them appropriately, they are no longer contagious after 2 weeks (Mayo Clinic, 2014). General symptoms of TB include weight loss, fatigue, night sweats, and fever, but if the lungs are infected coughing and coughing up blood, along with chest pain are commonly seen (CDC, 2012). Healthy individuals can carry the disease and never know they are a carrier unless a break in their immune system occurs. The immune system blocks the bacteria that causes TB from growing and becoming active, therefore sometimes never showing signs or symptoms (WebMD, 2014). Detection of tuberculosis requires medical attention and testing. Initially, a skin test will be done by injecting a small amount of tuberculin under the first layers of the skin in one s arm. According to the U.S. Food and Drug Administration (FDA) (n.d.), tuberculin is a purified protein derivative made from a human strain of Mycobacterium tuberculosis, the bacteria that causes TB. The protein derived from the bacteria is grown in laboratory medium and inactivated, thus not being able to transmit the disease (FDA, n.d.). 48 to 72 hours later, the injection site will need to be examined by a trained medical professional to measure the bump and determine if the reaction to the tuberculin is positive (American Lung Association [ALA],

4 3 2014). If the injection site is deemed positive it shows that the one has been infected with the TB germ. To determine if the germ has caused the actual disease to develop, a chest x-ray and sputum culture would need to be performed (ALA, 2014). A blood test can also be performed to measure how the immune system reacts to the germ that causes TB (ALA, 2014). History of TB Traces of TB have been found in thousands of years old Egyptian mummies, and was a common disease in both Imperial Rome and Ancient Greece centuries ago (NIH, 2012). In the late 1880 s Robert Koch, a German microbiologist watched TB under the microscope. Koch was able to use staining techniques to help distinguish the TB bacteria from others, leading him to growing the bacteria in his lab for study, and ultimately directing him to the discovery of how TB is spread (NIH, 2012). The gram stain below shows under the microscope tuberculosis bacteria stained blue (NIH, 2012.) As the findings of how TB spread became known, the testing of how and what to treat with became important. In 1849, an era of sanatorium began where treatment of TB was continuous exposure to sunlight, fresh air, cold, and plenty of food (NIH, 2012.) Swedish Hospital in Denver was established in 1905 as tuberculosis sanatorium, and later converted into a

5 4 full-care hospital (HealthONE, n.d.). Patients in these sanatoriums were set next to open windows or even rooftops to gain the appropriate rest thought at this time to be the best treatment for tuberculosis. French scientists, Albert Calmette and Camile Guerin developed a vaccine against TB in 1908 (NIH, 2012.) They extracted Mycobacterium bovis, which causes TB in cattle, from a dead cow, and every 3 weeks for 13 years grew a new batch of the bacteria. Over time the bacteria weakened and was eventually unable to cause the disease, yet was still able to initiate the immune system in protection against tuberculosis. This vaccine was first given in 1921 to an infant whose mother died had from TB. Over a billion people have been vaccinated to date, yet it is still unclear of its truthful effectiveness (NIH, 2012). Although never found to be very effective in protecting adults, this vaccine, named Bacille Calemette-Guerin (BCG), is still used today to prevent TB from children in some countries (CDC, 2012). Along with Koch s breakthrough discovery of growing and observing TB under microscope, comes the significance of the age of antibiotic therapy against TB. In 1944, streptomycin was administered to a critically ill TB patient, and within days the patient showed great process. At this time it was found that streptomycin in combination could cure TB and not put the patient at risk for becoming resistant to antibiotic therapy. Isoniazid, rifampin, and ethambutol, all introduced in the 1940 s and 50 s, are drugs still used today to treat tuberculosis (NIH, 2012.) Other common therapies currently used to treat TB are pyrazinaminde and vitamin D (Mayo Clinic, 2013). Who is Affected by Tuberculosis? According to the Livestrong Foundation (2014), about one-third of the world s population carries tuberculosis bacteria. In 2012, the United States reported 9,945 cases of TB

6 5 which rates at about 3.2 cases per 100,000 people (CDC, 2013.) Although any person is at risk of becoming infected with TB bacteria, there are certain groups that are at a higher risk. Anyone that comes in contact with a person with active TB, such as hospital workers, nursing home staff, or even prions and shelters, are at great risk (Livestrong Foundation, 2014). Those who are at the highest risk of contracting the disease and becoming very ill, and possibly dying from TB are those with weakened immune systems (Livestrong Foundation, 2014). According to the Global Alliance for TB (2014), women are more likely to carry the disease, with estimation that over the next 5 years up to 4 million women will die from TB globally. Children are also another worry as TB has been found difficult to diagnosis in pediatrics. The Global Alliance for TB (2014) has estimated that hundreds of thousands of children suffer from the disease. Tuberculosis affects ethnicities and races of all types. In the United States, the CDC (2013) list Asians at the top for TB at 18.9 cases per 100,000 people, and Native Hawaiians and Pacific Islanders are listed 2 nd with about 12.3 cases per 100,000. Caucasians rank the lowest for TB with a rate of about 0.8 cases per 100,000 people (CDC, 2013). Locations of Tuberculosis Tuberculosis is everywhere, dating way back to Egyptian mummies and ancient European countries, to China, and the United States. Over centuries TB has spread from person to person, and country to country. The global map below from the World Health Organization (WHO) (2006) shows the significance of tuberculosis in each country in Some of the most prominent areas shown are South Africa, India, Greenland, and Indonesia (WHO, 2006).

