ADAMA SCIENCE AND TECHNOLOGY

UNIVERSITY
School of Applied Natural Sciences
Title:- Prevalence of TB and its impacts
on human health
by:- Efa Taye
Advisor:- Dr. Mesele Admasu
Acknowledgements
First of all I would like to thank almighty God for being with me in all aspects of
my works. Next I would like to thanks my advisor Dr. Mesele Admasu for his
support and giving me constructive suggestions for undertaking this seminar
course work on time.

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Table of Contents
Acknowledgements............................................................................................................................... i
Acronyms............................................................................................................................................iii
1. Introduction......................................................................................................................................1
2. Literature review.............................................................................................................................. 2
2.1. Definition of tuberculosis..........................................................................................................2
2.2. Conditions associated with TB disease..................................................................................... 3
2.2.1. HIV infection......................................................................................................................3
2.2.2. Diabetes mellitus (DM)......................................................................................................3
2.2.3. Smoking..............................................................................................................................3
2.2.4. Alcohol consumption..........................................................................................................3
2.2.5. Silicosis.............................................................................................................................. 3
2.3. Prevalence of TB.......................................................................................................................3
2.4. Classification of tuberculosis.................................................................................................... 4
2.4.1. Active TB........................................................................................................................... 4
2.4.2. Latent TB............................................................................................................................4
2.5. TB Epidemiology...................................................................................................................... 5
2.5.1. Transmission and Pathogenesis of Tuberculosis................................................................ 5
2.5.2. The global burden of tuberculosis......................................................................................6
3. Status of Tuberculosis...................................................................................................................... 7
3.1. World distribution......................................................................................................................7
3.2. Tuberculosis status in Africa.................................................................................................... 7
3.3. Tuberculosis status in Ethiopia.................................................................................................7
3.4. Signs and symptoms..................................................................................................................7
3.5. Diagnosis...................................................................................................................................7
4. Risk factor of pulmonary Tuberculosis on human health.................................................................8
4.1 Tuberculosis in Pregnancy..........................................................................................................8
4.2. Treatment of Tuberculosis in Pregnant and Breastfeeding Women.......................................... 9
5. The Challenge of Controlling TB Disease in the most Vulnerable Populations.............................. 9
6. Conclusion......................................................................................................................................10
7. Reference........................................................................................................................................11

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Acronyms

ART…………………………………………..Antiretroviral therapy
CDC ………………………………………….Central Diseases control
DOT…………………………………………..Directly observed treatment
FMOH ............................. ………………Federal Ministry of Health
LTBI …………………………………………..Latent Tuberculosis infection
MBT ………………………………………….Mycobacterium tuberculosis
NDOH ……………………………………….National Department of Health
PTB…………………………………………….Pulmonary tuberculosis
SCRU…………………………………………..soul city research unit
TNF-a ……………………………………………
WHO ………………………………………. . ...Word Health organization

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1. Introduction
Tuberculosis (TB) is one of the most wide spread infection known in the world. Approximately 1.7
billion people or one-third of the world’s population is infected with mycobacterium tubercle
bacilli. Every year, about nine million cases of active TB disease and 2 million deaths occur
globally. Most of the cases of active TB (7 million) are in Asia and Africa (Lenjisa, et al., 20015).
TB was declared as a global emergency in 1993 by the World Health Organization (WHO) and it is
a leading cause of morbidity and mortality worldwide, accounting for about 9.6 million new cases
and 1.5 million deaths estimated to have occurred in 2014 (WHO, 2015).Despite the availability of
effective drugs, tuberculosis (TB) is still a global threat and one of the major public health problems
in the 21st century (Gebrezgabiher et al., 2016). It is not only a public health problem, but also a
socio-economic issue (Gebrezgabiher et al., 2016). Tuberculosis was attributed to be caused by risk
factors such as smoking, alcohol, hard work, exposure to cold and sharing with TB patients. In
contrast, many participants believed that TB was hereditary(Fikru Melaku et al., 2015). Despite the
measures taken, the burden of the disease is still high, especially in developing countries including
Ethiopia. It is estimated that by 2020, there will be over 1 billion new TB infections and 200 million
people will succumb to clinical disease and about 35 million will die if TB control is not further
strengthened (Fikru Melaku et al., 2015). TB Epidemiology is contagious and airborne (Glaziou et
al.,2015). The risk of acquiring Mycobacterium tuberculosis infection is essentially determined by
exogenous factors. TB is most commonly transmitted from a person with infectious pulmonary TB
to others by droplet nuclei, which are aerosolized by coughing, sneezing, or speaking (Glaziou et
al.,2015). Transmission and Pathogenesis of Tuberculosis is an airborne bacterial infection caused
by M.Tuberculosis which affects any part of the body and most commonly the lungs. M.
Tuberculosis is exposed to the air as droplet nuclei from coughing, sneezing , shouting or singing of
individuals with pulmonary or laryngeal TB (Agyeman and Asenso, 2017).

