- A million and a half people dying from TB
- Death From a Preventable Disease: Tuberculosis
- A Gentle Death: Tuberculosis in 19th Century Concord
- Who is most at risk?
- Global impact of TB
- Symptoms and diagnosis
- TB and HIV
- Multidrug-resistant TB
- Global commitments and the WHO response
- Tuberculosis Symptoms and Risk Factors
- Diagnosing Tuberculosis
- Treating Tuberculosis
- New Discoveries for Treating Tuberculosis
- Make an Appointment
A million and a half people dying from TB
Each year, for those people dying of pulmonary TB the following can often be true:
“When TB wakes up and gets into the lungs, it eats them from the inside out, slowly diminishing their capacity, causing the chest to fill up with blood and the liquidy remains of the lungs. A wet, hacking cough is evocative of TB. The lungs now in liquid form are sloshing around in the chest. Cough that up, even in microscopic, impossible to see droplets, near other people, and they have a very good chance of getting TB too.”
“Eventually, liquid replaces the lungs, the suffering patients cannot get enough oxygen, and respiratory failure occurs, they can no longer breathe and they drown. It’s painful, it’s drawn out. It’s an awful way to die. But before any of this happens the disease weakens you, diminishes your capacity for work, and puts your family and friends, and anyone else you come into contact with, at risk. Individual death is only part of the problem”.1“McMillen, Christian W. “Discovering Tuberculosis, Yale University, 2015
The problem of global TB results in the deaths each year of nearly one and a half million people. Deaths from TB are deaths from a disease that for many years has been treatable and curable. More than 30 million people have died since the World Health Organisation declared TB to be a global emergency in 1993.
For the number of people dying from TB in each high burden country see the deaths from TB . For more generally about TB see TBFacts
An estimated 205,000 children died from TB in 2018.
Death From a Preventable Disease: Tuberculosis
It’s estimated that about two million people per year die worldwide from tuberculosis. What makes this number so tough to swallow is that tuberculosis is a highly treatable disease, and can even be prevented in some people with a tuberculosis vaccine. So why are people still dying?
We know how to diagnose tuberculosis. We know how to treat it and keep it from coming back. We even know how to prevent many cases of tuberculosis. So, considering what we know, two million deaths each year seems a bit much.
But there are other complications at work that make beating tuberculosis infection more difficult.
“Among the many reasons for the number of deaths associated with TB include late diagnosis in many countries in the world and co-infection with HIV without access to adequate HIV treatment,” says George Smulian, MD, associate director of the division of infectious diseases at the University of Cincinnati.
Poor nutrition and not taking medications as prescribed are additional reasons people die from tuberculosis, according to Dr. Smulian.
Fatality Risk Factors for Tuberculosis
People with HIV and tuberculosis are at a much greater risk of dying from tuberculosis, because the TB infection can be much more difficult to treat and control. Tuberculosis is actually the primary cause of death for people with HIV.
Anyone who receives a late diagnosis is also at a greater risk of dying from tuberculosis. The later you start treatment, the more time the bacteria have to spread throughout the lungs and to other parts of the body. The earlier you receive tuberculosis treatment, the better your prognosis.
The Importance of Taking Your Tuberculosis Treatment
Doctors in the United State emphasize the importance of tuberculosis treatment compliance — taking medicines as prescribed — and take steps to make sure their patients don’t miss a dose.
“In the United States, most patients receive treatment for tuberculosis using directly observed therapy (DOT), where each dose of the medication is administered by a health care worker who observes the patient taking the medication, ensuring that all medication is taken,” says Smulian.
People who stop taking their tuberculosis medications early, or who don’t take them properly, are at a much greater risk of death from tuberculosis than those who do what they’re supposed to do. The antibiotics must keep working to destroy all of the bacteria in your body.
Saving Lives of People With Tuberculosis Infection
Besides making sure that people stick with their treatments, what else can be done to save lives?
- Identify tuberculosis as early as possible.
- Treat it as early as possible.
- Identify co-infection of tuberculosis and HIV.
