Questions and Answers About Tuberculosis and TB Treatment

Tuberculosis (TB) is a serious bacterial disease. It is a particular public health concern because it can spread through the air when a person with TB disease coughs, sneezes, laughs, sings, or even speaks. TB is found most often in the lungs, but can spread to other parts of the body. Untreated, it can destroy lung tissue and make breathing difficult or impossible. Left untreated or improperly treated, TB can be fatal.

TB disease develops when the immune system cannot keep tuberculosis bacteria under control, and bacteria begin to rapidly multiply and destroy tissue in the body: the bacteria can actually create a cavity or hole in the lung. People with TB disease are sick, and usually have symptoms.

TB disease can develop very soon after infection, or may appear many years after infection. People with TB disease can spread TB to others.

People with TB Disease:

• Usually have signs and symptoms
• Usually feel sick
• May spreads TB bacteria to others
• Usually have a positive TB test
• May have an abnormal chest x-ray, or positive sputum smear or culture
• Need treatment to stop the disease

TB disease normally affects the lung and is known as pulmonary TB. When TB occurs outside the lung it is referred to as extra-pulmonary TB. TB in the lungs or throat can be infectious, meaning the bacteria can be spread to other people. People with TB disease are most likely to spread it to those they spend time with every day, including family members, friends, coworkers, classmates, commuters, etc. TB disease in other parts of the body – such as the kidney or spine – is usually not easily spread to others.

The likelihood that TB will be transmitted heavily depends on the following factors.

• Infectiousness of the person with TB disease
• Environment in which exposure occurred
• Duration of exposure
• Virulence of the organism

TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks or sings. People nearby may breathe in these bacteria and become infected. TB is most commonly spread to others in confined, poorly ventilated spaces. Although anyone can be exposed to TB disease, certain groups are at higher risk for exposure, including health care professionals, the homeless, and individuals from countries where TB is highly prevalent.

TB is NOT spread by

• shaking someone's hand
• sharing food or drink
• touching bed linens or toilet seats
• sharing toothbrushes
• kissing

The general symptoms of TB disease include feeling tired, weight loss, loss of appetite, fever, and night sweats. The symptoms of TB disease of the lungs also include a bad cough that does not improve and which lasts 3 weeks or more, chest pain, and coughing up blood. Symptoms of TB disease occurring outside of the lungs depend on the area affected.

Since symptoms of TB usually start gradually, often TB is not suspected, or is misdiagnosed as another illness.

TB disease can be treated by taking anti-tuberculosis drugs for 6 to 12 months or longer. It is very important that people who have TB disease finish this medicine, and take their drugs exactly as ordered. If they stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly, the germs that are still alive may become resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat.

In Mississippi the local health department staff meets regularly with patients who have TB to watch them take their medications. This is called directly observed therapy (DOT). DOT helps the patient complete treatment in the least amount of time. Treatment is usually divided into two phases: the initial phase and the continuation phase. The initial phase begins with four drugs given daily for fourteen consecutive days. The remainder of the initial phase (usually about 2 months) may be daily or twice weekly depending on the patient's drug tolerance and the extent of the disease or the patient's other conditions. The continuation phase typically will last an additional 4 to 7 months with not less than 2 drugs. Laboratory testing is performed at regular intervals or as needed to monitor the patients progress and drug tolerance.

When a person is diagnosed with TB infection, it means that they have been exposed to someone with TB disease, have inhaled TB bacteria, and become infected with TB. About 5% of infected people progress to TB disease within the first two years after becoming infected. Another 5% will develop disease later. People who are infected:

• Have no symptoms
• Don't feel sick
• Cannot spread TB to others
• Usually have a positive TB skin test or TB blood test (Interferon Gamma Release Assay)
• May develop TB disease if not treated for TB infection

People at greater risks of progressing to TB disease usually have a weakened immune system. Older people; children under the age of 5; people with chronic illness (especially diabetes), lung diseases, or certain cancers; those who smoke, abuse substances, or take immune suppressive medications such as TnF inhibitors; or those with HIV infection have much higher risk of developing TB disease if not treated.

