The causative agent of tuberculosis is a bacterium (Mycobacterium tuberculosis), which most often affects the lungs. Tuberculosis is curable and preventable.
Tuberculosis spreads from person to person through the air. When people with pulmonary TB cough, sneeze, or expectorate, they release TB bacteria into the air. To become infected, a person only needs to inhale a small amount of these bacteria.
About one quarter of the world's population is infected with tuberculosis. This means that people are infected with the TB bacteria but are not (yet) sick and cannot transmit it.
The chance that people infected with TB bacteria will develop TB in their lifetime is 5-15%. People with weakened immune systems, such as people with HIV infection, people who are malnourished or people with diabetes, and people who use tobacco, are at much higher risk of getting the disease.
When a person develops active TB, symptoms (cough, fever, night sweats, or weight loss) may remain mild for many months. This can lead to delays in seeking medical attention and the transmission of bacteria to others. Over the course of a year, a person with an active form of tuberculosis can infect 5-15 people with whom he has close contacts. Without proper treatment, on average 45% of HIV-negative people with TB and almost all HIV-positive people with TB die.
Who is at greatest risk?
Tuberculosis primarily affects adults during their most productive years. However, all age groups are at risk. More than 95% of cases and deaths occur in developing countries.
People infected with HIV are 18 times more likely to develop active TB (see section on TB and HIV below). People who have other health conditions that weaken the immune system are also at higher risk of developing active TB. In people suffering from malnutrition, the risk increases 3 times. In 2021, 2.2 million new cases of tuberculosis were reported worldwide and were linked to malnutrition.
Alcohol use disorders and tobacco smoking increase the risk of tuberculosis by 3.3 and 1.6 times, respectively. In 2021, 0.72 million new cases of tuberculosis worldwide were attributed to alcohol use disorders and 0.70 million cases were attributed to smoking.
The disease cannot be stopped quickly
Tuberculosis until the 40s of the last century was an incurable disease, but for the eighth decade it has been treated quite successfully. Especially if the infection is not advanced and has not had time to cause significant damage to the body. Nevertheless, today among all infectious diseases tuberculosis is the No. 1 killer in the world. “10 million people get sick with it every year, and 1.5 million die,” says Professor, Doctor of Medical Sciences, Director of the Federal State Budgetary Institution “National Medical Research Center for Phthisiopulmonology and Infectious Diseases” of the Ministry of Health of the Russian Federation, President of the Russian Society of Phthisiologists and the Association of Phthisiologists, chief freelance TB specialist of the Ministry of Health of the Russian Federation Irina Vasilyeva.
Thanks to the system of treatment and control of the disease built back in the USSR, by 1990 in our country, tuberculosis incidence rates were lower than ever. But with the collapse of the country, the number of people infected with Koch’s bacillus began to grow, because socio-economic upheavals lead to an increase in socially significant diseases. Since the 1990s, a real epidemic of tuberculosis began. The number of infected people grew until the early 2000s. Then the incidence rate reached a plateau and began to decline only in 2010. “Unlike many other infections, tuberculosis does not cause sudden growth,” explains Irina Vasilyeva, “since Mycobacterium tuberculosis multiplies relatively slowly (only once a day), but for this reason it cannot be stopped quickly.”
Nevertheless, in recent years, Russia has managed to achieve enormous success, because if in 2013 our country was in 13th place among states with a high burden of tuberculosis (130 thousand cases were detected per year), then in 2021 Russia moved to last place in the top twenty such countries. Over 5-6 years, the incidence has decreased by almost half, to 78 thousand cases per year. Today in Russia, the incidence of tuberculosis annually falls by 7-10%, and mortality - by 12-15%.
Question answer
Why was the tuberculosis vaccine canceled?
Global impact of tuberculosis
Tuberculosis is common throughout the world. In 2021, the largest number of new TB cases occurred in the South-East Asia Region (44% of new cases), followed by the African Region (25%) and the Western Pacific Region (18%).
In 2021, 87% of new TB cases occurred in 30 countries with a high TB burden. Two-thirds of new TB cases occurred in eight countries - India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.
Fatigue
From her third year, Ksenia Shchenina mainly remembers the feeling of endless fatigue and constant guilt for it: “Fatigue, fatigue, fatigue, it’s hard to get up in the morning, the feeling that I can’t cope with anything and everything is falling out of my hands.”
