TUBERCULOSIS

&

SMOKING
By

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WAMUBIRIGWE SAMUEL BCH 1

Introduction

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This is a systemic mycobacterial disease caused by Mycobacterium tuberculosis, but also occasionally M. Bovis. Its also known as Kochs disease. Tubercular decay has been seen in Egyptian mummies dating as far as 3000-2400BCE. Phthisis (Greek word for consumption), Hippocrates identified it as most widely spread disease at around 460 BCE. In most cases it affects the lungs i.e. Pulmonary tuberculosis (PTb). It can also spread outside the lungs resulting in extrapulmonary TB

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The absolute number of TB cases has been falling since 2006, rather than rising slowly as indicated in previous global reports* About 13% of TB cases occur among people living with HIV* Its estimated to have an infection rate of 22%. A person with active TB, but left untreated goes on to infect 10-15 other people annually. Until 50 years ago, there were no medicines to cure TB. Strains of TB resistant to all major anti-TB drugs have also emerged
* Global Tuberculosis control report 2011

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Epidemiology
Tuberculosis is spread from infectious patients to susceptible individuals by droplet infection. A person only needs to inhale a small number of the bacilli to be infected. Approx. 1/3 of the worlds population is infected The mycobacterium can survive in dry conditions outside the body and can not be affected by weak disinfectants Fortunately not all people that are exposed to the bacteria progress to develop clinical disease, since they develop active natural immunity to the disease.

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Ugandas TB profile as of 2010

POPULATION 2010 (MILLIONS) 33 ESTIMATES OF BURDEN 2010 Mortality (excluding HIV) Prevalence (incl HIV) Incidence (incl HIV) Number
(thousands)

Rate (per 100 000 pop) 15 (9.922) 193 (95306) 209 (168254)

5.1 (3.37.3) 64 (32100) 70 (5685)

Incidence (HIV-positive)
Case detection, all forms (%)

38 (3046)
61 (5176)

112 (91136)

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However tuberculosis may flare up, and the person develops clinical disease when this immunity is compromised or generally depressed .i.e. During famine Old age HIV infection Chemotherapy Infants Diabetics Use of immunity suppressing drugs People with HIV and TB infection are much more likely to develop TB. Its assumed that 5-10% of people that are infected with TB but without AIDS develop the disease compared to the 30% of those with AIDS

Presentation

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The way TB presents varies greatly according to the system or the organ affected i.e.
Bones, joints (skeletal TB) Lungs (pulmonary TB) Kidneys Ovaries (female reproductive organs) Abdominal cavity (peritonis/gastrointestinal TB) Meninges (Potts disease) Heart and blood vessels

The signs and symptoms of tuberculosis can be easily understood from the clinical history of the disease

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Early signs and symptoms

Productive cough Positive tuberculin test Night sweats Weight loss Fatigue

Late signs and symptoms

Loss of appetite Enlargement of the lymph nodes(in the neck and other areas) Difficulty breathing Blood stained sputum (haemoptysis) Chest pain Symptoms of other organs involved

Diagnosis

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Diagnosis of tuberculosis may be made by;

Radiology (X-rays) Microscopic examination Tuberculin test (Manteux test) Blood testing Microbiological culture of bodily fluids Medical history and physical examination

However new TB tests have been developed that are fast and accurate i.e.
Polymerase chain reaction Amplified mycobacterial TB direct test (MTD Gen-Probe)

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Risk factors for tuberculosis

HIV/AIDS

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Over crowding
Poor ventilation Malnutrition Alcoholism Diabetes mellitus Low income groups Employees in high risk congregate groups Immunity suppressing drugs Health workers with infected clientelle

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Prevention

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The Bacillus Calmette Guerin (BCG) vaccine was first used in the 1920s, and tests have found it to be very variable in its ability to protect people from infection in modern settings A drug called isoniazid (INH) can be used as a preventive therapy for those who are at high risk of becoming infected with tuberculosis The WHO recommends that HIV positive people with latent tuberculosis be offered isoniazid (INK) preventive therapy as needed

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A TB patient should also be advised not to spit anywhere carelessly Over crowding and poor ventilation in homes should be avoided Early diagnosis and treatment

Isolation
Nutrition
A patient with TB covers her mouth in an attempt to stop the spread of the disease

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Through the Health Sector Strategic Plan III (HSSPIII 2010/112014/15), the govt of Uganda came up with the following strategies and interventions to reduce the morbidity, mortality and transmission of tuberculosis;
Expand and consolidate high-quality DOTS services in all districts by 2010

Expand and strengthen TB/HIV collaborative activities, address MDR-TB and other challenges in special settings and populations
Contribute to the Strengthening of health systems

Engage all care providers in TB care

Empower people with TB and the communities to participate in TB care

Build capacity for TB control

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Tuberculosis in children
Over 250000 children 10yrs and below develop TB and 100000 will continue to die from TB each year
Tuberculosis and malnutrition often go together, and a child with TB may present as failure to gain weight, loss of energy, and coughing for more than 3 weeks In children, it is difficult to diagnose TB due to the problems associated with collecting their sputum specimens Hence its usually made primarily basing on disease history, clinical signs and symptoms, and a tuberculin skin test, though not considered a confirmatory test

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WHO guidelines for diagnosis of TB in children

History of contact with a suspect or confirmed case of pulmonary TB
One with loss of weight, cough, fever, and does not respond to antibiotic therapy for acute respiratory disease