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2. Literature review
2.1. Definition of tuberculosis
The disease is caused by the bacillus Mycobacterium tuberculosis (MTB). Pulmonary tuberculosis
(PTB) is the most common form of TB in humans occurring in over 80% of cases. Person-to-person
spread occurs when an infected individual coughs, sneezes or speaks releasing minute droplet nuclei
each containing between 1-5 TB bacilli, which are able to remain airborne in any indoor space for
up to 4 hours (SCRU,2015). The tubercle bacillus is extremely sensitive to direct sunlight, but can
survive in the dark for several hours. The infectious dose of tuberculosis is between 1 and 10 bacilli.
Left untreated, a person with active TB can infect an average of 10-15 people each year. Once an
individual has been infected with the mycobacterium, progression to active tuberculosis depends on
the person’s immune status. Disease will develop in only 10% of person’s with normal immunity;
half the cases will occur within 2 years after infection. People at the extremes of life children under
the age of 5 years and the elderly – are most at risk. Conditions associated with immunosuppression
and other factors e.g. HIV infection, diabetes mellitus, smoking, alcohol consumption, silicosis and
certain workplace settings, also increase the risk of progression to active disease (SCRU,2015).
TB disease in humans is a communicable disease caused by Mycobacterium tuberculosis. Although
it can affect any part of the body, generally only active pulmonary and laryngeal TB pose a risk of
transmission from one person to another. Like influenza, M. tuberculosis is transmitted when a
susceptible individual inhales air containing droplet nuclei carrying the tubercle bacilli. Once
inhaled, the droplet nuclei eventually reach the lungs and frequently spread throughout the body. In
most cases, a competent immune system limits the multiplication of the tubercle bacilli, although
some bacilli remain dormant but viable, rendering a condition known as latent TB infection
(CDC, 2000).
Globally, TB remains the second leading cause of death from an infectious disease (Dye,2010 and
WHO,2014) . TB affects mostly adults in the economically productive age groups; around two-
thirds of cases are estimated to occur among people aged 15–59years and also more common
among men than women (WHO,2011).
Tuberculosis still affects mainly Asian and African countries, and Ethiopia is one of the top five
affected countries in Africa (Fikru Melaku et al., 2015). In developing countries, about 7% of all
deaths are attributed to TB which is the most common cause of death from a single source of
infection among adults. Despite the measures taken, the burden of the disease is still high,
especially in developing countries including Ethiopia (Fikru Melaku et al., 2015).

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2.2. Conditions associated with TB disease
A number of conditions predispose individuals who have been exposed to TB infection to
developing active TB disease (SCRU,2015).

2.2.1. HIV infection

50-60% of HIV positive people infected with TB will go on to develop active disease. The annual
risk of TB in an HIV positive person is 10% (from recent infection and reactivation of latent TB)
compared to a lifetime risk of 10% in a healthy individual. HIV positivity also increases the rate of
relapse and re-infection as well as the proportion of smear-negative TB. This can cause delayed
diagnosis and initiation of treatment resulting in poor treatment outcomes. Therefore rapid
diagnosis and early initiation of treatment is key to reduction of TB mortality in people living with
HIV(SCRU,2015)..