- Identify and treat patients with latent tuberculosis infection — the point before the tuberculosis infection becomes the disease itself.
- Prevent the development of active tuberculosis disease.
These steps are “the most important measures to reduce death from TB,” stresses Smulian.
Help From the Public Health Officials
Administering tuberculosis medications at least three times a week is a good goal, and, Smulian says, is “possible for many health departments and has been associated with much better outcomes.”
But in other areas of the world, this is often not possible and “therefore medication compliance is often and drug resistance more common,” he says.
But sometimes the money for TB treatments is tough to come by.
“There is concern: With cuts in budgets associated with the current economy, some programs will be cut, leading to more missed treatment and greater treatment failure and drug resistance,” says Smulian.
A Gentle Death: Tuberculosis in 19th Century Concord
by Constance Manoli-Skocay
Staff Assistant, William Munroe Special Collections, Concord Free Public Library
Tuberculosis is something we don’t often think about anymore. But 19th century Concordians were frighteningly aware of the symptoms: the flushed cheeks, the bright eyes, fever, loss of appetite, and most of all, the cough. It was feared, but regarded with a peculiar resignation because it was so unavoidable. It was dreaded, but at the same time romanticized. It was a disease that reflected the culture of its time: the victim slowly, gracefully fading away, transcending their corporeal body, their immortal soul shining through.
In reality, tuberculosis, commonly called consumption in the 19th century, killed more people in New England, particularly in the Boston area, than any other disease. It affected the poor more often than the wealthy, females more than males, and people of all ages. Anyone could be a victim, but it was especially prevalent among young adults, cruelly striking down those in the prime of their lives.
Unfortunately for 19th century New Englanders, the disease was not well understood. Its cause would not be discovered until 1882. In the meantime, beliefs about the disease reflected the cultural and scientific thinking of the time. It was thought that it might be a vaguely environmental, “something in the air”; but more likely caused by the victim’s own constitution, either physiologically, psychologically, or both. It was not believed to be contagious, so those suffering from the disease were not avoided.
Recommended steps toward prevention included fresh air, a wholesome diet, exercise, and healthy manual labor. In “Consumption in America,” a series of three articles published in the Atlantic Monthly in 1869, Dr. Henry Bowditch theorized that damp soil was the main cause of consumption. He advised towns to drain wet areas and families to occupy only sunlit homes sited on dry soils.
The disease affected Concordians in two ways: by the sheer number of people who contracted it and by the way it descended upon certain families. Thanks to the record- keeping and analysis done by men like Lemuel Shattuck, Ezra Ripley, and Edward Jarvis, there are statistics on deaths in Concord which detail dates, ages, and causes. These records show that consumption was the leading cause of death in Concord in the first half of the 19th century. The same was true in neighboring towns: Acton, Billerica, Bedford, and Carlisle all exhibiting the similar results. Tuberculosis was everywhere.
Concord families unduly affected by consumption included the Barretts, Buttricks, Melvins, Heywoods, and Hosmers. In these families, death from consumption took place both within as well as across generations. In the records can be found family tragedies, such as the case of Lucy and Lemuel Phillips, sister and brother, who died within a month of each other in 1802. She was 19 and he was 22. The Dudley family lost Rebecca in 1803 (age 19), Mary in 1804 (age 26) and their father, Samuel, in 1806. Mary E. Wright died in January of 1837 at age 42 and her daughter, Mary, in April at age 16. Cases like these are found throughout the records. Caring for each other and simply living in the same home were enough to spread consumption through a family.
Some of Concord’s most revered families fell victim to tuberculosis. Both Emerson and Thoreau came from what were recognized as “consumptive” families- those with many cases. The first known case in the Emerson family was that of Reverend William Emerson, Ralph Waldo’s father, who had the disease when he died in 1811 at the age of 42. Ruth Haskins Emerson went on to raise their children herself, and by her hard work the Emerson brothers grew to adulthood and went on to attend Harvard College. However, all had symptoms of tuberculosis. Both Edward and Charles died of it while in their late twenties. Waldo appeared to have symptoms of the disease at various times in his life, once writing of having “a mouse gnawing at his chest,” but died of an unrelated illness at age 79.