It was 2008, Ksyusha was twenty years old. She came to Moscow from Khabarovsk, studied at the Institute of Journalism and Literary Creativity and led student life in its classically romantic version: concerts of the White Guard, love, meetings with online friends, first publications in Time Out and on Zvukah.ru . I didn’t go to the doctors - there were no other symptoms, so Ksyusha attributed her condition to her own character and scolded herself all the time: “I’m lazy.” I only got to the doctors when I arrived home for the summer holidays and, closer to departure, decided to get examined at my native district clinic for the year ahead. The therapist gave me a referral for tests, sent me to a cardiologist and for fluorography.
But when the time came to receive the results of fluorography at the reception, for some reason Ksyusha was not given them and was sent to the doctor. The following dialogue took place in the office:
- What is your last name? Ah, so it's you!
- What do you mean, me?
-Have you finally arrived? And where have you been for two years?
- What?
It quickly became clear that when Ksyusha came home for the summer after her first year in 2006 and, as part of an on-duty visit to doctors, had a fluorography done, and then flew back to study without taking the results, the changes characteristic of tuberculosis were already obvious in the picture. To a reasonable question why they didn’t report this, the doctor replied that it seemed like they were calling home. Indeed, my mother recalled, at some point they called from the clinic and said: “Your daughter has something wrong with her lungs, let her come in when she’s in Khabarovsk.” Mom conveyed exactly the message to Ksyusha: “There’s something wrong with the lungs, if you come home during the holidays, come in.” By next summer everything was safely forgotten.
It was the end of August, return tickets to Moscow were purchased, and the fourth year began in a week. The therapist announced: “If you’re lucky, make it within a year. Tomorrow morning with a ticket to see a pulmonologist.” - “I have things to do in the morning, can I come later?” - “Your lungs are decomposing, what’s going on?!” Here Ksyusha quietly said “Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh” and left. “No brochures, no explanations, whether it can be treated or not, what should I prepare for, what kind of disease is this of the great Russian writers.”
Photo: © gp6-chelny.ru
Symptoms and diagnosis
Common symptoms of active pulmonary TB are a cough, sometimes producing sputum and blood, chest pain, weakness, weight loss, fever and night sweats. WHO recommends the use of molecular diagnostic rapid tests as the initial diagnostic test for all people with signs and symptoms of tuberculosis, as these tests have high diagnostic accuracy and will lead to significant improvements in the early detection of tuberculosis and drug-resistant tuberculosis. WHO recommends Xpert MTB/RIF, Xpert Ultra and Truenat as rapid tests.
Diagnosing multidrug-resistant tuberculosis and other resistant forms of tuberculosis (see section on multidrug-resistant tuberculosis below), as well as HIV-associated tuberculosis, can be difficult and expensive.
Tuberculosis is especially difficult to diagnose in children.
Focus on children
The most dangerous thing is the suspension of vaccination and screening activities in children and adolescents who develop tuberculosis asymptomatically. Statistics show that their level of use of immunodiagnostic methods has dropped to 35-40% in recent months.
“At the moment, the situation with tuberculosis is stable both among adults and among children and adolescents,” says Professor, Doctor of Medicine, Head of the Department of Childhood and Adolescent Tuberculosis of the Federal State Budgetary Institution “National Medical Research Center for Phthisiopulmonology and Infectious Diseases” of the Ministry of Health of the Russian Federation, chief freelance pediatric TB specialist at the Ministry of Health of the Russian Federation Valentina Aksenova . “Today, when all restrictions have already been lifted, we call on all children’s and adolescent institutions and parents to resume diagnostic activities. As before, skin tests are used for this (Mantoux in children under 7 years of age, Diaskintest - from 7 years of age and older), and if indicated, laboratory tests are used, for example T-SPOT.TB. At the same time, for those who have suffered from coronavirus, the ELISPOT test will be the most informative. Its use is possible in all age groups. In the context of COVID-19, we must strive to implement new methods for diagnosing tuberculosis as much as possible, identify new risk groups, including those with drug-resistant forms of the disease, and create a full-fledged sanatorium and health center for children and adolescents.”