2.2.2. Diabetes mellitus (DM)

The prevalence of TB is higher amongst persons with diabetes the weak immune system associated
with diabetes trebles the risk of developing TB amongst diabetics compared to the general
population. TB and other infections also complicate the management of blood sugar levels in
diabetics. ‘The regular interaction with health care workers during TB treatment provides an
excellent opportunity for health education and counseling for better diabetes control to improve the
general health status of the patient’ (NDOH, 2014)

2.2.3. Smoking
Active and passive smoking is a risk factor for TB, independent of alcohol use and other
socioeconomic factors. Active smoking is associated with recurrent TB and death due to TB
disease. The risk of TB is also higher in children exposed to passive smoking(SCRU,2015).

2.2.4. Alcohol consumption

High alcohol consumption (on average >40g alcohol per day) is associated with a three-fold risk of
developing TB. Alcohol has a direct toxic effect on the immune system and the physical effects of
alcohol abuse may impair the immune system. Excessive alcohol use is also associated with poor
TB treatment adherence and a higher relapse rate(SCRU,2015).

2.2.5. Silicosis
Exposure to silica dust is a risk factor for the development of pulmonary tuberculosis. Silica impairs
the alveolar macrophages thus weakening the lung’s defence mechanisms against the tubercle
bacillus. These can remain encapsulated within the silicotic nodules and can cause reactivation of
tuberculosis in patients with silicosis(SCRU,2015).

2.3. Prevalence of TB
There were an estimated 12 million prevalent cases (11 million – 13 million) of TB in 2012,
equivalent to 169 cases per 100,000 population. By 2012, the prevalence rate had decreased 37%

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globally since 1990 . Current forecasts suggest that the Stop TB Partnership target of halving TB
prevalence by 2015 compared with a baseline of 1990 will not be met worldwide(Glaziou et
al.,2015).
Regionally, prevalence rates are declining in all six WHO regions. The region of the Americas
halved the 1990 level of TB prevalence by around 2004, well in advance of the target year of 2015,
and the best estimate suggests that the Western Pacific Region achieved the 50% reduction target in
2012. Reaching the 50% reduction target by 2015 appears feasible in the Southeast Asia region and
also in the European region with a relatively small acceleration in the current rate of progress. The
target appears out of reach in the African and eastern Mediterranean regions. In Africa, prevalence
rates increased substantially during the 1990s, and by 2007 were still far above the 1990 level. With
limited access to antiretroviral therapy (ART), HIV has probably had a smaller effect on TB
prevalence than on incidence because the duration of TB among HIV-infected patients is relatively
short: for people with advanced HIV infection, the progression to severe tuberculosis is rapid, with
a marked reduction in life expectancy (Glaziou et al.,2015).

2.4. Classification of tuberculosis

2.4.1. Active TB
Active TB is an acute inflammatory condition associated with tissue injury due to increased
generation of free radicals and ROS (Reactive oxygen species). ROS and RNI (Reactive Nitrogen
Intermediates) are produced as a consequence of phagocytic respiratory burst (Deepak et al., 2011).

2.4.2. Latent TB
Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to
Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (WHO,
2015; Mack., et al., 2009) . One third of the world's population is estimated to be infected with
Mycobacterium tuberculosis (Getahun et al., 2015). The vast majority of infected persons have no
signs or symptoms of TB disease and are not infectious, but they are at risk for developing active
TB disease and becoming infectious (Getahun et al., 2015). The lifetime risk of reactivation TB for
a person with documented LTBI is estimated to be 5–15%, with the majority developing TB disease
within the first 5 years after initial infection (Comstock, Livesay and Woolpert,1974). However, the
likelihood of progression of LTBI to active TB depends on bacterial, host, and environmental
factors (Getahun et al., 2015). The reactivation of TB can be averted by preventivetreatment.
Currently available regimens for the treatment of LTBI have an efficacy ranging from 60% to 90%,
the protection of which can last for up to 19 years (Lobue and Menzies, 2010). Although people

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with LTBI do not manifest overt symptoms of active TB and are not infectious, but they are at
increased risk for developing active disease, about one in ten latent infections eventually progresses
to active disease, which,if left untreated, kills more than 50% of its victims (Aman et al., 2017).