Emerson’s marriage to Ellen Tucker was prematurely ended by tuberculosis. Their relationship had a storybook quality to it: two gifted young people in the midst of passionate first love, a world of opportunity awaiting them. She was just 16 when they met, attractive, intelligent, and energetic, and within a year they were engaged. But both romantically and tragically, she was also from a consumptive family and already had the disease. They were married in September of 1829 and she died on February 8, 1831, only nineteen years old. Their relationship had been intensified by the knowledge that it would be necessarily brief. “My angel is gone to heaven this morning and I am alone in the world and strangely happy,” he wrote to his Aunt Mary Moody Emerson two hours after Ellen had died. Her struggle was over. His second wife Lydian would later graciously name their first daughter after Ellen.
Henry David Thoreau succumbed to tuberculosis at the age of 44. For Thoreau, too, it was a family illness. His grandfather had died of it in 1801, and when Henry’s father died in 1859 his symptoms were consistent with tuberculosis. His brother John was living with it, though tetanus took him first, and their sister Helen became a victim in 1849 at age thirty-six. Henry himself had developed a severe cold in the early winter of 1860 that kept him housebound and diminished his productivity. The following spring he took a trip to Minnesota (at the time thought to be a favorable place for recovery from respiratory problems), but when he returned two months later his health had further declined. He continued to work on various projects and papers, but he was failing. With his sister Sophia by his side, he died on the morning of May 6th, 1862.
Was there a citizen in 19th century Concord who had not been touched by the loss of a friend or family member to consumption? Sisters, mothers, sons, daughters, fathers were lost to this omnipresent disease. It was an intimate, if unwelcome, part of everyone’s life. And not until the advent of antibiotics could the lurking fear of consumption be put to rest.
Editor’s Note: Tuberculosis is not gone if forgotten. Since 1985, TB has slowly come back in the US. Though the number of cases reported in the US has been dropping 1992, there were more than 16,000 cases reported in 2000. See the Center for Disease Control and Prevention to find out more.
Photos: Top – Special Collections, Concord Free Public Library.
All others – courtesy of ArtToday.
Article appeared in the Concord Magazine, by Hometown Websmith, Concord, Mass., Winter 2003.
©2015. William Munroe Special Collections, Concord Free Public Library, Concord, Massachusetts.
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Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most often affect the lungs. Tuberculosis is curable and preventable.
TB is spread from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air. A person needs to inhale only a few of these germs to become infected.
About one-quarter of the world’s population has latent TB, which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease.
People infected with TB bacteria have a 5–15% lifetime risk of falling ill with TB. Persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a higher risk of falling ill.
When a person develops active TB disease, the symptoms (such as cough, fever, night sweats, or weight loss) may be mild for many months. This can lead to delays in seeking care, and results in transmission of the bacteria to others. People with active TB can infect 5–15 other people through close contact over the course of a year. Without proper treatment, 45% of HIV-negative people with TB on average and nearly all HIV-positive people with TB will die.
Who is most at risk?
Tuberculosis mostly affects adults in their most productive years. However, all age groups are at risk. Over 95% of cases and deaths are in developing countries.
People who are infected with HIV are 19 times more likely to develop active TB (see TB and HIV section below). The risk of active TB is also greater in persons suffering from other conditions that impair the immune system. People with undernutrition are 3 times more at risk. There were globally 2.3 million new TB cases in 2018 that were attributable to undernutrition.
1.1 million children (0–14 years of age) fell ill with TB, and 230 000 children (including children with HIV associated TB) died from the disease in 2018.
Alcohol use disorder and tobacco smoking increase the risk of TB disease by a factor of 3.3 and 1.6, respectively. In 2018, 0.83 million new TB cases worldwide were attributable to alcohol use disorder and 0.86 million were attributable to smoking.
Global impact of TB
TB occurs in every part of the world. In 2018, the largest number of new TB cases occurred in the South-East Asian region, with 44% of new cases, followed by the African region, with 24% of new cases and the Western Pacific with 18%.