Sometimes people are given treatment to prevent TB infection even if their TB test is negative. This is often done with infants, children and HIV-infected people who have recently spent time with someone who has infectious TB disease. These groups are at very high risk of developing serious TB disease soon after they are exposed to TB bacteria. If you are prescribed treatment for TB infection, it is important that you take all of your pills exactly as prescribed. You should follow-up regularly with your health care provider while on medication so they can monitor how you are doing.

A person with TB infection needs to take anti-tuberculosis drugs in order to kill the TB germs and prevent TB disease from developing in the future. Some people are more likely than others to develop TB disease once they have TB infection. This includes people with HIV infection, people who were recently exposed to someone with TB disease, smokers, people with certain medical conditions such as diabetes and kidney problems, and persons taking immunosuppressive drugs.

The newest and best treatment for TB infection requires two drugs given in one directly observed dose per week for 12 weeks. Other single drug treatment options take from four to nine months to complete.

TB exposure occurs when a person shares air with someone who has active infectious TB disease. You may have been exposed to TB if you spent time near someone with TB disease of the lungs or throat. You can only get infected by breathing in TB germs that a person expels into the air. You cannot get TB from someone's clothes, drinking glass, eating utensils, handshake, toilet, or other surfaces where a TB patient has been. Most people are never exposed to a person with active infectious tuberculosis disease for a period long enough to become infected. People most likely to become infected are those that share air with a TB case for prolonged period of time, either in a single or group setting. Individuals more likely to be exposed to TB include health care workers, the homeless, persons living or working in congregate or long term care facilities, and persons traveling to or living in countries with high TB prevalence. An estimated 10-15 million U.S. residents and one-third of the world's population are currently infected with the TB organism. A TB Interferon Gamma Release Assay (blood test) will identify TB infection.

Untreated, TB infection can progress to TB disease. A person with TB infection does not feel sick and has no symptoms. Persons with TB infection cannot spread the infection to others. A skin test or blood test can detect the presence of TB infection. TB infection should be treated to prevent it from progressing to TB disease which can be spread to others.

You can get a TB skin test or blood test at a local health clinic or your doctor's office. The tests are quick and simple, and give results in only a few days. A blood test is the preferred test and is more specific than a skin test. A skin test can require two to four visits whereas the blood test can be performed with a single visit. (TB skin test are typically not given on Thursdays because of the required time-frame for the follow-up visit.)

You should get a TB test if:

• You have spent time with a person who has active TB.
• You have the symptoms of TB: coughing for more than two weeks, pain in the chest, coughing up blood, and fatigue.
• You have a chronic disease such as diabetes, or another condition that weakens the immune system.
• You have lived or traveled in a foreign country where TB is common.
• You have lived or worked in a place where TB is common: migrant farm camps, prisons, homeless shelters or other crowded places where disease can spread.
• You use drugs injected with needles that may not be sterile.
• You have HIV infection.
• You are going to start a TNF inhibitor or other immunosuppressive therapy (get tested before starting)
• You are being evaluated for treatment with immunosuppressive drugs such as TnF inhibitors for arthritis

State laws and regulations require that TB infection, suspected TB, or cases of tuberculosis be reported to the Mississippi State Department of Health. Active TB must be reported within 24 hours of first suspicion. Anyone with a positive skin test or IGRA is required to be reported to the Mississippi State Department of Health within 7 days. Specific information on reporting requirement may be found in the Rules and Regulations Governing Reportable Diseases. MSDH provides treatment and follow-up of all TB patients and contacts.

The transmission of Mycobacterium tuberculosis in correctional facilities presents a public health problem for correctional facility employees and inmates and the communities into which untreated inmates may be released. A primary reason for the high risk of TB infection and TB disease in correctional facilities is the disproportionate number of inmates who have risk factors for exposure to TB or, if infected, for development of active disease. These risk factors include crowded communal living, infection with HIV, substance abuse, and being a member of a lower socioeconomic population that has poor access to health care.

With this in mind, the Department of Health and the Department of Corrections work collaboratively to ensure all inmates and employees are tested for tuberculosis, and that those found to be infected are appropriately treated. This helps stop the spread of TB and helps protect all communities statewide. Additionally, the State TB Program has assigned nurses to all three state correctional facilities to ensure open communication with the facilities, address questions and concerns, monitor patient progress, ensure appropriate treatment and follow-up, and facilitate discharge planning for TB and HIV patients.