2.5. TB Epidemiology
TB is contagious and airborne (Glaziou et al.,2015). The risk of acquiring Mycobacterium
tuberculosis infection is essentially determined by exogenous factors. TB is most commonly
transmitted from a person with infectious pulmonary TB to others by droplet nuclei, which are
aerosolized by coughing, sneezing, or speaking. Other routes of transmission are uncommon and of
no epidemiologic significance. The probability of contact with a person who has an infectious form
of TB, the intimacy and duration of that contact, the degree of infectiousness of the case, and the
shared environment in which the contact takes place are important determinants of the likelihood of
transmission. About one-third of the world’s population is estimated to have been exposed to TB
bacteria and potentially infected (Glaziou et al.,2015) . Of those infected, only a small proportion
will become sick with TB (Glaziou et al.,2015) but people living with HIV, people with weakened
immune systems caused by the prolonged use of medicines such as steroids or TNF-a inhibitors,
and patients with diabetes, renal insufficiency, and silicosis (among other morbidities) have amuch
greater risk of falling ill from TB (Glaziou et al.,2015).

2.5.1. Transmission and Pathogenesis of Tuberculosis

TB is an airborne bacterial infection caused by M.Tuberculosis which affects any part of the body
and most commonly the lungs. M.Tuberculosis is exposed to the air as droplet nuclei from
coughing, sneezing , shouting or singing of individuals with pulmonary or laryngeal TB (Agyeman
and Asenso, 2017).
Transmission occurs through inhalation of these droplet nuclei which passes through the mouth or
nasal cavities, the upper respiratory tract, bronchi and finally reaches the alveoli of the lungs
(Agyeman and Asenso, 2017). Once the M. Tuberculosis or he tubercle bacilli reaches the alveoli,
they are ingested by alveolar macrophages resulting in the destruction or inhibition of a greater
proportion of the inhaled tubercle bacilli (Agyeman and Asenso, 2017). The small unaffected
proportion multiplies within the macrophages and is released upon death of the macrophages. Live
released tubercle bacilli spread via the bloodstream or lymphatic channels to any part of the body
tissues or organs in addition to highly susceptible areas of TB infection such as the lungs, larynx,
lymph nodes, spine, bone or kidneys (Agyeman and R Asenso, 2017). In about 2 to 8 weeks
(Agyeman and Asenso, 2017), an immune response is triggered which allows white blood cells to
encapsulate or destroy majority of the tubercle bacilli. The encapsulation by the white blood cells
results in a barrier around the tubercle bacilli forming a granuloma (Agyeman and Asenso, 2017).
Once inside the barrier shell, the tubercle bacilli is said to be under control and thus establishing a
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state of latent tuberculosis infection (LTBI). Persons at this stage show no symptoms of TB, are
unable to spread the infection and as such not considered as TB cases (Agyeman and Asenso, 2017).
On the other hand, if the immune system fails to keep the tubercle bacilli under control, rapid
multiplication of the bacilli ensues which leads to a progression from LTBI to a case of TB. The
time for progression to TB may be soon after LTBI or longer occurring after many years. A TB case
is highly infectious and can spread the bacilli to other people (Agyeman and Asenso, 2017).

2.5.2. The global burden of tuberculosis

Tuberculosis ranks alongside HIV/AIDS as the top infectious killer worldwide, with 9.6
million new incident cases and 1.5 million deaths estimated to have occurred in 2014 (Raviglione
and Sulis, 2016). Of note, more than two thirds of the global TB burden is reported in Africa and
Asia, and in absolute terms India, Indonesia and China account for the highest number of TB cases
amounting to 43% of the global burden (Raviglione and Sulis, 2016). The human
immunodeficiency virus (HIV) is the strongest risk factor for TB, and TB is the first cause of death
among people living with HIV , even in an era of scale up of antiretroviral therapy (ART), causing
one third of all HIV-related deaths. In 2014, HIV-infected persons accounted for 1.2 million (12%)
of the estimated 9.6 million people globally who developed TB (Raviglione and Sulis, 2016) . At
the end of the same year, TB contributed to one third of the 1.2 million deaths from HIV/AIDS and
HIV was responsible for 25% of the 1.5 million TB deaths. The majority (nearly three quarters) of
these estimated HIV-associated TB cases and deaths are in the African Region, with eastern and
southern African countries carrying most of the global burden. ART coverage among known HIV-
infected TB patients in 2014 was 77%, which represents a further increase from previous years, but
it is still far from the World Health Organization recommendation that all HIV-positive people with
TB should receive it (Raviglione and Sulis, 2016) .Other co-morbidities such as those related to
diabetes mellitus, smoking, and alcohol abuse are currently emerging in high, middle and low-
income countries as potentially associated with a greater risk of latent TB infection (LTBI) to active
disease (two to three-fold higher in diabetics and sprogression from Smokers, for instance) as well
as a less favorable treatment outcome (Raviglione and Sulis, 2016).