In 2018, 87% of new TB cases occurred in the 30 high TB burden countries. Eight countries accounted for two thirds of the new TB cases: India, China, Indonesia, Philippines, Pakistan, Nigeria, Bangladesh and South Africa.
Symptoms and diagnosis
Common symptoms of active lung TB are cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats. Many countries still rely on a long-used method called sputum smear microscopy to diagnose TB. Trained laboratory technicians look at sputum samples under a microscope to see if TB bacteria are present. Microscopy detects only half the number of TB cases and cannot detect drug-resistance.
The use of the rapid test Xpert MTB/RIF® has expanded substantially since 2010, when WHO first recommended its use. The test simultaneously detects TB and resistance to rifampicin, the most important TB medicine. Diagnosis can be made within 2 hours and the test is now recommended by WHO as the initial diagnostic test in all persons with signs and symptoms of TB.
Diagnosing multidrug-resistant and extensively drug-resistant TB (see Multidrug-resistant TB section below) as well as HIV-associated TB can be complex and expensive. In 2016, 4 new diagnostic tests were recommended by WHO – a rapid molecular test to detect TB at peripheral health centres where Xpert MTB/RIF cannot be used, and 3 tests to detect resistance to first- and second-line TB medicines.
Tuberculosis is particularly difficult to diagnose in children.
TB is a treatable and curable disease. Active, drug-susceptible TB disease is treated with a standard 6-month course of 4 antimicrobial drugs that are provided with information and support to the patient by a health worker or trained volunteer. Without such support, treatment adherence is more difficult.
Between 2000 and 2018, an estimated 58 million lives were saved through TB diagnosis and treatment.
TB and HIV
People living with HIV are 19 (15-22) times more likely to develop active TB disease than people without HIV.
HIV and TB form a lethal combination, each speeding the other’s progress. In 2018 about 251 000 people died of HIV-associated TB. In 2018, there were an estimated 862 000 new cases of TB amongst people who were HIV-positive, 72% of whom were living in Africa.
WHO recommends a 12-component approach of collaborative TB-HIV activities, including actions for prevention and treatment of infection and disease, to reduce deaths.
Anti-TB medicines have been used for decades and strains that are resistant to one or more of the medicines have been documented in every country surveyed. Drug resistance emerges when anti-TB medicines are used inappropriately, through incorrect prescription by health care providers, poor quality drugs, and patients stopping treatment prematurely.
Multidrug-resistant tuberculosis (MDR-TB) is a form of TB caused by bacteria that do not respond to isoniazid and rifampicin, the 2 most powerful first-line anti-TB drugs. MDR-TB is treatable and curable by using second-line drugs. However, second-line treatment options are limited and require extensive chemotherapy (up to 2 years of treatment) with medicines that are expensive and toxic.
In some cases, more severe drug resistance can develop. Extensively drug-resistant TB (XDR-TB) is a more serious form of MDR-TB caused by bacteria that do not respond to the most effective second-line anti-TB drugs, often leaving patients without any further treatment options.
In 2018, MDR-TB remains a public health crisis and a health security threat. WHO estimates that there were 484 000 new cases with resistance to rifampicin – the most effective first-line drug – of which 78% had MDR-TB. The MDR-TB burden largely falls on 3 countries – India, China and the Russian Federation – which together account for half of the global cases. About 6.2% of MDR-TB cases had extensively drug-resistant TB (XDR-TB) in 2018.
Worldwide, only 56% of MDR-TB patients are currently successfully treated. In 2016, WHO approved the use of a short, standardized regimen for MDR-TB patients who do not have strains that are resistant to second-line TB medicines. This regimen takes 9–12 months and is much less expensive than the conventional treatment for MDR-TB, which can take up to 2 years. Patients with XDR-TB or resistance to second-line anti-TB drugs cannot use this regimen, however, and need to be put on longer MDR-TB regimens to which 1 of the new drugs (bedquiline and delamanid) may be added.