Treatment
Tuberculosis can be treated and cured. For active drug-sensitive tuberculosis, a standard six-month course of treatment with four antimicrobial drugs is given, with patient education and support from a health worker or trained volunteer. Without such support, it is more difficult to adhere to the treatment regimen.
Since 2000, it is estimated that 63 million lives have been saved by diagnosing and treating tuberculosis.
Methods of infection
The method of infection does not have a decisive influence on the damage to certain organs. However, in the case of antenatal infection, the liver, spleen, peritoneum, mesenteric lymph nodes, and rarely the lungs are affected. Alimentary infection in half of the cases leads to damage to the abdominal organs, and in half to the respiratory organs. The incidence of tuberculosis is influenced by the severity and duration of infection.
After the endemic decline, the main role in the incidence of tuberculosis is played not by exogenous, but by endogenous infection. This is evidenced by the increase in the incidence of diseases in the adult population.
Living together with a patient with tuberculosis in favorable housing and living conditions can only lead to accidental or periodic infection, otherwise frequent infection is possible. This explains the frequency of cases of superinfection of contact persons in the family, apartment or at work. The latter happens quite often among the staff of anti-tuberculosis institutions.
Tuberculosis and HIV infection
People with HIV infection are 18 (15–21) times more likely to develop active TB than people without HIV infection.
HIV infection and tuberculosis are a deadly combination and accelerate each other's progression. In 2021, approximately 208,000 people died from HIV-associated tuberculosis. In 2021, the proportion of notified TB patients with a documented HIV test result was 69%, up from 64% in 2021. In the WHO African region, with the highest burden of HIV-associated TB, 86% of TB patients had documented HIV test result. Overall, in 2019, 88% of TB patients diagnosed with HIV received ART.
To reduce mortality, WHO recommends a 12-prong approach based on collaboration on tuberculosis and HIV, including measures to prevent and treat infection and disease.
What kind of prevention?
The disease is transmitted through the air, and it is impossible to completely protect against tuberculosis. In addition, tuberculosis does not leave behind antibodies, so you can get sick with it several times.
Today, newborns in maternity hospitals are given the vaccine against tuberculosis - BCG (Bacillus Calmette-Guerin), but it also does not completely protect against infection, but only reduces the risk of infection and the development of severe forms of tuberculosis.
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Doctors recommend that adults and adolescents over 15 years of age adhere to a healthy lifestyle, do not smoke, do not drink alcohol, and undergo fluorography once every two years. For children from one to 14 years of age, an early diagnosis is tuberculin testing - the Mantoux test, which is regularly done in schools.
Multidrug-resistant tuberculosis
Anti-TB drugs have been used for decades, and strains resistant to one or more drugs have been reported in every country surveyed. Drug resistance occurs when anti-TB drugs are used inappropriately, as a result of inappropriate prescribing by health care providers, poor quality of drugs, or premature discontinuation of treatment by patients.
Multidrug-resistant tuberculosis (MDR-TB) is a form of tuberculosis caused by bacteria that does not respond to isoniazid and rifampicin, the two most effective first-line anti-TB drugs. MDR-TB can be treated and cured using second-line drugs. However, such treatment options are limited and require extensive chemotherapy (lasting up to two years) with expensive and toxic drugs.
In some cases, wider drug resistance may develop. Tuberculosis, caused by a bacterium that does not respond to the most effective second-line anti-TB drugs, can leave patients without any further treatment options.
In 2021, MDR-TB continued to pose a crisis and health security threat. In 2019, a total of 206,030 people with multidrug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) were identified and registered, an increase of 10% compared to 186,883 people in 2021 ). About half of the global MDR-TB burden occurs in 3 countries: India, China and the Russian Federation.
Currently, treatment success is achieved in only 57% of patients with MDR-TB. In 2021, WHO recommended a new accelerated (9-11 months) treatment regimen using only oral drugs for patients with MDR-TB. The study found that patients found it easier to complete this treatment regimen compared to longer regimens lasting up to 20 months. Fluoroquinolone resistance should be excluded before initiating treatment with this regimen.
According to WHO guidelines, detection of MDR/RR-TB requires bacteriological confirmation of TB and drug resistance testing using molecular rapid tests, culture methods or sequencing technologies. Its treatment requires a course of second-line therapy of at least 9 months and up to 20 months, accompanied by counseling and monitoring of side effects. WHO recommends expanding access to oral-only treatment regimens.