3. Status of Tuberculosis
3.1. World distribution
Tuberculosis (TB) is one of the most wide spread infection known in the world. Approximately 1.7
billion people or one-third of the world’s population is to be infected with mycobacterium tubercle
bacilli. Every year, about nine million cases of active TB disease and 2 million deaths occur
globally. Most of the cases of active TB (7 million) are in Asia and Africa (Harries and Dye2006;
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WHO,2009; Aziz and Wright, 2005)

3.2. Tuberculosis status in Africa

In 2016 an estimated 1.3 million people who were HIV negative died of TB. In addition there were
374,000 million deaths resulting from TB disease among people who were HIV positive. So there
were a total of 1,674,000 million TB related deaths. An estimated 250,000 children died of TB in
2016 including children with HIV associated TB (WHO, 2017).

3.3. Tuberculosis status in Ethiopia

In Ethiopia, the effort of controlling tuberculosis began in the early 1960s the establishment of TB
centers and sanatorium in three major urban areas of the country (FMOH,2008). A nationwide
survey conducted in Ethiopia between 1987&1990 showed that the annual risk of infection of 1.4%
which is lower than the 3.0% reported in 1953-1955 (Azbite, 1992). In 1992, a standardized TB
prevention and control program, incorporating directly observed treatment, short course (DOTs)
was started as a pilot in Arsi and Bale zones of Oromia region (FMOH, 2008).

3.4. Signs and symptoms

Literature, opera, and art have popularized the traditional symptoms and signs of pulmonary
tuberculosis : cough, sputum, haemoptysis, breathlessness, weight loss, anorexia, fever, malaise,
wasting, and terminal cachexia in various combinations, not only in the descriptions of the
heroes,heroines, and villains but also among the artists, poets, and musicians themselves
(Dormandy,1999).

3.5. Diagnosis
There are five key components of a complete evaluation of TB disease. These are: (I) medical
history taking; (II) physical examination; (III) test for M. Tuberculosis infection; (IV) chest
radiograph and (V) bacteriologic examination of clinical specimens (CDC, 2016).
The diagnosis of TB depends on numerous factors namely; self-presentation of persons with TB
symptoms to health care facility, high index of TB suspicion among health care professionals, TB
screening practices in health facilities, sensitivity and specificity of diagnostic test used, turnaround
time for delivery of laboratory results, and the capacity to trace people with positive results and start

them on treatment (NDOH,2014).

4. Risk factor of pulmonary Tuberculosis on

human health
Tuberculosis can develop after inhaling droplets sprayed into the air from a cough or sneeze by

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someone infected with Mycobacterium tuberculosis. The disease is characterized by the
development of granulomas (granular tumors) in the infected tissues. The usual site of the disease is
the lungs, but other organs may be involved. The primary stage of the infection is usually
asymptomatic. Primary pulmonary TB develops in the minority of people whose immune systems
do not successfully contain the primary infection. In this case, the disease may occur within weeks
after the primary infection. TB may also lie dormant for years and reappear after the initial infection
is contained (Ferrara & Meacci, 2005). The risk of contracting TB increases with the frequency of
contact with people who have the disease, with crowded or unsanitary living conditions and with
poor nutrition. Recently, there has been an increase in cases of TB. Factors that may contribute to
the increase in tuberculosis infection in a population are: an increase in the number of homeless
individuals (poor environment and poor nutrition), the appearance of drug-resistant strains of TB,
incomplete treatment of TB infectious (such as failure to take medications for the prescribed length
of time) which can contribute to the emergence of drug-resistant strains of bacteria. Individuals with
immune systems damaged by AIDS have a higher risk of developing active tuberculosis, either
from new exposure to TB or reactivation of dormant mycobacteria. In addition, without the aid of
an active immune system, treatment is more difficult and the disease is more resistant to therapy
(Ferrara & Meacci, 2005).