In July 2018, the latest evidence on treatment of drug-resistant TB was reviewed by an independent panel of experts convened by WHO. A rapid communication on key changes to recommendations for the treatment of drug-resistant TB has been issued by WHO, to be followed by the release of updated and consolidated WHO policy guidelines later in the year.
WHO also approved in 2016 a rapid diagnostic test to quickly identify these patients. Sixty-two countries have started using shorter MDR-TB regimens. By the end of 2018, 90 countries reported having introduced bedaquiline and 57 countries reported having introduced delamanid, in an effort to improve the effectiveness of MDR-TB treatment regimens.
Global commitments and the WHO response
On 26 September 2018, the United Nations (UN) held its first- ever high-level meeting on TB, elevating discussion about the status of the TB epidemic and how to end it to the level of heads of state and government. It followed the first global ministerial conference on TB hosted by WHO and the Russian government in November 2017. The outcome was a political declaration agreed by all UN Member States, in which existing commitments to the Sustainable Development Goals (SDGs) and WHO’s End TB Strategy were reaffirmed, and new ones added.
SDG Target 3.3 includes ending the TB epidemic by 2030. The End TB Strategy defines milestones (for 2020 and 2025) and targets (for 2030 and 2035) for reductions in TB cases and deaths. The targets for 2030 are a 90% reduction in the number of TB deaths and an 80% reduction in the TB incidence rate (new cases per 100 000 population per year) compared with levels in 2015. The milestones for 2020 are a 35% reduction in the number of TB deaths and a 20% reduction in the TB incidence rate. The strategy also includes a 2020 milestone that no TB patients and their households face catastrophic costs as a result of TB disease.
The political declaration of the UN high-level meeting included four new global targets:
- treat 40 million people for TB disease in the 5-year period 2018–2022;
- reach at least 30 million people with TB preventive treatment for a latent TB infection in the 5-year period 2018–2022;
- mobilize at least US$ 13 billion annually for universal access to TB diagnosis, treatment and care by 2022;
- mobilize at least US$ 2 billion annually for TB research.
The political declaration also requested the UN Secretary-General, with support from WHO, to provide a report in 2020 to the General Assembly on global and national progress, as the basis for a comprehensive review at a high-level meeting in 2023. The Director-General of WHO was requested to continue to develop a multisectoral accountability framework for TB (MAF-TB) and to ensure its timely implementation.
WHO is working closely with countries, partners and civil society in scaling up the TB response. Six core functions are being pursued by WHO to contribute to achieving the targets of the UN high-level meeting political declaration, SDGs, End TB Strategy and WHO strategic priorities:
- Providing global leadership to end TB through strategy development, political and multisectoral engagement, strengthening review and accountability, advocacy, and partnerships, including with civil society;
- Shaping the TB research and innovation agenda and stimulating the generation, translation and dissemination of knowledge;
- Setting norms and standards on TB prevention and care and promoting and facilitating their implementation;
- Developing and promoting ethical and evidence-based policy options for TB prevention and care;
- Ensuring the provision of specialized technical support to Member States and partners jointly with WHO regional and country offices, catalyzing change, and building sustainable capacity;
- Monitoring and reporting on the status of the TB epidemic and progress in financing and implementation of the response at global, regional and country levels.
While the number of reported tuberculosis cases in this country is declining, the disease—once the number one cause of death in the U.S.—is still one of the deadliest diseases around the world, with approximately 2 million tuberculosis-related deaths each year. The team of experts from Pulmonary & Critical Care Medicine at the University of Michigan provides comprehensive, multidisciplinary care for people with tuberculosis, offering the latest treatments plus groundbreaking research for those with antibiotic resistance.
Tuberculosis is caused by a bacteria called Mycobacterium tuberculosis. While the bacteria generally attacks the lungs, other parts of the body can be affected, too, including the brain, kidney and spine.
There are two types of tuberculosis:
- Latent tuberculosis: While you have a tuberculosis infection, your immune system is able to keep you from getting sick. You don’t have symptoms and can’t spread the disease. It is possible for latent tuberculosis to turn into active tuberculosis years later. Only 5-10% of people with latent tuberculosis who don’t receive treatment will eventually develop active tuberculosis.