By the end of 2021, 89 countries had started using fast-track MDR-TB treatment regimens, and 109 countries had imported or started using bedaquiline to improve the effectiveness of MDR-TB treatment.
Tuberculin reaction
After the patient is cured, the tuberculin reaction remains positive and does not yet indicate the presence of not only infection, but also immunity. The tuberculin reaction is, first of all, an immunological reaction. The results of tuberculin diagnostics do not reflect the epidemiological situation: tuberculosis. More precisely, the effectiveness of the fight against tuberculosis is characterized by the risk of infection, that is, the increase in infection. The risk of infection is the percentage increase (%) in the number of people infected during the year. This figure should not exceed 1%. If the risk of infection exceeds 2%, then at 70 years of age 90% of the population will be infected.
99%
According to WHO, a third of the world’s population is infected with the “dormant” tuberculosis bacterium. Russian doctors call the figure much more impressive - from 70% to 99% of the country's residents are carriers of Koch's bacillus. But, despite the striking contrast in the numbers, the difference is small for the time being: a person gets sick only if the bacteria enters the active stage - this can happen when immunity drops sharply. As long as the immune system is in order, a person, even if he is a carrier of bacteria, is healthy and is not able to infect others.
They die from tuberculosis. But they die if the disease is advanced or the person is not treated for some reason - tuberculosis detected in time is almost 100% curable. The bad news is that while oncology and HIV are at least partly well-known and both activists and the media remind about the need for prevention and regular tests, tuberculosis is practically absent in the current information field, which means it is not so easy to notice it in the early stages. that's simple. In addition to the “great Russian writers”, the disease is associated with “consumptive young ladies”, as well as with marginal and declassed elements - for example, the homeless or prisoners.
“My mother was shocked when she heard my diagnosis - after all, there is a stereotype that this is a disease of alcoholics, drug addicts and dysfunctional families”
Few people know that people aged 18–44 years most often get sick, and the peak occurs at 25–34 years among women and 35–44 years among men. When Masha, at the age of eighteen, after a long treatment for pneumonia, was diagnosed with tuberculosis, her family found it so difficult to believe that she and her mother went to Moscow to the Central Research Institute of Tuberculosis on the Yauza River for confirmation. The name "Masha" is not real. The VKontakte and Skype accounts through which we communicate are also registered under a fictitious name. The conversation takes place without video or any personal details - the girl does not even name her hometown. The onset of Masha’s illness is similar to Ksenia’s story: “For about four months I felt weaker than usual, but I chalked it up to the fact that it was winter, that I went to work six months ago, and that I was tired out of habit. I had a long cold and thought about taking some vitamins in the spring. I was talking to my friends, and they responded: “Oh, I’m tired too.”
Masha has been healthy for a long time, she went to university and got married, but no one in her current circle knows about the several years she spent in the tuberculosis clinic, with the exception of her parents and husband - the social stigma of tuberculosis is such that it’s scary and embarrassing to talk about. “My mother was shocked when she heard my diagnosis - after all, there is a stereotype that this is a disease of alcoholics, drug addicts and dysfunctional families. And we have a prosperous, intelligent home, our own business. Where?" Only when she got sick, Masha didn’t make a secret of this, but after talking with people in the hospital, she was very scared: “Even my brother turned away from one girl: don’t call, don’t write to me anymore - to that extent.”
And most importantly, the idea of the symptoms of the disease remained the same, at the level of the novels of Turgenev, Dostoevsky and Lydia Charskaya. But symptoms familiar from classical literature, such as bloody sputum, appear in the later stages. In fact, the symptoms of tuberculosis are as follows. Chronic fatigue, irritability, sweating, the temperature rises slightly - up to 37.2–37.5, and is easy to bear on your feet: there is no chills. And no bloody cough. And often even the most ordinary cough. In most cases, people with the initial stage of tuberculosis simply do not think that something abnormal is happening to them: the desire to sleep, decreased performance, conversations “I should go on vacation”, “I’m tired” are attributed to the tension of modern life. There is a joke among patients at tuberculosis dispensaries: “If it seems to you that a loved one suddenly began to behave like the last m... <bad person>, send him for fluorography, perhaps he has tuberculosis.”
Fluorograph Photo © stockphotos.ru
