Some risk factor that can modify the occurence of miliary tuberculosis are socioeconomic development, BCG vaccination,

history of malignancy, history of prevous tuberculosis, corticosteroid use, solig organ tranpslantation, and HIV infection.
1. Socio-economic development

Improvement of living conditions, nutritional status of populations, and another socio-economic aspects can decrease the incidence and specific mortality of TB if compared to previous decades when vaccination and antibiotics have not been found (dapet dari Wira, 2010). Tuberculosis is a disease of the poor : over 95% of cases in developing countries are from poor communities. In industrialised countries, tuberculosis generally affects the most disadvantaged social groups(dapet dari Wira, 2010). 2. BCG vaccination Theres no clear explanation for the role of BCG vaccination. BCG

vaccine is believed to protects against miliary and menigeal disease in young children, but it may be less effective in protecting against pulmonary disease in either children or adults. The mechanism of protection against miliary meningeal tuberculosis in young children is unknown, although BCG vaccine likely prevents dissemination of M tuberculosis after infection. A recent population-based study suggested that BCG vaccine may also prevent M tuberculosis infection in children. It is unknown why BCG may confer less protection against pulmonary disease than disseminated tuberculosis (Sterling,et.al 2007). BCG vaccination also has epidemiological impact. Based on the analysis of public health statistics of some European countries has shown that BCG vaccination reduces the number of tuberculosis cases in vaccinated subjects as compared to those unvaccinated. This reduction measures the direct effect of BCG, i.e. directly conferred protection on those who receive the vaccine. However, it does not have any significant impact on

bacillus transmission in a population. The BCG vaccination is therefore is justified by its direct effect (protection against severe forms in children, in particular), but it is not a good tool to reduce transmission (dapet dari Wira, 2010). 3. History of malignancy The association between tuberculosis and cancer has been recognized as significant for many years. The incidence of tuberculosis may be particularly high in patients with hematologic malignancies because of the T-cell immunodeficiency caused by the underlying disease and/or its treatment. In addition, the diagnosis of tuberculosis may be problematic because the symptoms of tuberculosis can overlap those of the hematologic malignancy (particularly lymphoma), and the immunodeficiency may attenuate the clinical symptoms of tuberculosis (Silva,et.al. 2005). The prevalence of tuberculosis in patients with hematologic malignancies has been reported to be between 0.72% and 2.6%. The mortality rate of tuberculosis in these patients may be high, possibly due to diagnosis delay. In a retrospective study of the clinical records of 917 patients observed in Hematology Service of the Hospital Universitrio Clementino Fraga Filho, a teaching hospital in Rio de Janeiro, Brazil from January 1990 to December 2000, found that the prevalence of tuberculosis in patients with hematologic malignancies was 2.6%, and was highest in patients with CLL (Chronic Lymphocytic Lymphoma) (Silva,et.al. 2005). 4. History of previous tuberculosis Most cases of miliary tuberculosis occur in high prevalence areas after primary infection while it occurs mostly in elderly people in low prevalence areas due to activation of the disease. As one third of the worlds population is currently infected with M tuberculosis, the control or elimination of tuberculosis globally is a formidable task, even if all patients are treated successfully with currently available anti-TB drugs. Dormant bacilli persisting in such cured patients and in latent

tuberculosis are potential sources of active disease, as there are no drugs that act on dormant bacilli (Vijayan,et.al. 2007). 5. Corticosteroid use Occurrence of disseminated tuberculosis or milliary tuberculosis is influenced by wide use of immunosuppressive agents especially for certain immunological disorders and after organ transplantation.
6. Bone marrow transplantation

Bone marrow transplantation (BMT) is a unique model of extreme iatrogenic immunosuppression during which the recipient is susceptible to life-threatening opportunistic infections caused by a variety of pathogens. In a study of 183 patients (17 years of age or older) who underwent BMT at Queen Mary Hospital, Hong Kong, during 4-years period (1991 to 1994), found that the incidences of M tuberculosis 0.1 to 2.2%. Chronic graft-versus-host disease (GVHD) is highly associated with the development of tuberculosis. there are several possible mechanisms in chronic GVHD that may predispose the subject to tuberculosis. The period of impairment of T-cell function may be indefinite in chronic GVHD. Because T cells play an important role in protective immunity against tuberculosis, chronic GVHD as a risk factor for development of tuberculosis post-BMT can be readily perceived (Mary,et.al. 1998). 7. HIV infection Coincident with the spread of the human immunodeficiency virus (HIV) epidemic, the incidence of tuberculosis is increasing in both developing and in industrialized countries. HIV infection is the single most important risk factor for the reactivation of latent tuberculosis or the progression of active disease. It is now well established that tuberculosis is an important manifestation of the immunodeficiency induced by HIV (Marschall, 2008).