Tuberculosis

Fact sheet N104 March 2012

Key facts

Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent. In 2010, 8.8 million people fell ill with TB and 1.4 million died from TB. Over 95% of TB deaths occur in low- and middle-income countries, and it is among the top three causes of death for women aged 15 to 44. In 2009, there were about 10 million orphan children as a result of TB deaths among parents. TB is a leading killer of people living with HIV causing one quarter of all deaths. Multi-drug resistant TB (MDR-TB) is present in virtually all countries surveyed. The estimated number of people falling ill with tuberculosis each year is declining, although very slowly, which means that the world is on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015. The TB death rate dropped 40% between 1990 and 2010.

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-third of the world's population has latent TB, which means people have been infected by TB bacteria but are not (yet) ill with disease and cannot transmit the disease. People infected with TB bacteria have a lifetime risk of falling ill with TB of 10%. However persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a much higher risk of falling ill. When a person develops active TB (disease), the symptoms (cough, fever, night sweats, weight loss etc.) may be mild for many months. This can lead to delays in seeking care, and results in transmission of the bacteria to others. People ill with TB can infect up to 10-15 other people through close contact over the course of a year. Without proper treatment up to two thirds of people ill with TB will die.

Who is most at risk? Tuberculosis mostly affects young 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 co-infected with HIV and TB are 21 to 34 times more likely to become sick with TB (see TB and HIV section). Risk of active TB is also greater in persons suffering from other conditions that impair the immune system. About half a million children (0-14 years) fell ill with TB, and 64 000 (a range of 58 000 to 71 000) children died from the disease in 2010. Tobacco use greatly increases the risk of TB disease and death. More than 20% of TB cases worldwide are attributable to smoking. Global impact of TB TB occurs in every part of the world. In 2010, the largest number of new TB cases occurred in Asia, accounting for 60% of new cases globally. However, Sub-Saharan Africa carried the greatest proportion of new cases per population with over 270 cases per 100 000 population in 2010. In 2010, about 80% of reported TB cases occurred in 22 countries. Some countries are experiencing a major decline in cases, while cases are dropping very slowly in others. Brazil and China for example, are among the 22 countries that showed a sustained decline in TB cases over the past 20 years. China, in particular, has made dramatic progress in TB control. Between 1990 and 2010, the TB death rate in the country fell by almost 80% and the total number of people ill with TB dropped by half. 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. With three such tests, diagnosis can be made within a day, but this test does not detect numerous cases of less infectious forms of TB. Diagnosing MDR-TB (see Multidrug-resistant TB section below) and HIV-associated TB can be more complex. A new two-hour test that has proven highly effective in diagnosing TB and the presence of drug resistance is now being rolled-out in many countries. Tuberculosis is particularly difficult to diagnose in children. Treatment

TB is a treatable and curable disease. Active, drug-sensitive TB disease is treated with a standard six-month course of four antimicrobial drugs that are provided with information, supervision and support to the patient by a health worker or trained volunteer. Without such supervision and support, treatment adherence can be difficult and the disease can spread. The vast majority of TB cases can be cured when medicines are provided and taken properly. Since 1995, over 46 million people have been successfully treated and an estimated 7 million lives saved through use of DOTS and the Stop TB Strategy recommended by WHO and described below. TB and HIV At least one-third of the 34 million people living with HIV worldwide are infected with TB bacteria, although not yet ill with active TB. People living with HIV and infected with TB are 21 to 34 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. Someone who is infected with HIV and TB is much more likely to become sick with active TB. In 2010 about 350 000 people died of HIV-associated TB. Almost 25% of deaths among people with HIV are due to TB. In 2010 there were an estimated 1.1 million new cases of HIV-positive new TB cases, 82% of whom were living in Africa. As noted below, WHO recommends a 12-component approach to integrated TB-HIV services, including actions for prevention and treatment of infection and disease, to reduce deaths. Multidrug-resistant TB Standard anti-TB drugs have been used for decades, and resistance to the medicines is growing. Disease strains that are resistant to a single anti-TB drug have been documented in every country surveyed. Multidrug-resistant tuberculosis (MDR-TB) is a form of TB caused by bacteria that do not respond to, at least, isoniazid and rifampicin, the two most powerful, first-line (or standard) antiTB drugs. The primary cause of MDR-TB is inappropriate treatment. Inappropriate or incorrect use of antiTB drugs, or use of poor quality medicines, can all cause drug resistance. Disease caused by resistant bacteria fails to respond to conventional, first-line treatment. MDRTB is treatable and curable by using second-line drugs. However second-line treatment options are limited and recommended medicines are not always available. The extensive chemotherapy required (up to two years of treatment) is more costly and can produce severe adverse drug reactions in patients.