With abdominal swelling, hard painless mass and free fluid

With signs suggesting meningitis or disease in the central nervous system

Painless firm or soft swelling in a group of superficial lymph nodes

A child that does not return to normal health after measles or whooping cough

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Treatment
Antibiotics are used to kill the mycobacteria. It serves two purposes; to cure the patient and to prevent spread to others The Directly Observed Treatment Short course(DOTS) strategy, was recommended by WHO in order to decrease the TB epidemic As of 2010, a combination of four antibiotics Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol are being used Thiacetazole was scrapped from the list due to its dangerous side effects

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Other drugs that may be used to treat TB include:

Amikacin Ethionamide Moxifloxacin Para-aminosalicylic acid Streptomycin

When people do not take their TB medications as recommended, the infection becomes much more difficult to treat Medicines used to treat TB may cause side effects like changes in vision, orange or brown-colored tears and urine, body rash etc including liver problems

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Public health importance of tuberculosis

Its fatal
Its curable

Its a highly infectious disease

There is free treatment for TB Loss if working days Stigma due to association with AIDS

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As part of the DOTS strategy, a patient with tuberculosis takes daily doses of pills during supervised treatment

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SMOKING

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A local artiste wastes his lungs (Courtesy of the Red Pepper publications)

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Introduction

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Smoking is often referred to merely as a bad habit that simply requires adequate willpower to conquer effectively A more practical model describes smoking as a chronic relapsing condition that often requires ongoing medical and behavioral treatment In 2009, cross-sectional study among 2,789 students in 19 high schools in Kampala district revealed that 17.5% reported to have smoked tobacco, 37.9% were trying or started smoking before the age of 10, and 5.3% currently smoke (Kidimu Gilbert The New Vision May 29 2011) Tobacco dependence (smoking)is listed as a disease in the International Classification of Diseases (ICD 9)

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Why do people smoke?

To relieve stress To build confidence To feel warm To pass time To express happiness To find a sense of belonging To build self esteem

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Risks associated with smoking

Smokers not only increase their risk of lung diseases, including lung cancer, but they also increase their risk of other illnesses like heart disease, emphysema, stroke, and oral cancer Body odour/smell

Reduced sense of smell and taste

Irritation of the eyes, nose, and throat Chest discomfort Coughing Chronic bronchitis, a long-term inflammation of the bronchi (large airways), is characterized by coughing productively over a long period of time, etc...

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Secondhand smoke
Secondhand smoke is that which is exhaled by smokers, and also smoke emitted from the burning end of a lit cigarette, cigar, or pipe and is inhaled by another person It can also be referred to as involuntary or passive smoking to the non smoker

However, there is also third hand smoke which is the residue of chemicals exhaled onto surfaces and the smokers clothes (Simon Chapman, Professor of
Public Health, University of Sydney)

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Common symptoms associated with exposure to second hand smoke irritation of the eyes, nose, and throat coughing excessive phlegm (mucus in the airways) chest discomfort or pain Loss of appetite Children and infants exposed to tobacco smoke are more likely to experience ear infections, asthma, and are at a higher risk for Sudden Infant Death Syndrome (SIDS)

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Through health promotion messages against smoking Community out reaches to the young people Strict government policies against smoking and tobacco use Providing smoking sections in public places Encouraging good health practices to relieve stress Counseling, and support groups Nicotine replacement products

Prevention

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Benefits of quitting smoking

Decreased risk of lung disease Decreased risk of heart disease Decreased risk of developing cancers Reduced cigarette stains on fingers and teeth Reduced occurrence of a hacking cough Elimination of cigarettes smell on clothing and hair Improved sense of smell and taste

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Smoking related diseases

Most people who decide to quit smoking do so because they realise how much damage it brings to their health. This is a reasonable concern, because half of smokers die from smoking-related diseases and ailments i.e. Heart attacks

Emphysema
Cancer, particularly lung cancer, cancers of the larynx and mouth, and pancreatic cancer

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Smoking related illnesses cont

Caries (tooth decay) Atherosclerosis Coronary heart disease Lupus Strokes Raynaud's disease Cataracts Tuberculosis Leukoplakia Less oxygen to the brain

Acute Myeloid Leukemia

Chronic bronchitis

Colds
Lowered immune response

Osteoporosis

Sleep difficulties

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Smoking related illnesses

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Symptoms of smoking-related lung diseases

Constant chest pain Wheezing

Recurring lung infections

Bloody or rust-coloured sputum

Hoarseness, swelling of the neck and face

Pain and weakness in the shoulder, arm, or hand Unexplained fever

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Treatment
Since smoking is habit and a chronic relapsing condition, its treatment is aimed at rehabilitating the patient and also towards the smoking related illnesses i.e.
Taking up a daily exercise or activity to relieve stress Nicotine replacement therapy (patches, gum, lozenges) Counseling

Supportive environments

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Public health importance of smoking

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It brings a bad smell on the smokers clothing and body Cigarettes cause staining of the fingers and teeth It can also cause behavioral disturbances and concentration problems of hyperactivity (ADHD) in children (Hillel R. Alpert, researchers from Harvard School of Public Health's Center for Global Tobacco Control) Its associated with increased severity of asthma, lower respiratory tract infections in infants It raises the risks of getting heart attacks, strokes, and cancers Smoking during pregnancy is associated with premature births, miscarriages, still births and excessive bleeding

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References
Communicable diseases by Erick Nordberg
http://www.avert.com/ http://www.health.kompas.com/ http://www.who.int/media centre Our Bodies, Ourselves for the New Century, by Boston Womens health book collection http://www.wikipedia.org/

http://www.bettermedicines.com/
The New Vision , May 29 2011 A.D.A.M medical encyclopedia Global TB control report 2011