Written Assignment, Unit 1

Epidemiology

HS 3311-01 - AY2022-T5

Mehrnaz Siavoshi
(Instructor)

Epidemiology of Tuberculosis
Introduction

Tuberculosis (TB) is an infectious disease caused by a bacterium (mycobacterium

tuberculosis), that mostly affects the Lungs (causing pulmonary TB) even though it may

affect other parts of the body. The transmission of this disease occurs through the

inhalation of airborne particles containing M. tuberculosis. Being the primary source of

the bacteria, the sputum expectorated by untreated tuberculosis patients. (Aschengrau,

and Seage. 2020) This disease is nowadays not only preventable but also curable.

Regardless, and according to the WHO one third of the global population is still infected

with TB and in 2020, 1.5 million people still died of TB worldwide. The following eight

countries of, China, India, Pakistan, Nigeria, the Philippines, Bangladesh and South

Africa, account to two-thirds of the global burden of the disease. (WHO.2021)

Tuberculosis is an old disease and it has been described around the word in various ways

for many centuries. It’s not until the 1950s that an effective treatment has been achieved

alongside with a preventable therapy. It was considered as a won battle by the 1960s and

efforts were largely ignored or weakened. In the 1980s with the deterioration of TB

control and eradication plans and with the growing of the HIV pandemic, TB rebounds

worldwide. Some strains even spread as multidrug-resistant tuberculosis (MDR TB) In

1993, the WHO, declares tuberculosis a global emergency and even though effective

progress has been achieved in its eradication, TB still remains as a leading cause of

premature death among young adults in the world. (WHO.2021)

The epidemiologic triangle or triad of diseases, is a model that can help to understand

infectious diseases and how they spread. The triangle has 3 vertices Agent (microbe
causing the disease - “what”), Host (organism harboring the disease - “who”) and

Environment (external factors allowing disease transmission - “where”).

In the case of tuberculosis, the Agent is mycobacterium tuberculosis, a rod-shaped, slow

growing, acid-fast bacteria that causes TB. Only four species of mycobacteria are highly

pathogenic in humans. Nowadays the complete genome is revealed, and rapid advances

in genotyping methods advanced the understanding of molecular epidemiology of the

bacillus. Including that M. tuberculosis is not a mutation of M. bovis, but that both are

derived from a common ancestor long before infecting humans. (Nelson and Williams.

2014) The M. tuberculosis has a relative high resistance which makes it to survive in

harsh climate and still remain potent. The body doesn’t have the ability to prevent the

spread, as well as to fight the bacterial growth. The bacteria tend to stay dormant (slow

grower) in the body however TB bacteria may also grow fast. This actually decides the

course of the disease.

The host factors of tuberculosis relate to either immunity and the defensive action of the

host organism. This means that if the host has a decreased immunity, there is a higher

chance for TB to progress from latent to active disease stage. Decreased immunity might

be predisposed by malnutrition and other risk factors such as smoking, alcohol abuse,

cancer, diabetes or even other viral load as occurs with HIV patients. The host immunity

might be supplemented with vaccines that increases the chance to fight of tuberculosis.

Environmental factors are significant in the disease process of TB and mainly relate to

social factors. Some tend to accelerate the disease process, mainly including poverty, or

poor quality of life. Overcrowding, malnourishment, poor ventilated houses and lack of

adequate sanitation all are also responsible for increasing the chances of contracting TB.

Treatment and interventions

population existing in an active, dormant or semi-dormant growing state, effective drug-

based application is also complex. Key treatment is to adhere to a full treatment regimen

“which reduces the risk of treatment failure and the emergence of drug resistance”

(Nelson and Williams. 2014). The WHO has a global strategy for the eradication of TB

based on the directly observed therapy DOT. This implies that a healthcare worker

“monitors each TB patient closely and observes the patient take each dose of anti-

tuberculosis medication” (Nelson and Williams. 2014) The WHO recommends a

short/course DOT drug regimen for treating TB that includes the usage of four drugs -

isoniazid, rifampin, pyrazinamide and ethambutol for 2 months, followed by four months

of treatment with only isoniazid and rifampin. (WHO.2021)

One of the most serious problems in TB control is non-adherence to treatment.

DOTS is the internationally recommended strategy to improve adherence, reduce the risk

of acquired drug resistance and increase the possibility of cure. Health professionals can

develop and adapt strategies such as DOTS, individualized treatment regimens,

nutritional support and social benefits, according to local conditions. According to a 2018

meta/analysis on which type of interventions might improve adherence to tb treatment, to

study concluded that DOTS strategy increased the cure rate by 18% and by 16% with

patient education and counselling. (Müller et al. 2018)

There are several types of necessary interventions. Social interventions as seen in

Brazil, for example in 2019 with the introduction of several measures to end hunger,

achieve food security and improve nutrition, such as The Bolsa Familia program,

(conditional cash transfer program) directly affected TB treatment outcomes and

demonstrated a 7.6% higher rate cure according to Lancet Global Health. Still in Brazil,

a very worrisome issue is TB spread in prisons. At the time of incarceration less than 10%
of people entering have TB. However, every year of incarceration is associated with a 25%

to 40% increase in risk infectious and when released with a high increase rate of spread

into the surrounding communities. Overcrowding, poor ventilation, poor nutrition and

widespread drug and alcohol abuse exacerbate the disease spread. It was suggested a mass

entry screening to stop newly released people to spread the disease to the population at

large that is contributing to not only tackle this issue but to the decrease of TB both in

prisons as well as among the population. (Müller et al. 2018)

References:

Ann Aschengrau, George R. Seage III (2020) Essentials of epidemiology in public health.

Fourth edition. Burlington, Jones & Bartlett Learning. USA

WHO. (2021). Global Tuberculosis Report. Retrieved from:

https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-

report-2021

Kenrad E. Nelson and Carolyn Masters Williams. (2014). Infectious Disease Epidemiology.

Theory and Practice. Third edition. Jones & Barnett. USA

Müller AM, Osório CS, Silva DR, Sbruzzi G, de Tarso P, Dalcin R. (2018). Interventions

to improve adherence to tuberculosis treatment: systematic review and meta-analysis. Int

J Tuberc Lung Dis. Jul 1;22(7):731-740. doi: 10.5588/ijtld.17.0596. PMID: 29914598.