In some cases more severe drug resistance can develop. Extensively drug-resistant TB, XDR-TB, is a form of multi-drug resistant tuberculosis that responds to even fewer available medicines, including the most effective second-line anti-TB drugs. There were about 650 000 cases of MDR-TB present in the world in 2010. It is estimated that about 9% of these cases had XDR-TB. Annually, about 440 000 fell ill with MDR-TB and 150 000 died due to this form of tuberculosis. WHO response WHO's pursues six core functions in addressing TB.

Provide global leadership on matters critical to TB. Develop evidence-based policies, strategies and standards for TB prevention, care and control, and monitor their implementation. Provide technical support to Member States, catalyze change, and build sustainable capacity. Monitor the global TB situation, and measure progress in TB care, control, and financing. Shape the TB research agenda and stimulate the production, translation and dissemination of valuable knowledge. Facilitate and engage in partnerships for TB action.

The WHOs Stop TB Strategy, which is recommended for implementation by all countries and partners, aims to dramatically reduce TB by public and private actions at national and local levels such as:

pursue high-quality DOTS expansion and enhancement. DOTS is a five-point package to: o secure political commitment, with adequate and sustained financing o ensure early case detection, and diagnosis through quality-assured bacteriology o provide standardized treatment with supervision and patient support o ensure effective drug supply and management and o monitor and evaluate performance and impact; address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations; contribute to health system strengthening based on primary health care; engage all care providers; empower people with TB, and communities through partnership; enable and promote research.

For more information contact:

WHO Media centre Telephone: +41 22 791 2222 E-mail: mediainquiries@who.int Tuberkulosis (TB) Unduh versi PDF