Multi-drug resistant TB (MDR-TB) is tuberculosis disease in which the TB bacterium is resistant to both isoniazid and rifampin, the two strongest anti-tuberculosis medications. TB can become resistant to antibiotics when the drugs are misused or mismanaged, when patients do not complete their full course of treatment, when healthcare providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs; or when the drugs are of poor quality. Treating MDR-TB is complicated and involves the use of second-line medications that carry greater risk of side effects and adverse reactions. Patients taking these drugs must be monitored closely throughout the course of treatment. The regimen usually requires at least 18-24 months and must be individualized based upon the patient's medical history. Treatment for patients co-infected with HIV can be more complicated, usually further lengthening treatment time.

Extensively drug resistant TB (XDR-TB) is a relatively rare type of MDR-TB. XDR-TB is defined as TB which is resistant to isoniazid and rifampin, plus resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). Because XDR-TB is resistant to first-line and second-line drugs, patients are left with treatment options that are much less effective and may require prolonged treatment.

Yes. Bovine tuberculosis refers to infection with bacteria called Mycobacterium bovis, or M. bovis. Mycobacterium bovis is related to another organism that causes tuberculosis in humans, Mycobacterium tuberculosis, but M. bovis is found most commonly in cattle and other animals. People can become infected with M. bovis when they consume raw milk and unpasteurized dairy products. Symptoms of bovine tuberculosis in people depend on the parts of the body infected; most infections result in no or only mild symptoms, including fever, night sweats, abdominal pain, and diarrhea. A comprehensive testing program conducted by the U.S. Department of Agriculture, state animal health agencies, and livestock ranchers has virtually eliminated bovine tuberculosis from cattle in the United States. However, bovine tuberculosis remains common in many developing countries, and persons should refrain from consuming imported dairy products that are not pasteurized.

A TB contact is a person that has been exposed to TB. TB contacts are ranked from high priority to low. High priority means either the person has had prolonged exposure, or that the person is highly susceptible to becoming infected and progressing to TB disease — children under the age of 5 or persons infected with HIV or on immunosuppressive therapy. Contacts should be promptly tested once exposure is known, and tested again about 10 weeks after the last known exposure. If either test is positive, the person is considered infected and requires additional follow-up and treatment.

From infection to development of a positive TB test (the incubation period) can take 2 to 10 weeks. The risk for developing active disease is the highest in the first two years after infection. If not treated, a risk continues throughout your lifetime.

DOT (directly-observed therapy) means that a trained health care worker or other designated individual (excluding a family member) provides the prescribed TB drugs and watches the patient swallow every dose. DOT is the most effective strategy for making sure patients take their medicines. Mississippi was the first state to adopt DOT as the standard of care. It is now recommended by the Centers for Disease Control and World Health Organization as the standard for treating TB.

• We cannot predict who will take medications as directed, and who will not. People from all social classes, educational backgrounds, ages, genders, and ethnicities can have problems taking medications correctly.
• Studies show that 86-90% of patients receiving DOT complete their therapy, compared to 61% for those on self-administered therapy.
• DOT helps patients finish TB therapy as quickly as possible, without unnecessary gaps.
• DOT helps prevent TB from spreading to others.
• DOT decreases the risk of drug-resistance resulting from erratic or incomplete treatment.
• DOT decreases the chances of treatment failure and relapse.

• A nurse or other trained health care worker from the patient's county public health department normally provides DOT.
• In some situations, it works best for clinics, home care agencies, correctional facilities, treatment centers, schools, employers, and other facilities to provide DOT, under the guidance of the local health department.
• Family members should not be used for DOT. DOT providers must remain objective.
• For complex regimens including IV/IM medications or twice daily dosing, home care agencies may provide DOT or share responsibilities with the local health department.
• If resources for providing DOT are limited, priority should be given to patients most at risk.
• In some cases observed therapy may be performed using live streaming video.

• "Start where the patient is."
• Protect confidentiality.
• Communicate clearly.
• Avoid criticizing the patient's behavior; respectfully offer helpful suggestions for change.
• Be on time and be consistent.
• Adopt and reflect a nonjudgmental attitude.