4.1 Tuberculosis in Pregnancy

There are no studies to our knowledge that have systematically assessed the direct relationship of
pregnancy and the risk of tuberculosis (Getahun et al., 2012).
Several reports showed that pregnant women with un-treated tuberculosis, including those living
with HIV, have poor obstetric and perinatal outcomes (Getahun et al., 2012) . Pulmonary tuber-
culosis was associated with an approximate 2-fold increase in premature birth, neonates that are low
birth weight and small for gestational age, and a 6-fold increase in perinatal deaths (Getahun et al.,
2012). Similarly, with the exception of tuberculosis lymphadenitis, extrapulmonary tuberculosis has
adverse outcomes for pregnancy including increased antenatal hospitalization and neonatal
complications (Getahun et al., 2012).

4.2. Treatment of Tuberculosis in Pregnant and

Breastfeeding Women
There is no difference in the treatment of tuberculosis among male and female patients. The
recommended treatment for women newly diagnosed with pulmonary and extrapulmonary
tuberculosis is a daily regimen for 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol
(intensive phase), followed by 4 months of isoniazid and rifampicin (continuation phase). This
recommended regimen is safe to use during pregnancy (Getahun et al., 2012).
and maternal exposure to these drugs showed no risk of congenital abnormality in a large

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population-based study (Czeizel et al.,2001). Pyridoxine supplementation is recommended for all
pregnant or breastfeeding women taking isoniazid. Similarly, vitamin K should be administered at
birth to the infant of a mother taking rifampicin because of the risk of postnatal hemorrhage
(Getahun et al., 2012)

5. The Challenge of Controlling TB Disease in

the most Vulnerable Populations.
Since TB does not homogeneously affect the population, selected high risk groups should be
identified in all settings as they deserve special attention and should be addressed specifically with
additional interventions ( Sulis et al., 2014). TB is mostly a poverty-related disease: this can explain
its uneven distribution in different population groups. Poor housing and environmental conditions,
food insecurity, financial difficulties, illiteracy, unfavourable psychosocial circumstances are among
the major determinants of TB and concomitantly affect the capacity of sick persons to access health

care service (Sulis et al., 2014). Well-defined vulnerable groups include people living with HIV
infection, prisoners, homeless people, migrants/refugees, and substance or heavy alcohol users.
Besides the increased risk of exposure to M. tuberculosis, vulnerable groups are also more likely to
progress to active disease once they are infected due to the immune compromised status of their
underlying condition. Moreover, in some of these groups TB may remain for a long time
undiagnosed, thus representing a source of infection for the entire community Social
marginalization is often responsible for a limited access to health services leading to diagnostic
delay, clinical worsening and poor adherence to treatment, and eventually to a less favorable

outcome ( Sulis et al., 2014). A common discouraging factor to seek medical care is the fear of
stigmatization that is also an important determinant of poor adherence. The most fragile populations
should be identified in each country in order to develop and implement tailored interventions aimed
at addressing the needs of hard to reach groups. Global disease control will not be achieved without
a cross-cutting approach towards these social determinants of the disease (Sulis et al., 2014).

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6. Conclusion
Tuberculosis (TB) is one of the most wide spread infection known in the world. It is an airborne
bacterial infection caused by M.Tuberculosis which affects any part of the body most commonly
affects the lungs. This diseases is the most common form of TB in humans occurring in over 80%
of cases. Person-to-person spread occurs when an infected individual coughs, sneezes or speaks
releasing minute droplet nuclei each containing between 1-5 TB bacilli and also , the prevalence of
TB is higher amongst persons with different types of other diseases, most people can affected

amongst with HIV. Depending on understanding the symptoms its possible to prevent and treat
this diseases, thhere is no difference in the treatment of tuberculosis among male and female
patients. There are many conditions associated with TB such as:- HIV infection, Diabetes mellitus,
smoking, Alcohol consumption, Silicosis and etc. TB does not homogeneously affect the
population.

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