Apa TB Itu? Tuberkulosis (TB) adalah infeksi yang disebabkan oleh bakteri. TB biasanya memengaruhi paru, tetapi juga dapat memengaruhi organ lain, terutama pada Odha dengan jumlah CD4 di bawah 200. TB adalah penyakit yang sangat berat di seluruh dunia. Hampir sepertiga penduduk dunia, dan sepertiga Odha terinfeksi TB. Sistem kekebalan tubuh yang sehat biasanya dapat mencegah penyakit aktif. TB adalah penyebab kematian yang besar untuk Odha di seluruh dunia, menurut WHO. Nama tuberkulosis berasal dari tuberkel. Tuberkel adalah tonjolan kecil dan keras yang terbentuk waktu sistem kekebalan membangun tembok mengelilingi bakteri TB dalam paru. Infeksi ini disebut TB paru. Infeksi dapat menyebar dari paru ke ginjal, tulang belakang dan otak. Infeksi ini disebut TB luar paru. TB luar paru ditemukan pada orang yang sudah terinfeksi TB tetapi belum diobati. Odha yang tinggal di daerah rawan TB dapat mengembangkan TB luar paru. TB aktif di paru dapat menyebabkan batuk selama tiga minggu atau lebih, kehilangan berat badan, kelelahan terus-menerus, keringat basah kuyup pada malam, dan demam, terutama pada sore hari. Gejala ini mirip dengan gejala yang disebabkan PCP (lihat Lembaran Informasi (LI) 512). Gejala ini dapat berbeda bila TB juga terjadi di bagian tubuh lain. Bila Odha dengan TB mengalami gejala tanpa alasan jelas, sebaiknya disampingkan penyakit TB aktif. TB menular melalui udara, waktu seseorang dengan TB aktif pada paru batuk, bersin atau bicara. Sinar ultraviolet dalam cahaya matahari dapat mematikan TB. Ventilasi yang baik mengurangi risiko infeksi TB. Namun orang yang tinggal dekat dengan orang dengan TB aktif mudah terinfeksi. Hal ini terutama mungkin bila kita pada tahap infeksi HIV lanjut. Kita dapat terinfeksi TB pada jumlah CD4 berapa pun. TB dan HIV: Pasangan yang Buruk Banyak jenis virus dan bakteri hidup di tubuh kita. Sistem kekebalan tubuh yang sehat dapat mengendalikan kuman ini agar mereka tidak menyebabkan penyakit. Jika HIV melemahkan sistem kekebalan, kuman ini dapat mengakibatkan infeksi oportunistik (IO). Angka TB pada Odha sering kali 40 kali lebih tinggi dibanding angka untuk orang yang tidak terinfeksi HIV. Angka TB di seluruh dunia meningkat karena HIV. TB dapat merangsang HIV agar lebih cepat menggandakan diri, mengurangi jumlah CD4 dan memburukkan infeksi HIV. Karena itu, penting agar orang dengan HIV mencegah dan mengobati TB. Bagaimana TB Didiagnosis?

Ada tes kulit yang sederhana untuk TB. Sebuah protein yang ditemukan pada bakteri TB disuntik pada kulit lengan. Jika kulit kita bereaksi dengan bengkak, itu berarti kita kemungkinan terinfeksi bakteri TB. Hasil tes kulit yang positif bukan berarti kita TB aktif. Jika HIV atau penyakit lain sudah merusak sistem kekebalan kita, kita mungkin tidak menunjukkan reaksi pada tes kulit, walaupun kita terinfeksi TB. Kondisi ini disebut anergi. Oleh karena masalah ini, dan karena kebanyakan orang di Indonesia sudah terinfeksi TB, jadi tes kulit sekarang jarang dipakai di sini. Jika kita anergi, pembiakan bakteri dari dahak (lihat alinea berikut) adalah cara terbaik untuk diagnosis TB aktif. Bila kita mempunyai gejala yang mungkin disebabkan oleh TB, dokter akan minta kita menyediakan tiga contoh dahak untuk diperiksa, termasuk satu yang diminta dikeluarkan dari paru pada pagi hari. Dokter juga mungkin melakukan rontgen dada. Dokter juga akan coba membiakkan bakteri TB dari contoh dahak atau cairan yang diambil dari bagian tubuh lain yang dapat mengena TB. Tes ini dapat memerlukan jangka waktu dua sampai empat minggu, tergantung pada cara yang dilakukan. Sulit mendiagnosis TB aktif, terutama pada Odha, karena tampaknya mirip dengan pneumonia, masalah paru lain, atau infeksi lain, dan juga dapat terjadi di luar paru. Namun tes baru yang lebih cepat sedang dikembangkan. Bagaimana TB Diobati? Jika kita terinfeksi TB, tetapi tidak mengalami penyakit aktif, kemungkinan kita diobati dengan isoniazid (INH) untuk sedikitnya enam bulan, atau dengan INH plus satu atau dua obat lain untuk tiga bulan. INH dapat menyebabkan masalah hati, terutama pada perempuan. Sebuah penelitian pada 2001 menunjukkan bahwa penggunaan INH bersamaan dengan rifapentin seminggu sekali selama tiga bulan sama efektif. CDC-AS sekarang mengusulkan terapi jangka lebih pendek ini. Sayangnya rifapentin berinteraksi dengan beberapa protease inhibitor. Penyesuaian takaran mungkin dibutuhkan, tetapi belum diteliti. Jika kita mengalami TB aktif, kita diobati dengan antibiotik. Karena bakteri TB dapat menjadi kebal (resistan) terhadap obat tunggal, kita akan diberi kombinasi antibiotik. Obat TB harus dipakai untuk sedikitnya enam bulan, tetapi kebanyakan kasus TB dapat disembuhkan dengan antibiotik yang ada. Jika kita tidak memakai semua obat, TB dalam tubuh kita mungkin jadi resistan dan obat tersebut akan menjadi tidak efektif lagi. Ada jenis TB yang resistan terhadap beberapa antibiotik. Ini disebut TB yang resistan terhadap beberapa obat atau MDR-TB, atau yang resistan terhadap semua obat lini pertama dan kedua (XDR-TB). Jenis TB ini jauh lebih sulit diobati. Lebih banyak jenis obat harus dipakai untuk jangka waktu yang lebih lama. Angka kesembuhan lebih rendah dibandingkan TB yang lazim. Masalah Obat Beberapa antibiotik yang dipakai untuk mengobati TB dapat merusak hati atau ginjal. Begitu juga beberapa obat antiretroviral (ARV). Bisa jadi sulit untuk memakai obat TB dan ARV sekaligus. INH dapat menyebabkan neuropati perifer (LI 555), seperti juga beberapa ARV, jadi