- Active tuberculosis: This type of tuberculosis can occur weeks or years after becoming infected. When tuberculosis attacks the lungs, you will have symptoms, and can spread the disease to others.
Tuberculosis is spread when a person breathes in tuberculosis bacteria from a person with active tuberculosis. The tiny droplets that contain the bacteria are released into the air when the infected person coughs, sneezes, laughs or sings.
More than 22,000 tuberculosis cases are reported each year in the U.S. An estimated 10 to 15 million people in the country have latent tuberculosis. If not treated properly, active tuberculosis can be fatal.
Tuberculosis Symptoms and Risk Factors
Symptoms of tuberculosis—these can include:
- Night sweats
- Unexplained weight loss
- Rapid heart beat
- Coughing up bloody mucus (called sputum) from the lungs
- Chest pain
If other parts of the body are affected, the symptoms differ and may include back pain if the disease attacks the spine, or blood in the urine if you have tuberculosis in your kidneys.
Risk factors for tuberculosis—while anyone can get tuberculosis, a number of factors can put you at higher risk:
- Sharing the same breathing space with someone who has active tuberculosis
- Living in or traveling to countries where tuberculosis is common
- Living or working in a group home or prison
- Having HIV/AIDS (tuberculosis is one of the leading causes of death for those infected with HIV worldwide)
- Having little to no access to medical care, being homeless, or abusing drugs or alcohol
- Being underweight or of advanced age
- Having a medical condition such as diabetes or certain types of cancers
The disease is not spread by shaking hands, kissing, using public toilets or sharing food and drink.
If you think you may have been infected, it’s important to be tested. Our pulmonologists, who specialize in lung diseases, can properly diagnose and treat tuberculosis, or determine if your symptoms are related to another cause.
We will conduct a comprehensive exam, including listening to your lungs and checking your lymph nodes for swelling, collecting a thorough history and performing a skin test.
A skin test is simple and involves using a small needle to put tuberculin under the skin, usually on the inside of the arm. After the test, you must return in 48 to 72 hours to be checked for a reaction. If there is a reaction, the size of the reaction is measured. A negative test usually means you are not infected; however, the test may be falsely negative if you’ve been exposed very recently. It takes 2-10 weeks after exposure to tuberculosis for the skin test to react positive. A positive reaction usually means you have been infected with the tuberculosis bacteria. It does not necessarily mean you have active tuberculosis. A chest x-ray or sputum sample may be needed to determine if you have latent or active pulmonary tuberculosis.
The sputum (mucus from the lungs) sample is tested to see if there are tuberculosis bacteria present. To detect tuberculosis in another part of your body—called extrapulmonary tuberculosis—a biopsy, CT scan and/or MRI may be required.
Tuberculosis is easily prevented and cured with medication, but treatment time is quite long, generally taking about six to nine months, sometimes longer. It’s crucial to take your medication as prescribed—for the entire duration of treatment—and not miss doses. Otherwise, you have to take the medication longer or start your treatment over again.
Latent tuberculosis usually only requires one antibiotic taken for nine months. For active tuberculosis, a combination of four antibiotics are typically prescribed as treatment, usually taken for six months.
Drug-resistant tuberculosis is a form of tuberculosis where the bacteria are resistant to some or all of the antibiotics used to treat the disease. This can also occur when antibiotics are misused, which is another reason it’s important to take all of your medication according to your doctor’s instructions. People with drug-resistant tuberculosis have less effective treatment options.
New Discoveries for Treating Tuberculosis
Researchers at the University of Michigan’s Life Sciences Institute and College of Pharmacy have uncovered how tuberculosis builds drug resistance. The discovery could provide scientists with a new direction to try to combat drug-resistant tuberculosis and to head off the continued spread of this deadly infectious disease.
Make an Appointment
To schedule an appointment for tuberculosis evaluation or treatment, call us at 888-287-1084.