7 6 Low-socioeconomic countries where people have unsanitary conditions, low-income, poor nutrition, live in dense housing and shared living spaces, and where medical treatment is difficult to find is where TB is most prevalent. The Global Alliance for TB (2014) states that TB and poverty run a cruel cycle where TB in turn worsens poverty. Tuberculosis in the United States is on the decline. The 9,945 U.S. cases noted above is the lowest recorded since 1959 brought the start of national reporting. The graph below shows the decline in recorded TB cases from the early 1980 s to 2012, the latest data available. Note the increase in cases in the late 1980 s to about This resurgence of disease at this time was linked to the eruption of HIV, outbreaks of TB in confined areas such as hospitals, delays in treatment of TB, and the increase of TB cases among foreigners (CDC, 2012). Cuts in funding for TB research, education, and treatment was also a huge factor in the reemergence of TB. TB prevention and control programs, unable to respond due to the cuts, literally started disappearing.

8 7 (CDC, 2013). The Problem with Tuberculosis Although rates are declining and the number of cases are decreasing, tuberculosis is still a major problem in the United States. Drug resistance is a major factor in why TB is continuing to be such a problem. Multidrug-resistant tuberculosis (MDR TB) is caused by an organism that does not respond to the two most potent treatments for TB, isoniazid and rifampin (CDC, 2012). Resistance to treatment occurs when the drugs are either not taken completely by the patient, or if the wrong dose and length of dose is given (CDC, 2012). MDR TB rates have decreased in the United States, from about 99 cases in 2011 to 72 in 2012 (CDC, 2013). As the numbers of tuberculosis cases have steadily decreased, the disease has localized itself in areas where the population may be difficult to treat with today s public health measures. Even with the screening efforts and available drug treatments, the persistence of TB is continuing to pose threat. Another widespread outbreak, like that of the 1980 s and early 90 s, is not something public health officials and healthcare personal should ignore. In the United States, immigrants and travelers will continue to pose risks, along with communal living and unsanitary

9 8 living conditions in low-income areas. Tuberculosis research and treatments have made immense progress, but it is clear that elimination and eradication of this disease will require more public education, better prevention techniques, such as an improved vaccination, along with quality testing, and enhanced treatments. Focus needs to be set on the populations as risk, such as those who live in confined areas, and those who are poor and unable to seek treatment. Education is key and should be made available to everyone so that the understanding of risk can be made. Another measure to help prevent the spread of TB is to have prisons, nursing home communities, and hospitals look into developing policies where their population can be screened for TB. Epidemiologic research should focus on geological trends of tuberculosis, and look into its relation with other diseases of those areas at that time. A Conclusion about Tuberculosis Although tuberculosis is declining year after year it is still a major public health concern, and not just an epidemic, but a global pandemic and public health emergency. Countries all over the world are affected including right here in the United States. In 2000, the United States reported 776 deaths, and in 2010, 569 deaths from TB were documented; a remarkable 27 percent decrease. Thanks to the development of medications and treatments, along with improved social and economic conditions, TB is on the decline. Yet with this decline, public health official s need to continue searching for the breakthrough that is going to help not only cure tuberculosis, but also eliminate it from the list of concerns.

10 9 References American Lung Association. (2014). Understanding tuberculosis. Retrieved May 29 th, 2014 from Centers for Disease Control and Prevention. (2013). Trends in tuberculosis, Retrieved May 28, 2014 from Centers for Disease Control and Prevention. (2012). Tuberculosis. Retrieved May 28, Global Alliance for TB. (2014). Economic impact of TB. Retrieved May 28, 2014 from HealthONE LLC. (n.d.). Swedish medical center: Hospital fast facts. Retrieved May 28, 2014 from Livestrong Foundation. (2014). Charactersitcs of tuberculosis. Retrieved May 29, 2014 from Mayo Clinic. (2014). Tuberculosis: Causes. Retrieved May 29, 2014 from Mayo Clinic. (2013). Tuberculosis: Treatments and drugs. Retrieved May 29, 2014 from National Institutes of Health. (2012). Tuberculosis. Retrieved May 28, 2014 from WebMD. (2014). What is tuberculosis? Retrieved May 28, 2014 from United States Food and Drug Administration. (n.d.). Tuberculin purified protein derivative. Retrieved May 29, 2014 from World Health Organization. (2006). Tuberculosis notification rates, Retrieved May 28, 2014 from

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