dapat terjadi masalah bila obat ini dipakai bersama. Pengobatan TB juga dapat menyebabkan sindrom pemulihan kekebalan (lihat LI 483). Juga, banyak ARV berinteraksi dengan obat yang dipakai untuk memerangi TB lihat LI 407 untuk informasi mengenai interaksi obat. Rifampisin umumnya dipakai untuk mengobati TB. Obat ini dapat mengurangi tingkat ARV dalam darah kita di bawah tingkat yang diperlukan untuk mengendalikan HIV. ARV dapat meningkatkan tingkat obat TB ini sehingga mengakibatkan efek samping yang berat. Rifampisin tidak boleh dipakai jika kita memakai kebanyakan protease inhibitor (PI) atau NNRTI. Ada pedoman khusus untuk dokter jika kita memakai obat untuk memerangi TB dan HIV sekaligus. Untuk alasan ini, lebih baik TB diobati sebelum terapi ARV (ART) dimulai. Namun bila jumlah CD4 di bawah 350, ART sebaiknya dimulai segera setelah efek samping obat TB sudah hilang. Garis Dasar TB adalah penyakit berat dan membunuh lebih banyak Odha dibanding dengan semua penyakit lain. TB dan HIV saling memburukkan. Ada pengobatan efektif untuk infeksi TB, dan untuk penyakit TB aktif. Jika kita pernah dekat dengan orang TB aktif, atau mempunyai gejala TB, sebaiknya kita segera dites dan diobati. Pengobatan untuk TB perlu jangka waktu yang lama, dan dapat sulit dipakai sekaligus dengan ARV, tetapi obat tersebut dapat menyembuhkan TB. Beberapa obat TB dapat berinteraksi dengan ARV, jadi pengobatan harus direncanakan dengan hati-hati jika kita memiliki TB dan HIV sekaligus. Penting dipahami bahwa semua obat TB harus dipakai untuk jangka waktu sesuai perintah dokter.

Pneumonia
Fact sheet N331 October 2011

Key facts

Pneumonia is the leading cause of death in children worldwide. Pneumonia kills an estimated 1.4 million children under the age of five years every year more than AIDS, malaria and tuberculosis combined. Pneumonia can be caused by viruses, bacteria or fungi. Pneumonia can be prevented by immunization, adequate nutrition and by addressing environmental factors. Pneumonia can be treated with antibiotics, but around 30% of children with pneumonia receive the antibiotics they need.

