In This Article Tuberculosis among Adults and the Determinants of Health

  • Introduction
  • Latent TB Infection
  • TB and Human Immunodeficiency Virus (HIV) Coinfection
  • TB and Migration
  • TB Control and Prevention

Public Health Tuberculosis among Adults and the Determinants of Health
by
Awal D. Khan, Hazel D. Dean
  • LAST MODIFIED: 23 August 2017
  • DOI: 10.1093/obo/9780199756797-0170

Introduction

Tuberculosis (TB) is a widespread communicable disease that poses a serious, demonstrable threat worldwide. TB is caused primarily by a bacterium discovered by Robert Koch in 1882, known as Mycobacterium tuberculosis, which typically affects the lungs but can also affect other organs. If untreated, infected persons can progress to active TB disease within weeks, or they can remain asymptomatic indefinitely with latent TB infection (LTBI). Approximately 9.6 million new cases and 1.5 million deaths occurred from TB worldwide in 2014 (World Health Organization 2015, cited under Reference Works). Approximately 2–3 billion persons are infected with M. tuberculosis, of whom approximately 5–10 percent will develop active disease during their lifetime if untreated. Social, economic, and structural determinants of health drive the TB epidemic, including poverty, living conditions (e.g., overcrowding or residence in prisons or homeless shelters) and urbanization, globalization through migration, and lack of access to health services or adherence to medications. The global distribution of TB cases is affected by recognized social determinants of health (SDH) among persons in low- and high-burden countries. Additionally, characteristics like coinfection with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), diabetes mellitus (DM), smoking, and alcohol consumption are associated with increased risk of developing TB after being infected. Recent research has focused on other modifiable environmental and social risk factors, modification of which, at the population level, can have a substantial impact on TB incidence. Well-recognized factors that can lead to increased risk for active TB disease on an individual level include defects in cellular immunity and immunosuppressive drugs. Effective TB control and prevention includes identifying persons with active TB as quickly as possible and initiating treatment and preventing TB among persons with LTBI. A chief problem facing effective TB control and prevention is treatment with multiple drugs for ≥6 months, which makes patient adherence to therapy difficult. Despite the remarkable progress made by medical science during the 20th century, the effectiveness of TB diagnosis, treatment, and vaccination remains less than satisfactory. Screening for TB and LTBI, treatment of active TB, and prophylactic treatment of LTBI remain important tools for global TB elimination efforts. Given the wide recognition that TB disease is often associated with SDH, it is important to discuss conditions that share and overlap with the risk factors driving TB epidemiology and the health of the population. The sections of this article focus on TB, LTBI, TB coinfections, TB among immigrants and refugees, TB among vulnerable and marginalized population groups, and diagnosis and treatment of drug-susceptible cases.

General Overviews

TB is an ancient disease. It has accompanied humans for centuries and has surged in great epidemics, accounting for the deaths of more persons than any other disease (Daniel 2006, cited under Reference Works). Although global TB incidence has slowly declined, it remains a major public health problem, especially in low- and middle-socioeconomic countries. It has been linked to traditional (chronic poverty and malnutrition) and newly emerging risk factors (coinfections), but social, environmental, and structural determinants of TB are still associated with its epidemiology and control and prevention strategies. Since the mid-1990s, the World Health Organization (WHO), through its STOP TB initiatives and its collaborative partnerships, has led worldwide national efforts to curb the TB pandemic through the development and dissemination of guidelines, along with technical and policy reports. The WHO recommends treatment of drug-sensitive TB cases with a standard six-month course of four antimicrobial drugs under the supervision and support of a health worker or trained volunteer. The vast majority of TB cases can be cured when medicines are administered and taken correctly. Introductory books that explain diagnostics, treatments, and immunologic perspectives can provide excellent reference sources, although some are from the early 2000s. Iseman 2000, Dormandy 2000, and Raviglione 2006 (all cited under Textbooks) provide excellent historical perspectives of TB. The US Centers for Disease Control and Prevention (CDC) develops TB core curricula as reference manuals for clinicians, and the WHO provides data and background information on TB for member countries. Health care–related journals publish scholarly reviews that highlight ongoing challenges of TB diagnosis, treatment, and management, along with perspectives on interactions between communicable and noncommunicable disease and the global need for investment and political leadership. Scholars have focused on geopolitical causes that have a considerable impact on TB morbidity (e.g., poverty, migration, and comorbidities)—see, for example, Keshavjee and Lane 2015 (cited under Lancet) and Zumla, et al. 2013 (cited under New England Journal of Medicine). Reviews and editorials have focused on the need for identifying biomarkers and diagnostics, new anti-TB drugs, new vaccines, strengthening of health-care systems, and scale-up of services (screening, testing, referral, and treatment). Published theses, years-in-review, seminars, and technical series have delineated the chronological progress in TB control and highlighted the overarching TB challenges and needs facing us in the 21st century.

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