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.4 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. Children can be protected from pneumonia, it can be prevented with simple interventions, and treated with low-cost, low-tech medication and care. Causes Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. The most common are:

Streptococcus pneumoniae the most common cause of bacterial pneumonia in children; Haemophilus influenzae type b (Hib) the second most common cause of bacterial pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia; in infants infected with HIV, Pneumocystis jiroveci is one of the commonest causes of pneumonia, responsible for at least one quarter of all pneumonia deaths in HIV-infected infants.

Transmission Pneumonia can be spread in a number of ways. The viruses and bacteria that are commonly found in a child's nose or throat, can infect the lungs if they are inhaled. They may also spread via air-borne droplets from a cough or sneeze. In addition, pneumonia may spread through blood, especially during and shortly after birth. More research needs to be done on the different pathogens causing pneumonia and the ways they are transmitted, as this has critical importance for treatment and prevention. Symptoms The symptoms of viral and bacterial pneumonia are similar. However, the symptoms of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia. The symptoms of pneumonia include:

rapid or difficult breathing cough fever chills loss of appetite wheezing (more common in viral infections).

When pneumonia becomes severe, children may experience lower chest wall indrawing, where their chests move in or retract during inhalation (in a healthy person, the chest expands during inhalation). Infants may be unable to feed or drink and may also experience unconsciousness, hypothermia and convulsions. Risk factors While most healthy children can fight the infection with their natural defences, children whose immune systems are compromised are at higher risk of developing pneumonia. A child's immune system may be weakened by malnutrition or undernourishment, especially in infants who are not exclusively breastfed. Pre-existing illnesses, such as symptomatic HIV infections and measles, also increase a child's risk of contracting pneumonia. The following environmental factors also increase a child's susceptibility to pneumonia:

indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung) living in crowded homes parental smoking.

Treatment

Pneumonia can be treated with antibiotics. These are usually prescribed at a health centre or hospital, but the vast majority of cases of childhood pneumonia can be administered effectively within the home. Hospitalization is recommended in infants aged two months and younger, and also in very severe cases. Prevention Preventing pneumonia in children is an essential component of a strategy to reduce child mortality. Immunization against Hib, pneumococcus, measles and whooping cough (pertussis) is the most effective way to prevent pneumonia. Adequate nutrition is key to improving children's natural defences, starting with exclusive breastfeeding for the first six months of life. In addition to being effective in preventing pneumonia, it also helps to reduce the length of the illness if a child does become ill. Addressing environmental factors such as indoor air pollution (by providing affordable clean indoor stoves, for example) and encouraging good hygiene in crowded homes also reduces the number of children who fall ill with pneumonia. In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk of contracting pneumonia. Economic costs Research has shown that prevention and proper treatment of pneumonia could avert one million deaths in children every year. With proper treatment alone, 600 000 deaths could be avoided. The cost of antibiotic treatment for all children with pneumonia in 42 of the world's poorest countries is estimated at around US$ 600 million per year. Treating pneumonia in South Asia and sub-Saharan Africa which account for 85% of deaths would cost a third of this total, at around US$ 200 million. The price includes the antibiotics themselves, as well as the cost of training health workers, which strengthens the health systems as a whole. WHO response In 2009, WHO and UNICEF launched the Global action plan for the prevention and control of pneumonia (GAPP). The aim is to accelerate pneumonia control with a combination of interventions to protect, prevent, and treat pneumonia in children with actions to:

protect children from pneumonia include promoting exclusive breastfeeding and hand washing, and reducing indoor air pollution; prevent pneumonia with vaccinations; treat pneumonia are focused on making sure that every sick child has access to the right kind of care -- either from a community-based health worker, or in a health facility if the disease is severe -- and can get the antibiotics and oxygen they need to get well.

For more information contact:

WHO Media centre Telephone: +41 22 791 2222 E-mail: mediainquiries@who.int